Trending Topics in Gastroenterology | GastroAGI

Routine Esophagram After POEM: Clinical Insight | Inspired by Expert Commentary

Introduction Routine esophagram after POEM has long been considered a safety checkpoint to rule out leaks before resuming oral intake. However, with improved procedural techniques and safety, its real-world value is increasingly being questioned. Clinical Insight Recent evidence suggests that clinically significant leaks after POEM are rare and almost always symptomatic. This raises an important question: 👉 Are we performing routine imaging out of habit rather than necessity? Routine esophagram: Adds radiation exposure Increases cost May delay diet advancement and discharge Often detects findings that are clinically insignificant Importantly, most actionable complications would be identified clinically, not radiologically. Key Message Routine esophagram has a low diagnostic yield in asymptomatic patients Clinical symptoms remain the most reliable trigger for intervention A selective, symptom-driven approach is likely more rational Conclusion In the modern POEM era, postoperative care should evolve from protocol-driven to patient-driven decision-making. Routine esophagram may no longer be necessary in all patients, and selective use could improve efficiency without compromising safety.

Post-Banding Ulcer Bleeding: Alime Pharmaco & Therap | March 2026

Introduction Endoscopic band ligation (EBL) remains the standard of care for managing oesophagal varices, both in acute variceal bleeding and for prophylaxis. However, post-banding ulcer bleeding (PBUB) is an important and often under-recognised complication, associated with significant morbidity and mortality. Identifying patients at higher risk for PBUB is clinically relevant, particularly in acute settings where outcomes are already compromised. Problem Statement Despite increasing recognition of PBUB, risk stratification remains inconsistent in clinical practice. Recent data have suggested that urgent EBL and renal dysfunction may increase PBUB risk, but real-world validation across larger cohorts is limited, and standardised definitions are lacking. Summary In this large real-world analysis of 920 EBL procedures, PBUB occurred in 3.4% overall, with a significantly higher incidence following urgent EBL compared to elective procedures (7.5% vs 1.4%). Urgent EBL emerged as a strong independent predictor of PBUB, reinforcing the vulnerability of patients undergoing intervention during acute bleeding episodes. Additionally, renal dysfunction was identified as a key risk factor, with patients having serum creatinine ≥1.5 mg/dL demonstrating markedly higher bleeding rates and an independent risk. These findings are consistent with prior literature and highlight a simple, clinically applicable framework combining urgency of EBL and renal function to identify high-risk patients. This approach may help guide closer monitoring and preventive strategies in routine practice.

Endoscopic Palliation in Pancreatic Cancer: AMJ, March 2026

This article reviews the endoscopic approach to palliation in pancreatic cancer, emphasising that most patients present with unresectable or metastatic disease, so symptom control becomes central to care. Because of the pancreas’ location, tumour growth commonly leads to biliary obstruction, gastric outlet obstruction (GOO), and pain from neural invasion. A major focus is the management of malignant biliary obstruction, which occurs in a large proportion of patients and can cause jaundice, pruritus, nausea, malabsorption, cholangitis, and delay in chemotherapy. The article highlights that biliary decompression is now commonly achieved using endoscopic or percutaneous techniques rather than surgery. The main drainage strategies: ERCP with placement of a plastic stent or self-expandable metal stent (SEMS) directly across the obstructed common bile duct. EUS-guided rendezvous technique, where a guidewire is passed into the bile duct and through the papilla to facilitate ERCP. EUS-guided biliary drainage (EUS-BD), which creates a new tract for bile drainage above the obstruction. EUS-HGS (hepaticogastrostomy), where a biliary SEMS drains the left intrahepatic duct into the stomach. EUS-CDS (choledochoduodenostomy), where a biliary SEMS or lumen-apposing metal stent drains the common bile duct into the duodenum. EUS-GBD (gallbladder drainage), where a lumen-apposing metal stent drains the gallbladder into the stomach or duodenum. Percutaneous transhepatic biliary drainage (PTBD) as an external/internal catheter-based option. The article also notes increasing use of preemptive biliary drainage when EUS-guided tissue diagnosis shows impending obstruction. Overall, the message is that endoscopic palliation has largely replaced surgical palliation, offering effective, less invasive relief of major pancreatic cancer complications.

