Trending Topics in Gastroenterology | GastroAGI

Cold EMR Is Safer Than Hot EMR for Large Colorectal Polyps-Endoscopy Feb.26

Introduction Endoscopic mucosal resection (EMR) is the standard of care for large (≥20 mm), nonpedunculated colorectal polyps. Over the last few years, cold EMR and thermal ablation–assisted EMR have been increasingly adopted, aiming to reduce recurrence and adverse events. However, safety comparisons between these approaches—especially for serious adverse events—have remained limited. This large, multicenter analysis asks a simple but critical question: Which EMR technique is safer for large colorectal polyps—cold or hot? Problem statement Hot EMR has long been the default approach but carries inherent thermal injury risks—bleeding, perforation, and post-procedural pain. Cold EMR avoids cautery, but many endoscopists remain hesitant to use it for large lesions due to concerns about incomplete resection or bleeding. At the same time, adjunctive margin or base ablation has been added to hot EMR to reduce recurrence, raising questions about whether added thermal injury worsens safety. What the study did (plain language) • Secondary analysis of four prospective, multicenter studies • Included nearly 1900 large (≥20 mm) nonpedunculated polyps • Compared: • Cold EMR • Hot EMR without ablation • Hot EMR with margin ablation • Hot EMR with margin + base ablation • Focused specifically on serious adverse events (bleeding, perforation, mortality) Key findings clinicians should remember 1) Cold EMR had the lowest serious adverse event rates Across all outcomes—serious adverse events, bleeding, and perforation—cold EMR consistently showed a safer profile than hot EMR. 2) Perforation and mortality were almost exclusive to hot EMR This is clinically meaningful: the most feared complications clustered with thermal resection, not cold techniques. 3) Thermal ablation did not worsen safety—but didn’t beat cold EMR Hot EMR with margin or margin-plus-base ablation did not increase serious adverse events compared with hot EMR alone. However, even with these refinements, hot EMR remained less safe than cold EMR. 4) Clipping matters in hot EMR When hot EMR was used, prophylactic clipping reduced serious post-EMR bleeding, reinforcing its role in selected cases. Clinical interpretation This study reinforces a growing message in therapeutic colonoscopy: If a large nonpedunculated colorectal polyp can be removed cold, it should be. Cold EMR appears to meaningfully reduce: • serious bleeding, • perforation, • and procedure-related mortality. Hot EMR still has a role—particularly for fibrotic lesions, non-lifting areas, or when en bloc resection is required—but it should no longer be the automatic default. Bottom-line takeaway for practice • Cold EMR = safest option for large nonpedunculated colorectal polyps when technically feasible. • Hot EMR should be reserved for selected cases, with careful use of clipping. • Ablation improves recurrence control but does not eliminate thermal risk. One-line GastroAGI takeaway: Cold EMR significantly reduces serious complications compared with hot EMR for large colorectal polyps.

