Trending Topics in Gastroenterology | GastroAGI

Recurrent Colorectal Polyps Require Advanced, Structured Endoscopic Management : Frontline Gastroenterology | May 2026

Introduction Colorectal Polyps are identified in up to half of screening colonoscopies and represent key precursor lesions for Colorectal Cancer. Advances in endoscopic resection techniques have dramatically reduced the need for surgery; however, recurrence or residual neoplasia after initial polypectomy remains an important clinical challenge. Recurrence rates may approach 20%, particularly after piecemeal resection of large lesions. Problem Statement Optimal management strategies for recurrent or residual colorectal polyps remain incompletely standardized. Limited evidence exists regarding selection among repeat endoscopic therapy, advanced resection techniques and surgery, particularly in technically difficult or fibrotic lesions. Summary This review comprehensively evaluates current evidence regarding management of recurrent or residual colorectal polyps after initial polypectomy, with particular emphasis on advanced endoscopic approaches and strategies to minimize repeated interventions. The review highlights that recurrence is strongly influenced by the initial resection technique. Piecemeal endoscopic mucosal resection (EMR) carries substantially higher recurrence risk compared with en bloc resection because microscopic residual neoplastic tissue may remain at resection margins. Larger lesion size, difficult location, multiplicity and lesion morphology additionally contribute to recurrence risk. Several patient-related factors were also associated with recurrent neoplasia, including male sex, older age, obesity and smoking history. These observations reinforce the multifactorial biology underlying colorectal neoplasia persistence and recurrence. A key theme throughout the review is the importance of expert initial resection. Incomplete primary therapy frequently converts otherwise manageable lesions into technically complex recurrent polyps characterized by fibrosis, scar formation and distorted tissue planes. These recurrent lesions are often substantially more difficult to eradicate than treatment-naïve lesions. The review discusses a spectrum of advanced therapeutic options for recurrent lesions. Repeat EMR may remain feasible for smaller residual adenomas, whereas more advanced approaches such as Endoscopic Submucosal Dissection can facilitate en bloc excision of scarred or recurrent lesions. Avulsion techniques combined with thermal margin ablation have also emerged as valuable tools for fibrotic residual disease not amenable to standard snare capture. The role of full-thickness endoscopic resection is additionally emphasized for selected nonlifting or heavily scarred lesions. These techniques may help avoid surgery in carefully selected patients while still achieving definitive resection. Importantly, the review underscores that surgery remains necessary in selected circumstances, particularly when invasive malignancy is suspected, complete endoscopic excision is not feasible or repeated endoscopic attempts have failed. However, the authors strongly advocate referral to advanced endoscopy centers before surgical referral whenever possible, given the morbidity associated with colorectal resection. A major practical message is that recurrent polyp management should ideally occur in highly experienced, well-resourced tertiary centers. Advanced imaging, expert lesion characterization and availability of multiple resection platforms are critical for maximizing endoscopic cure rates and minimizing repeated procedures. The burden of recurrent procedures is also appropriately highlighted. Beyond technical complexity, repeated interventions increase patient anxiety, healthcare utilization, procedural risk and surveillance burden. Consequently, achieving high-quality definitive initial resection is likely the most effective recurrence-prevention strategy. The review also reflects the broader evolution of therapeutic colonoscopy toward organ-preserving minimally invasive management. Increasingly sophisticated endoscopic techniques are now allowing successful treatment of lesions previously referred directly for surgery. Overall, this review emphasizes that recurrent colorectal polyps represent a technically demanding but increasingly manageable clinical problem. Optimal outcomes depend on expert lesion assessment, advanced endoscopic resection capability and early referral to specialized centers, with the overarching goal of achieving definitive organ-preserving therapy while minimizing repeated interventions and unnecessary surgery.