G-POEM in Severe Refractory Gastroparesis: Gut March 2026

Introduction Gastroparesis is a chronic disorder characterised by delayed gastric emptying without mechanical obstruction, leading to symptoms such as nausea, vomiting, early satiety, bloating, and postprandial fullness. Treatment options for severe and refractory gastroparesis are limited and often ineffective. Gastric per-oral endoscopic pyloromyotomy (G-POEM) is a minimally invasive endoscopic technique that divides pyloric muscle fibres to improve gastric emptying. Although observational studies have shown promising results, high-quality randomised evidence has been limited. Summary This randomised sham-controlled pilot trial evaluated the efficacy of G-POEM in severe gastroparesis. A total of 41 patients with refractory gastroparesis (diabetic, postsurgical, or idiopathic) were randomised to G-POEM (n=21) or sham procedure (n=20). The primary endpoint was treatment success, defined as a ≥50% reduction in the Gastroparesis Cardinal Symptom Index (GCSI) at 6 months. Key findings: Treatment success: 71% with G-POEM vs 22% with sham (p = 0.005) By aetiology: Diabetic gastroparesis: 89% response Postsurgical gastroparesis: 50% response Idiopathic gastroparesis: 67% response Gastric emptying: Median 4-hour gastric retention improved from 22% to 12% after G-POEM, No significant change after sham. Crossover results: Among 12 sham patients crossing over to G-POEM, 75% achieved symptom improvement. Clinical Takeaway This sham-controlled randomised trial demonstrates that G-POEM significantly improves symptoms and gastric emptying in severe refractory gastroparesis, particularly in diabetic cases. However, results remain less conclusive in idiopathic and postsurgical gastroparesis, and larger trials are required to confirm long-term benefits.

Colon Capsule Endoscopy vs Conventional Colonoscopy After Diverticulitis- Endoscopy | March 2026. DOI: 10.1055/a-2695-6904

Introduction After CT-confirmed diverticulitis, follow-up colonoscopy is routinely performed to exclude malignancy. Colon capsule endoscopy (CCE) offers a non-invasive alternative, but its impact on patient experience remains unclear. Summary In this randomized controlled trial of 159 patients, CCE was compared with colonoscopy 4–6 weeks after diverticulitis. Patients expected colonoscopy to cause greater discomfort; however, experienced physical and mental discomfort did not differ significantly between groups. Examination completion was slightly higher with colonoscopy (92%) than CCE (84%). No malignancies were detected. Nearly half of patients preferred CCE for future evaluation. The study shows that CCE is safe and patient-preferred, though colonoscopy remains diagnostically more complete.

METARSI Trial: Endoscopy International Open, Feb.26

The METARSI trial is a prospective, multicenter randomised controlled study comparing partially covered self-expanding metal stents (PC-SEMS) versus uncovered SEMS (U-SEMS) in patients with malignant unresectable distal biliary obstruction (DBO) undergoing ERCP. A total of 261 patients were randomised (130 PC-SEMS, 131 U-SEMS) with a 12-month follow-up. Most strictures were secondary to pancreatic adenocarcinoma (75%), and nearly half had metastatic disease. Key findings: Stent dysfunction rates were similar between groups (11% PC-SEMS vs 14% U-SEMS; P = 0.70). Overall survival did not differ significantly (median ~108 vs 100 days). Kaplan–Meier analysis showed comparable stent patency. A non-significant trend toward more procedure-related complications was observed in the partially covered group (2% vs 7%). Clinical Interpretation: There was no clear superiority of partially covered stents over uncovered stents in terms of dysfunction, survival, or patency. Given similar outcomes and potential migration risks associated with covered designs, stent selection should remain individualised based on anatomy, tumour characteristics, and operator experience. Takeaway: In malignant distal biliary obstruction, both PC-SEMS and U-SEMS perform comparably—routine preference for partially covered stents is not supported by this randomised evidence.