Even One Pancreatic Duct Cannulation Raises PEP Risk-Endoscopy Feb.25

Introduction Post-ERCP pancreatitis (PEP) remains the most frequent and feared complication of ERCP. We all recognize that repeated pancreatic duct (PD) cannulations increase risk—but in real life, many cases involve just one inadvertent guidewire entry into the PD. Until now, the clinical significance of a single PD cannulation has been debated, and practice varies: some teams escalate prophylaxis immediately, others don’t. This study addresses a practical question every ERCPist faces: Is a single inadvertent PD guidewire cannulation enough to meaningfully increase PEP risk? Problem statement Current thinking often focuses on “multiple cannulations” as the trigger for concern. But the true intraprocedural exposure—how often the PD is entered, how deep, and where the wire goes—has been poorly captured in routine datasets. Key uncertainties: • Does one main PD cannulation matter? • Does location (head vs body vs side branch) change the risk? • Should a single PD cannulation trigger immediate prophylaxis escalation (e.g., PD stent)? What they did (plain language) • Prospective, multicenter study across nine centers (biliary-indication ERCPs). • Real-time, third-party intraprocedural recording of PD wire entries (not just operator recall). • Standard 30-day follow-up for PEP outcomes. • Adjusted analysis accounting for other patient/procedure risk factors and prophylactic measures used. Key findings clinicians should remember 1) A single main PD cannulation is independently linked to PEP The key message: one inadvertent main PD cannulation is not “trivial.” Risk increases with single cannulation and stays similarly elevated with multiple cannulations—meaning the “first hit” may account for much of the risk signal. 2) Where the wire goes matters • Main duct cannulation into the head and body was associated with higher PEP risk. • Side-branch only cannulations did not show a clear association. 3) Clinical implication: prophylaxis should be triggered earlier Because one main PD cannulation already confers meaningful risk, this study supports a proactive stance: • If you inadvertently cannulate the main PD, treat it as a significant event—not a near-miss. Practical “what should I do tomorrow?” When to escalate prophylaxis (based on this study’s signal) • Any inadvertent main PD wire cannulation (even once), especially if it tracks into the head/body → strongly consider PD stent + standard prophylaxis bundle per your protocol. When risk may be lower (but still use judgment) • Side-branch-only cannulation without main duct entry → may not carry the same risk signal, but consider the full clinical context. Conclusion This real-time multicenter dataset suggests that PEP risk starts with the first inadvertent main PD cannulation, and that the classic “multiple cannulations” framework may underestimate risk from a single wire entry. These findings support early use of preventive interventions—particularly PD stenting—when the main pancreatic duct is inadvertently cannulated.

Reusable vs Single-Use Duodenoscopes: The Environmental Cost- Endoscopy Feb.26

Introduction Duodenoscope-related infection outbreaks—largely linked to reprocessing failures—drove the development of single-use duodenoscopes to eliminate cross-contamination risk. The safety argument is compelling. But ERCP already sits in a resource- and waste-heavy environment, and healthcare is increasingly being held accountable for its environmental impact. This study tackles a question many endoscopy leaders are now facing: If we move to disposable duodenoscopes, what is the environmental cost—and is universal single-use sustainable? Problem statement The clinical trade-off is no longer just infection control vs cost. It now includes a third axis: environmental responsibility. Single-use devices are incinerated as biomedical waste, and many are made predominantly from plastics and resins. Until now, we have lacked high-resolution data on: • what these scopes are actually made of, and • where the main carbon burden comes from (manufacturing vs transport vs disposal vs reprocessing). What the study did: A single-center team compared: • one reusable duodenoscope, and • two single-use duodenoscopes from different manufacturers (A and B). They did two things: 1. Material composition testing (what metals and plastics are inside). 2. Life-cycle assessment (LCA): a “cradle-to-grave” carbon footprint estimate covering production, transport, reprocessing (for reusable), and end-of-life disposal (incineration for single-use). They modeled three real-world strategies over the usable lifetime of one reusable scope: • All reusable • All single-use • Reusable with selective single-use (e.g., MDRO colonization/urgent cases) Key findings clinicians should understand 1) Reusable scopes are mostly metal; single-use scopes are mostly plastic Reusable duodenoscopes are largely built from metal alloys (high recyclability). Single-use devices are largely made of plastic polymers/resins (high incineration burden), and composition varies by manufacturer. 2) The major environmental hit for single-use is not transport—it’s disposal Because single-use scopes are biomedical waste, they are typically incinerated, and this step becomes a dominant driver of emissions. 3) Universal single-use creates a very large environmental footprint Across the modeled lifetime of one reusable scope, switching to “all single-use” produced dramatically higher total carbon emissions than staying reusable. 4) “Selective single-use” is a compromise strategy Using single-use scopes only for higher-risk situations (e.g., MDRO colonized patients, urgent cases where reprocessing logistics are limiting) reduces the environmental burden substantially compared with universal single-use—while still targeting the safety benefit where it’s most relevant. 5) Not all single-use scopes are equal The two single-use devices differed in per-scope carbon footprint, driven by differences in materials used. This supports the authors’ call for carbon footprint labeling to enable greener procurement decisions. Clinical interpretation This is not an “anti single-use” paper. It is a systems-level warning: If we default to universal single-use duodenoscopes—especially in high-volume ERCP centers—the environmental cost becomes difficult to justify without strong patient-outcome benefits. A more balanced approach emerges: • Keep reusable as the default, with optimal reprocessing and/or improved designs (e.g., disposable components/endcaps), and • reserve single-use for carefully defined indications where the infection-control advantage is highest. Conclusion Single-use duodenoscopes reduce cross-contamination risk, but universal adoption carries a substantial environmental burden—largely driven by plastic-heavy composition and mandatory incineration. The most realistic path forward is selective use plus better reprocessing and device design, supported by transparent carbon footprint labeling so endoscopy units can make informed, sustainable choices. Optional GastroAGI “Clinician Takeaway” Single-use duodenoscopes improve infection control, but universal adoption is environmentally costly—selective use may be the most responsible compromise.