STER Demonstrates Strong Real-World Outcomes for Upper GI Subepithelial Tumors : Gastrointest Endosc | May 2026

Introduction Submucosal Tunneling Endoscopic Resection has emerged as an important minimally invasive approach for management of upper gastrointestinal Subepithelial Tumors arising from or closely associated with the muscularis propria layer. Although extensive Asian experience has established the efficacy of STER, Western outcome data have remained limited, particularly regarding technical feasibility, fibrosis-related complexity and transmural resection requirements. Problem Statement Real-world U.S. data evaluating procedural success, adverse events and predictors of technical difficulty during STER for upper gastrointestinal subepithelial lesions are sparse. In particular, factors influencing transmural resection and incomplete resection remain poorly characterized. Summary This multicenter U.S. retrospective study evaluated outcomes of STER across eight tertiary centers for upper gastrointestinal subepithelial lesions originating from or inseparable from the muscularis propria layer. Most lesions had undergone prior diagnostic sampling before referral, and suspected gastrointestinal stromal tumors represented a major indication for intervention. STER achieved excellent technical outcomes, with en bloc resection and successful specimen retrieval in more than 94% of lesions. Importantly, no recurrences were observed during follow-up, supporting the oncologic adequacy and durability of endoscopic resection in appropriately selected lesions. A major finding was the impact of submucosal fibrosis on procedural complexity. Fibrosis was identified in nearly one-fifth of lesions and was universally associated with prior tissue sampling. Fibrotic lesions were substantially more likely to require transmural resection, highlighting how repeated biopsy or EUS-guided sampling may alter tissue planes and compromise technical ease of definitive endoscopic therapy. Gastrointestinal Stromal Tumor histology and extraluminal extension were also strongly associated with transmural resection requirements. These lesions likely reflect deeper muscular involvement and distorted anatomic planes, increasing procedural complexity and the need for full-thickness dissection. Importantly, although transmural resection prolonged procedure duration and increased R1 resection rates, it did not significantly increase adverse events. Most complications were managed conservatively, supporting the relative safety of advanced third-space endoscopic techniques in experienced centers. The study has several important practical implications for therapeutic endoscopy. First, it reinforces STER as an effective organ-preserving alternative to surgery for selected upper GI subepithelial tumors, particularly in lesions arising from the muscularis propria layer. Preservation of mucosal integrity through the tunneling approach likely contributes to reduced leak risk and faster recovery compared with exposed full-thickness techniques. Second, the findings challenge the routine use of extensive pre-resection tissue acquisition in lesions already strongly suspected to represent resectable GISTs or symptomatic muscularis propria tumors. Excessive prior sampling may induce fibrosis that complicates subsequent definitive resection without necessarily improving management decisions. The work also highlights the increasing sophistication of third-space endoscopy within Western practice. Historically concentrated in high-volume Asian centers, advanced submucosal tunneling techniques are now demonstrating reproducible safety and efficacy across U.S. tertiary institutions. Clinically, optimal patient selection remains critical. Lesions with extraluminal growth, deep muscular attachment or prior fibrosis may require advanced expertise and longer procedural planning. Nevertheless, even these technically challenging cases remained manageable endoscopically in experienced hands. Overall, this multicenter U.S. experience demonstrates that STER is a safe, effective and durable minimally invasive approach for selected upper gastrointestinal subepithelial tumors. The study additionally identifies prior sampling-induced fibrosis, GIST histology and extraluminal extension as key predictors of transmural resection complexity, emphasizing the importance of procedural planning and careful diagnostic sequencing.

Diathermy Principles Every Endoscopist Should Understand ; Frontline Gastroenterol | May 2026