EUS-Directed Transgastric ERCP (EDGE) in RYGB: GIE, Feb.26

Endoscopic ultrasound–directed transgastric ERCP (EDGE) has emerged as a transformative technique for managing biliary and pancreatic diseases in patients with Roux-en-Y gastric bypass (RYGB) anatomy. Traditional ERCP is technically challenging in RYGB due to altered anatomy, often requiring enteroscopy-assisted ERCP or laparoscopic-assisted ERCP—both limited by lower success rates or higher invasiveness. EDGE overcomes these barriers by creating a temporary gastrogastric or jejunogastric fistula using a lumen-apposing metal stent under EUS guidance, enabling access to the excluded stomach and standard duodenoscope-assisted ERCP. Reported technical and clinical success rates exceed 90%, with shorter procedure times and high therapeutic efficacy. Adverse events include stent migration, bleeding, and persistent fistula, though most are manageable. Compared to surgical or enteroscopy-based approaches, EDGE offers a minimally invasive, highly effective alternative and is increasingly considered first-line in expert centres for RYGB patients requiring ERCP.

Linaclotide Administration plus PEG for Colonoscopy Bowel Preparation- AJG Feb.26

High-volume polyethene glycol (PEG) solutions remain a major barrier to successful colonoscopy bowel preparation because of poor tolerability. Linaclotide, a guanylate cyclase-C agonist that increases intestinal secretion and transit, has been explored as an adjunct to bowel preparation, but the optimal dose and timing have been uncertain. This large, multicenter randomised trial evaluated whether short-term linaclotide pretreatment could safely allow a reduction in PEG volume without compromising bowel cleanliness. Adults undergoing screening or diagnostic colonoscopy were assigned to one of three strategies: standard high-volume PEG alone, linaclotide combined with high-volume PEG, or linaclotide combined with reduced-volume PEG. The key finding was that three days of linaclotide combined with a lower PEG volume achieved bowel preparation quality comparable to standard regimens. Importantly, this lower-volume strategy did not negatively affect clinically relevant colonoscopy outcomes, including polyp detection, adenoma detection, or completion of bowel preparation. From a tolerability standpoint, the reduced-volume PEG plus linaclotide regimen was associated with fewer adverse gastrointestinal symptoms compared with the higher-volume combination regimen. This suggests a potential patient-centred advantage, particularly for individuals who struggle with large-volume preparations. Overall, this study supports a practical and patient-friendly bowel preparation strategy in average-risk individuals: short-term linaclotide pretreatment allows PEG volume reduction while maintaining preparation effectiveness and safety. If confirmed in broader populations, this approach could improve patient adherence, comfort, and willingness to undergo colonoscopy without sacrificing diagnostic quality.

SOCCER Trial: Forceps Boost Cannulation Success in Difficult ERCP- AJG Feb.26

Introduction Difficult biliary cannulation remains one of the most common and consequential problems in ERCP. Failed cannulation drives repeat procedures, percutaneous or surgical rescue, higher costs, longer hospital stay—and it also increases post-ERCP pancreatitis (PEP) risk because repeated attempts and unintended pancreatic duct (PD) wire passes are key triggers. Forceps-assisted cannulation has been used as a “trick” in challenging papillae (periampullary diverticulum, redundant folds, awkward papilla orientation), but until now it lacked randomized controlled trial evidence. The SOCCER trial tests a simple question: Does forceps-assisted cannulation improve success when cannulation is difficult? Problem statement When cannulation becomes difficult, endoscopists typically escalate to: double-wire techniques, precut/needle-knife access, PD stenting strategies, etc. These can be effective but may increase complexity and sometimes risk. A low-cost mechanical approach—using forceps to expose and stabilize the papilla—could reduce failure and potentially reduce repeated traumatic attempts. But its true efficacy needed an RCT. What the trial did: Randomized adults with difficult cannulation scenarios during ERCP to: forceps-assisted cannulation, or standard cannulation without forceps “Difficult” included: papilla in/on a diverticulum, redundant tissue overlying the papilla, challenging papilla morphology (type 2–4), or difficult cannulation defined by attempts/time/unintended PD wire passages. Primary outcome: successful cannulation Secondary: difficult cannulation metrics after randomisation and PEP Key results clinicians should remember 1) Cannulation success improved substantially with forceps Forceps assistance achieved near-universal cannulation success in this difficult subset, while standard cannulation had a meaningful failure rate. 2) Crossover to forceps rescued failures All patients who failed initial standard cannulation and then crossed over to forceps were successfully cannulated—suggesting forceps is a reliable rescue option. 3) Forceps reduced the “trauma load” of cannulation Even when overall difficult-cannulation rates didn’t reach statistical significance, the forceps approach resulted in fewer cannulation attempts, which is clinically important because attempts correlate with PEP risk. 4) PEP rates were low and similar in both groups This suggests the technique improves access without adding measurable pancreatitis risk in this trial setting. Clinical interpretation: where this fits tomorrow This trial supports forceps-assisted cannulation as a practical, low-cost, low-complexity tool in ERCP—especially when the papilla is hard to expose or stabilize. Best-use scenarios periampullary diverticulum (papilla in/on rim) redundant folds/tissue obscuring papilla small/protruding/creased papilla configurations (type 2–4) early difficult cannulation where you want to avoid escalating to higher-risk access What it does not replace precut access when anatomy/duct orientation truly prevents standard entry prophylaxis strategies (rectal NSAID, PD stent when indicated) thoughtful escalation algorithms Bottom-line takeaway for GastroAGI In difficult ERCP cannulation, forceps assistance significantly improves cannulation success and reduces repeated attempts, without a signal for increased PEP. The SOCCER RCT moves forceps-assisted cannulation from “expert trick” to evidence-supported technique. One-line GastroAGI takeaway When cannulation gets difficult, forceps assistance can turn failures into successes.