Polyps ≥10 mm Alone: Low PCCRC Risk at 5 Years- Endoscopy Feb.26

Introduction Post-polypectomy surveillance is one of the biggest drivers of colonoscopy workload worldwide. Current guidelines often label any polyp ≥10 mm as “high risk,” triggering a 3-year surveillance colonoscopy. But many endoscopists have questioned whether size alone—especially for 10–20 mm lesions that are completely resected and lack dysplasia—really carries enough cancer risk to justify early repeat colonoscopy. This study asks a very practical question: Do patients with a ≥10 mm polyp as their only “high-risk” feature actually have a higher post-colonoscopy colorectal cancer (PCCRC) risk than patients with no polyps? Problem statement The “≥10 mm = high risk” rule may be too blunt. It can create: • unnecessary surveillance colonoscopies, • increased cost and patient burden, • and pressure on already stretched endoscopy capacity. Yet, relaxing surveillance must be safe—especially in screening programs. So the key gap is: What is the real PCCRC risk over 5 years when size is the only high-risk feature? What the study did: Using the Dutch FIT-based national screening program data (quality-assured colonoscopies), the authors compared two groups: • People with polyps ≥10 mm but no other high-risk features (no high-grade dysplasia, no dysplastic serrated lesions, no multiple high-risk findings). • People with no polyps at baseline colonoscopy. Because the Dutch guideline at that time recommended 5-year follow-up for a subgroup of these “size-only” patients, the authors could safely examine what happened over a 5-year window. Key results clinicians should remember 1) Cancer risk was low—and not higher than polyp-free patients Over 5 years, people with ≥10 mm polyps as the sole risk feature had a similarly low PCCRC risk compared with people who had no polyps. 2) This matters because it’s a large group Most “high-risk” patients in real life fall into this category where size is the only high-risk feature—especially the 10–20 mm range. 3) Quality of the baseline colonoscopy matters more than polyp size alone A major insight: PCCRC risk was strongly influenced by the endoscopist’s ADR. In other words, the safety of longer intervals depends heavily on performing a high-quality baseline colonoscopy. Clinical interpretation This paper challenges a common habit in surveillance: treating “≥10 mm” as automatically equivalent to “high cancer risk.” It suggests a more nuanced approach may be safe in the right setting—particularly when: • the colonoscopy is high quality (good prep, complete exam), • the lesion is completely resected (especially en bloc), • there is no dysplasia/high-risk histology, and • the endoscopist quality indicators (like ADR) are strong. Practical takeaway for clinicians and endoscopy units If confirmed in other settings, this evidence supports extending surveillance intervals for patients with a 10–20 mm polyp as the only high-risk feature, rather than automatically bringing everyone back in 3 years. This could: • reduce unnecessary procedures, • improve colonoscopy capacity for higher-risk patients, and • align surveillance intensity with actual cancer risk. Conclusion; In a national, quality-assured screening program, patients with ≥10 mm polyps without other high-risk features had PCCRC risk comparable to those with no polyps over a 5-year period. The study strongly suggests that colonoscopy quality and endoscopist performance may be more important than size alone when deciding surveillance intervals—especially for completely resected 10–20 mm lesions.