Introduction Electrosurgery forms the foundation of modern therapeutic gastrointestinal endoscopy. Procedures including polypectomy, Endoscopic Mucosal Resection, Endoscopic Submucosal Dissection, endoscopic sphincterotomy and third-space endoscopy all rely on controlled delivery of electrical energy to tissue. Despite routine use, many endoscopists select generator settings empirically without fully understanding the electrophysical principles that determine tissue effects, procedural efficiency and adverse event risk. Problem Statement Electrosurgical outcomes during endoscopy vary substantially even when identical generator settings are used. Inadequate understanding of factors such as voltage, current density, impedance, waveform modulation and tissue environment may contribute to unpredictable cutting, excessive thermal injury, delayed bleeding or perforation. Summary This clinically oriented review translates the fundamental physics of electrosurgery into practical endoscopic guidance. The authors emphasize that tissue effects are not determined solely by generator settings, but instead result from complex interactions among current density, tissue impedance, electrode geometry, application time and procedural technique. A key principle highlighted is that cutting and coagulation are fundamentally governed by current density and voltage behavior. High current density concentrated over a small tissue area generates rapid intracellular heating and vaporization, producing cutting effects. In contrast, lower-density current with prolonged application promotes protein denaturation, desiccation and coagulation. Thus, identical generator settings may produce very different outcomes depending on snare tension, electrode contact, tissue compression and duration of activation. The review carefully explains waveform modulation, one of the most misunderstood aspects of diathermy. Continuous low-voltage waveforms primarily facilitate cutting, whereas intermittent or pulsed higher-voltage waveforms generate coagulative effects. Modern blended currents dynamically alternate between these properties to balance effective tissue transection with hemostasis. Understanding waveform behavior is particularly important during advanced resections where excessive coagulation may impair dissection planes or increase delayed thermal injury. Another major focus is the influence of tissue environment, particularly the increasingly important distinction between procedures performed in air versus saline immersion. In underwater EMR and saline-assisted procedures, electrical current disperses differently because saline conducts current far more efficiently than air. This alters current density and tissue heating characteristics, meaning electrosurgical effects observed in conventional luminal procedures cannot simply be extrapolated to underwater techniques. The review additionally contrasts monopolar and bipolar electrosurgical systems. Monopolar devices remain dominant in GI endoscopy because of their versatility and cutting efficiency, but bipolar systems may provide more localized current flow and potentially reduced collateral injury in selected settings. Understanding current return pathways is also important for minimizing unintended thermal damage and ensuring safe device application. Importantly, the authors emphasize that electrosurgical safety depends heavily on technique rather than generator selection alone. Factors such as excessive tissue tenting, prolonged activation, inadequate submucosal lift and inappropriate immersion environments can markedly alter thermal spread and complication risk despite apparently correct settings. The review is especially valuable for trainees and general gastroenterologists because it reframes diathermy from a “preset-based” practice into a mechanistically predictable process. Developing conceptual understanding of electrosurgical physics may improve procedural precision, optimize resection quality and reduce complications across the expanding spectrum of therapeutic GI endoscopy. Overall, this review provides a highly practical electrophysical framework for understanding diathermy in gastrointestinal endoscopy and highlights how procedural context, tissue interaction and current behavior collectively determine clinical outcomes beyond generator settings alone.

Sedation Strategy Influences Aspiration Risk After PEG : Frontline Gastroenterol | May 2026