Robot-Assisted Gastric ESD Is Feasible and Safe-Endoscopy Feb.26

Introduction Endoscopic submucosal dissection (ESD) is the preferred curative treatment for early gastric cancer, but it remains technically demanding, largely because of poor traction and limited visualization during submucosal dissection. Multiple traction techniques have been proposed, yet most are either unstable, operator-dependent, or interrupt workflow. Robotic assistance—particularly flexible traction robots—has shown promise in animal models by providing stable, adjustable, and continuous traction. Until now, however, clinical data in humans were lacking. This pilot randomized trial represents the first real-world clinical evaluation of a traction robot–assisted ESD system for early gastric cancer. Problem statement The main challenges in gastric ESD are: • maintaining optimal traction throughout dissection, • avoiding muscularis propria injury, • and reducing technical difficulty without compromising oncologic outcomes. Whether robotic traction can improve safety or procedure efficiency in actual patients—beyond experimental models—has been unknown. What the study did: • Prospective, single-blind, randomized pilot trial • Patients with high-grade intraepithelial neoplasia or intramucosal gastric cancer • Randomized to: • Robot-assisted ESD (flexible single-arm traction robot), or • Conventional ESD • Performed in a tertiary referral center by experienced endoscopists Primary focus: procedure feasibility and safety, with procedure time as the main endpoint. Key findings clinicians should remember 1) Robot-assisted gastric ESD is feasible and safe All procedures were completed successfully, with no perforations in either group. This is the most important first signal for any new ESD technology. 2) Oncologic outcomes were equivalent • En bloc resection and R0 resection rates were similar between robotic and conventional ESD. 👉 This confirms that robotic assistance does not compromise curative intent. 3) Fewer muscular injuries with robotic traction Robot-assisted ESD significantly reduced muscularis propria injuries, suggesting: • better traction control, • more stable dissection planes, • and potentially lower risk of delayed complications. 4) No clear reduction in overall procedure time—yet Overall procedure time was not significantly shorter with robotic assistance. However, a learning-curve signal was evident: in later cases, robot-assisted ESD times trended shorter than conventional ESD. 👉 This suggests the true efficiency benefit may emerge after familiarization, not in early pilot experience. Clinical interpretation This study should be viewed as a proof-of-concept, not a practice-changing trial. Key messages for endoscopists: • Robotic traction works in real patients. • It appears to improve safety margins by reducing muscular injury. • It does not slow down ESD once operators gain experience. • Oncologic quality is preserved. The absence of clear time savings is expected in a pilot randomized trial and should not be overinterpreted. Bottom-line takeaway Traction robot–assisted gastric ESD is clinically feasible, safe, and oncologically sound, with early signals of improved procedural safety. Larger trials are now needed to determine whether robotic traction can meaningfully reduce complications, shorten learning curves, or expand access to high-quality ESD. One-line GastroAGI takeaway Robotic traction can safely assist gastric ESD and may reduce muscular injury without compromising resection quality.