AI in Endoscopy: ESGE Curriculum for Safe Use- Endoscopy Feb. 26

Introduction Artificial intelligence is rapidly entering routine GI endoscopy—particularly for polyp detection, lesion characterization, and quality assurance. While early studies show improved detection and efficiency, AI also introduces new risks: inappropriate trust, cognitive bias, deskilling, and uncertainty about how and when AI should be used in clinical decision-making. Recognizing this gap, European Society of Gastrointestinal Endoscopy (ESGE) has issued a formal Position Statement defining a structured curriculum for the safe, effective, and responsible use of AI in endoscopy. This document is not about which AI to buy—it is about how clinicians should be trained to use AI properly. ⸻ The core problem AI tools are being deployed faster than training standards can keep up. Key unanswered questions in daily practice include: • Who should be allowed to use AI in endoscopy? • What level of endoscopic skill is required before using AI? • How do we prevent over-reliance on AI? • How do we monitor whether AI improves—or harms—real-world performance? Until now, no formal competency framework existed. ⸻ What ESGE proposes: a 3-phase curriculum 1️⃣ Before adoption (Preadoption phase) • AI is not a shortcut for poor endoscopy Endoscopists must first be competent in standard endoscopic skills (scope handling, lesion visualization, interpretation). • AI literacy is mandatory Clinicians should understand: • what AI can and cannot do, • how algorithms are trained, • where bias and errors may occur. 👉 Message: AI supports good endoscopists—it does not replace fundamentals. ⸻ 2️⃣ Training phase • Hands-on training with approved AI systems is essential. • Education must go beyond buttons and alerts to include: • recognition of automation bias (blind trust in AI), • algorithm aversion (rejecting AI after seeing errors), • anchoring and conservatism bias. 👉 Message: Human–AI interaction is the new technical skill. ⸻ 3️⃣ Independent use & quality assurance • AI must never be used in isolation for clinical decisions. • Key quality indicators (e.g. ADR in colonoscopy) must be monitored: • before AI adoption, • during implementation, and • after routine use. • If performance worsens or unintended effects appear, AI de-implementation should be considered. 👉 Message: AI use must be auditable, reversible, and accountable. ⸻ What this means for clinicians • AI is an assistant, not an authority. • Final responsibility always remains with the endoscopist. • Safe AI use requires: • baseline endoscopic competence, • structured education, • awareness of cognitive traps, • continuous performance monitoring. This position statement reframes AI from a device issue to a professional competency issue. ⸻ Bottom-line takeaway for GastroAGI ESGE makes it clear: the success of AI in endoscopy depends less on algorithms and more on how clinicians are trained to use them. AI can improve quality—but only when embedded within a structured curriculum that prioritizes skills, judgment, and accountability.

Regenerative Endoscopy for Refractory GI Wall Defects- Endoscopy Feb.26

Introduction Gastrointestinal wall defects—such as leaks, fistulas, and chronic perforations—remain among the most frustrating complications in GI practice. Even with modern tools (clips, suturing, stents, vacuum therapy), chronic defects with inflamed, fibrotic, retracted margins often refuse to close. Many patients end up in prolonged hospital courses, repeated procedures, or high-risk surgery. This pilot trial explores a different strategy: rather than forcing closure mechanically, can we biologically “reboot” healing by injecting a regenerative cell-rich product directly into the defect margins? Problem statement When a defect becomes chronic, the tissue is no longer “fresh wound biology.” The margins become stiff and fibrotic, blood supply is poor, and standard endoscopic closure often fails even if the edges are approximated. The unmet need is a therapy that: • revitalizes scarred tissue, • supports angiogenesis and mucosal regeneration, and • can be delivered endoscopically, with low added risk and reasonable cost. This study evaluates tSVFem (stromal vascular fraction obtained from the patient’s own adipose tissue via mechanical processing) injected endoscopically into the defect border to promote regeneration. What they did (in plain language) • Single-center pilot: 30 consecutive patients with difficult defects after conventional options failed or were not possible. • 15 esophageal defects and 15 rectal defects. • Under the same session, they harvested a small amount of patient’s hip fat, mechanically processed it (filters + centrifugation), and then injected 1–2 mL into the four quadrants of the defect margins using a standard injection needle. • For larger defects (≥5 mm), they sometimes used endoscopic suturing to approximate margins, then injected the regenerative product. Primary endpoint: complete defect closure on endoscopic/radiologic follow-up. Also tracked: number of sessions, complications, recurrence. Key results clinicians will care about 1) Esophageal defects responded extremely well Most esophageal defects closed—often after a single session—and nearly all closed after a second session. Importantly, closure was described as being covered by new vascularized mucosa, suggesting true regenerative healing rather than a fragile seal. 2) Rectal defects improved, but closure was harder Rectal defects had a more modest overall closure rate, often requiring repeat sessions (sometimes 3–4 treatments). This is clinically intuitive: rectal fistulas/defects are exposed to contamination, pressure dynamics, and complex tract biology. 3) Defects communicating with urinary tract were tougher Rectal defects involving the urinary system closed less reliably than those communicating with other organs—likely reflecting ongoing inflammation from bacterial colonization, pH differences, and pressure gradients. 4) Safety signal was excellent in this pilot No intraprocedural or postprocedural adverse events were reported, and there was no recurrence within the short follow-up window. What this means in practice This is an early—but highly intriguing—proof-of-concept that regenerative endoscopy is feasible. The technique is attractive because it is: • Autologous (no rejection risk) • Minimally manipulated mechanically (important for real-world regulatory feasibility) • Endoscopically simple (injection needle rather than complex devices) • Potentially cost-aware compared with repeated advanced closure devices—though repeated sessions can add cost and logistics. Clinical takeaway For refractory esophageal defects, tSVFem injection looks particularly promising as a “tissue rescue” strategy. For rectal defects (especially urinary-tract communication), results are encouraging but incomplete—suggesting the need for: • protocol refinement, • better patient/defect selection, and • possibly combination strategies (e.g., scaffolds, repeated biologic dosing, improved tract control). Conclusion Endoscopic injection of autologous, mechanically processed adipose-derived stromal vascular fraction represents a new regenerative tool for complex GI defects—especially in the esophagus—where conventional endoscopic closure is frequently ineffective once fibrosis dominates. Larger controlled studies are now needed to define who benefits most, how many sessions are optimal, and how this approach compares with established endoscopic closure pathways.