Introduction Percutaneous Endoscopic Gastrostomy is widely performed for long-term enteral nutritional support in patients with neurological disease, dysphagia and chronic debilitating illness. Aspiration pneumonia remains one of the most important early complications following PEG insertion and contributes substantially to post-procedural morbidity and mortality. However, the influence of sedation and local anaesthesia practices on aspiration risk has remained poorly defined at a population level. Problem Statement Considerable variation exists in endoscopic sedation and throat anaesthesia practices during PEG insertion across institutions. Whether specific sedation approaches independently increase post-PEG aspiration pneumonia risk has not previously been evaluated in a large real-world multicentre cohort. Summary This large retrospective population-based study analyzed more than 33,000 adult patients undergoing PEG insertion across England between 2016 and 2021. Investigators integrated Hospital Episode Statistics with National Endoscopy Database provider-level sedation practices to evaluate associations between procedural anaesthesia strategies and aspiration pneumonia occurring within seven days of PEG placement. Substantial variation in sedation practice was observed across providers. Nearly half predominantly used combined midazolam-opioid sedation, while others favored midazolam alone, local anaesthetic throat spray or propofol/general anaesthesia approaches. Stroke represented the most common indication for PEG insertion and was associated with the highest baseline aspiration risk compared with other clinical indications. The strongest associations with post-PEG aspiration pneumonia were observed among providers predominantly using propofol/general anaesthesia and those combining midazolam with local anaesthetic throat spray. In contrast, aspiration risk was substantially lower among providers using midazolam alone or combined with opioids without routine throat spray. These findings suggest that suppression of protective airway reflexes may play a central role in aspiration pathogenesis during PEG procedures. The association with local anaesthetic throat spray is particularly notable because topical pharyngeal anaesthesia may impair laryngeal sensation and cough reflexes in already vulnerable dysphagic patients. Similarly, deeper sedation with propofol or general anaesthesia likely further compromises airway protection and swallowing coordination during and immediately after PEG insertion. Additional procedural and patient-level risk factors included low provider procedural volume, advanced age and emergency hospital admission. Providers performing fewer than 23 PEG procedures annually demonstrated higher aspiration rates, suggesting an important volume-outcome relationship and potential benefit of procedural centralization or enhanced training pathways. Clinically, the findings challenge routine use of aggressive sedation strategies during PEG insertion, particularly in frail neurological populations already predisposed to aspiration. The data support more individualized sedation approaches balancing patient comfort with preservation of airway protective reflexes. Overall, this large national study demonstrates that sedation and local anaesthesia practices substantially influence aspiration pneumonia risk following PEG insertion. The findings have important implications for endoscopy sedation protocols and suggest that minimizing deep sedation and cautious use of local anaesthetic throat spray may improve procedural safety in high-risk PEG populations.

3D-Printed Distal Caps for ESD: Clinical and Translational Gastroenterology | May 2026

Conventional Method Commercial distal attachment caps are routinely used during Endoscopic Submucosal Dissection to improve visualization, tissue traction, and procedural stability. Although effective, these caps are commercially manufactured, relatively costly, and offer limited customization for operator preference or lesion characteristics. Why a New Method Was Required As ESD expands globally, especially into resource-limited settings and training programs, there is growing interest in affordable and customizable accessories. The challenge has been whether low-cost 3D-printed devices can match the safety, efficiency, and ergonomics of standard commercial caps without compromising procedural outcomes. New Method The ENDOPRINT trial evaluated a custom 3D-printed distal cap made from flexible medical-grade resin against a standard commercial Olympus cap in an ex vivo multicenter porcine ESD model. Ninety-nine ESD procedures across centers in Prague, Olomouc, and Boston were randomized between the two devices. The study demonstrated identical median procedure times between both caps, with 100% en bloc resection and technical success rates in both groups. Importantly, operators consistently rated the 3D-printed cap superior for visibility, scope manipulation, and tissue retraction. Adverse events were uncommon and similar between groups. Clinical Utility This study suggests that 3D-printed caps may provide a safe, effective, and substantially lower-cost alternative to commercial ESD caps. The ability to customize cap design could improve ergonomics and procedural flexibility, particularly for training environments and advanced therapeutic endoscopy units. Although the study was ex vivo, the results support future in vivo evaluation and cost-effectiveness studies. If validated clinically, customizable 3D-printed accessories may represent an important step toward more accessible and personalized ESD practice worldwide

Post-ERCP Bleeding Risks Clarified in Large Meta-analysis : Gastrointest Endosc | May 2026

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.

Predictors of Post-ERCP Bleeding Identified in Large Meta-analysis : Gastrointest Endosc | May 2026

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.

International Consensus Defines Best Practices for EUS-Guided Gastroenterostomy : Gastrointestinal Endoscopy | May 2026

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.

EUS-Directed Transenteric ERCP Expands Options in Surgically Altered Anatomy : Gastrointestinal Endoscopy | May 2026

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.

Same-Day Discharge After G-POEM Appears Safe in Selected Patients | Gastrointestinal Endoscopy

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.