CADe in endoscopy - Endoscopy Feb. 26

Introduction Colonoscopy quality is often judged by the adenoma detection rate (ADR), because better detection is linked to lower risk of future colorectal cancer. AI-based computer-aided detection (CADe) systems reliably increase ADR in the short term. But many clinicians have a practical concern: if endoscopists start depending on AI, will their “native” detection skills worsen when AI is not used? In other words—does CADe cause deskilling over time? Problem statement Most CADe studies show an immediate ADR benefit, but they are usually short-duration trials and rarely address what happens months to years later in real-world practice. The unanswered question is: After CADe is implemented, do endoscopists maintain their performance in standard (non-CADe) colonoscopy, or does performance drift downward because AI is doing the “thinking”? This study specifically examined whether CADe leads to skill transfer (endoscopists learn and improve even without AI) or deskilling (performance drops without AI). What the study did: • Single-center, prospective, real-world study over 3 years (2021–2023). • CADe was installed in half of the colonoscopy rooms, and patients were distributed across CADe vs non-CADe rooms as part of routine workflow. • Endoscopists were grouped based on their baseline detection performance: • High detectors (already meeting quality benchmark) • Low detectors (below benchmark) • The key focus: How detection performance changed over time, both with CADe and without CADe, to see if skills improved or deteriorated. Key findings clinicians should know 1. CADe improved detection when it was used Across both strong and weaker detectors, AI support increased the ability to find adenomas and polyps—especially subtle lesions. 2. No evidence of deskilling in non-CADe colonoscopy The most clinically important finding: once CADe was introduced, performance in standard colonoscopy did not fall over time. In other words, using CADe did not make endoscopists worse when they scoped without AI. 3. High detectors showed meaningful skill transfer High-performing endoscopists not only benefited during CADe use, but also appeared to internalize improvements—their non-CADe performance stayed strong and in some analyses improved over time. 4. Low detectors improved with AI—but showed limited learning without AI Low detectors clearly benefited when CADe was on, but their unassisted learning curve did not show the same degree of sustained improvement. This suggests CADe helps them “in the moment,” but may not automatically translate into durable skill gains without additional training support. 5. CADe particularly helps with subtle lesions Detection gains were strongest for lesions that are easier to miss—such as flat lesions and sessile serrated lesions—supporting CADe as a quality-enhancing tool, not just a “polyp counter.” Practical conclusion for clinicians CADe can be implemented without fear of deskilling. Over 3 years of real-world use, endoscopists did not lose their baseline detection ability in standard colonoscopy. However, the study also suggests a key implementation lesson: • High detectors may naturally translate AI support into lasting skill improvement. • Low detectors may need structured feedback/training (beyond simply turning on AI) to convert CADe assistance into sustained independent performance. What this means for your practice / unit • If your unit is considering CADe, this study is reassuring: AI support does not appear to erode core skills. • CADe can be positioned not only as a detection aid but as a quality framework tool, especially for improving detection of subtle lesions. • For training programs: CADe should ideally be paired with targeted coaching, particularly for low detectors, to ensure long-term uplift even without AI. One-line GastroAGI “Clinical Takeaway” CADe boosts detection and—importantly—does not cause long-term deskilling; performance in non-CADe colonoscopy is maintained over time.

Colonoscopy-Related Adverse Events in the 21st Century - AJG 2026

The global incidence of colonoscopy-related adverse events (AEs) was analysed through a comprehensive meta-analysis of 82 population-based studies involving 38.5 million colonoscopies across 24 countries. The study categorised AEs into gastrointestinal and nongastrointestinal events. Gastrointestinal AEs included perforation (5.15 per 10,000 procedures), bleeding (18.39 per 10,000), and splenic injury (0.61 per 10,000). Nongastrointestinal AEs included cardiovascular events (52.11 per 10,000), respiratory events (4.26 per 10,000), and deaths (0.18 per 10,000). Despite the low overall risk, the findings emphasise the need for ongoing efforts to improve the safety of colonoscopy procedures. Subgroup analyses revealed some variability based on factors such as study design, region, and sample size. Most studies included in the analysis demonstrated a low to moderate risk of bias.

ESD – does techniques matter?(Endoscopy, Jan-2026)

Yes, techniques for Endoscopic Submucosal Dissection (ESD) matter significantly, as different techniques demonstrate varying advantages and outcomes depending on the clinical scenario. Based on the synthesized evidence from 18 randomized controlled trials (RCTs) involving 2,677 patients, three major techniques for ESD were compared: 1. **Tunnel/Pocket Method (Tu-ESD)** 2. **Traction Method (Tr-ESD)** 3. **Conventional Method (C-ESD)** ### Key Findings: - **Tu-ESD** achieved the highest ranking for **curative resection** (score 92.1) and was best for minimizing adverse events. - **Tr-ESD** ranked highest for **reducing procedure time** (score 100) and demonstrated significant reductions in procedure time compared with C-ESD (mean difference: –18.74 minutes). - Subgroup analyses by colorectal, gastric, and esophageal locations showed that: - **Tr-ESD** was superior for en bloc resection and procedure time. - **Tu-ESD** was best for curative resection and minimizing adverse events. ### Conclusion: Both Tu-ESD and Tr-ESD were found to be effective and safe compared to the conventional method (C-ESD). Given that different techniques offer distinct advantages, the choice of ESD technique should be tailored to the specific clinical scenario, lesion location, and procedural goals. This highlights the importance of selecting the appropriate method to optimize outcomes in ESD procedures.

TOF and endoscopic Occluders(Endoscopy, Jan-2026)

Tracheoesophageal fistulas (TOF) or gastrointestinal (GI)–tracheobronchial fistulas are abnormal connections between the trachea and the esophagus or GI tract. These conditions are often challenging to manage, especially when refractory to conventional treatments. Endoscopic occluders represent a minimally invasive therapeutic option for such fistulas, and recent studies have compared the efficacy and safety of different occluder designs. For example, in a retrospective cohort study, two novel occluders were evaluated: the double umbrella-shaped (DU) occluder and the mushroom umbrella-shaped (MU) occluder. The MU occluder demonstrated superior outcomes in terms of sustained occlusion, with a 12-month cumulative sustained occlusion probability of 82.1% compared to 65.5% for the DU occluder. Additionally, the MU occluder had fewer complications, such as esophageal wall injuries, which were observed in the DU group. Both occluders achieved 100% technical success rates, and adverse events were mild in both groups. The results suggest that the MU occluder may be a more effective and safer option for managing refractory GI–tracheobronchial fistulas. However, further prospective studies are necessary to validate these findings and optimize treatment protocols.