Trending Topics in Gastroenterology | GastroAGI

EUS, TIPS and Cavernous Transformation of the Portal Vein

EUS (Endoscopic Ultrasound), TIPS (Transjugular Intrahepatic Portosystemic Shunt), and Cavernous Transformation of the Portal Vein (CTPV) are interconnected concepts in the management of portal hypertension and its complications, particularly in patients with liver cirrhosis and CTPV. Here's a detailed explanation of these terms and their relationship: ### 1. **Cavernous Transformation of the Portal Vein (CTPV):** - CTPV refers to a condition where the portal vein becomes blocked or thrombosed (due to conditions such as portal vein thrombosis), leading to the formation of a network of collateral veins around the obstructed portal vein. These collateral veins attempt to bypass the blockage to maintain blood flow to the liver. - This condition often arises in patients with liver cirrhosis, portal hypertension, or hypercoagulable states. - CTPV poses significant clinical challenges, including: - **Recurrent variceal hemorrhage** (bleeding from enlarged veins in the esophagus or stomach). - **Ascites** (accumulation of fluid in the abdominal cavity). - Increased risk of complications due to the altered portal venous anatomy. ### 2. **TIPS (Transjugular Intrahepatic Portosystemic Shunt):** - TIPS is a minimally invasive procedure used to treat complications of portal hypertension, such as variceal bleeding and refractory ascites. - The procedure involves creating a shunt (connection) between the portal vein and a hepatic vein within the liver using a stent. This reduces portal vein pressure by allowing blood to bypass the liver and flow directly into the systemic circulation. - **Challenges in CTPV:** - In patients with CTPV, the portal vein is thrombosed or replaced by a network of collateral veins, making it technically difficult to perform TIPS. - The success rate of TIPS in patients with a patent portal vein is high (over 95%), but it drops to 60-70% in patients with CTPV due to the altered anatomy and difficulty in locating the portal vein. ### 3. **EUS (Endoscopic Ultrasound):** - EUS is a diagnostic and therapeutic tool that uses ultrasound imaging via an endoscope inserted into the gastrointestinal tract. It provides high-resolution images of structures adjacent to the GI tract, including the portal vein. - **Role in TIPS for CTPV:** - EUS can be used to guide the localization of the portal vein in patients with CTPV. This is particularly important because traditional TIPS relies on indirect navigation and blind needle puncture, which carries a high risk of complications like intra-abdominal hemorrhage. - In the study mentioned, EUS was used to locate the portal vein and mark it with a metallic coil. This coil served as a direct target for TIPS puncture, significantly improving the accuracy and safety of the procedure. ### 4. **EUS-TIPS Hybrid Approach:** - The integration of EUS-guided portal vein localization with TIPS represents a novel and innovative approach to managing CTPV. - **Key Findings from the Study:** - The study demonstrated the technical success and safety of combining EUS with TIPS in a cohort of 10 patients with liver cirrhosis and CTPV. - All patients successfully underwent the procedure without EUS-related adverse events. - During follow-up, no patients experienced recurrent variceal hemorrhage or ascites, although 30% of patients developed overt hepatic encephalopathy (a known complication of TIPS). - This hybrid approach addresses the limitations of traditional TIPS in CTPV and offers a safer and more effective alternative for these high-risk patients. ### 5. **Conclusion:** - The combination of EUS and TIPS represents a paradigm shift in the management of CTPV, providing a more precise and safer method for treating complications of portal hypertension in patients with altered portal venous anatomy. - This novel approach has the potential to improve clinical outcomes and expand the applicability of TIPS in challenging cases like CTPV.

REACT for colorectal ESD

REACT, which stands for Repositionable Elastic Adaptive Customizable Traction, is an innovative traction method designed to assist in Endoscopic Submucosal Dissection (ESD) for colorectal lesions. ESD is a minimally invasive procedure used to remove complex gastrointestinal lesions, including those in the colon and rectum, while preserving surrounding healthy tissue. However, conventional ESD can be challenging due to issues like poor visibility of the submucosal layer, difficulty in maneuvering instruments, and the need for precise dissection. ### What is REACT-Assisted ESD? REACT-assisted ESD employs orthodontic elastic bands to provide traction during the procedure. These elastic bands are customizable, repositionable, and adaptable, making them highly versatile for different lesion morphologies and locations. The REACT method allows the operator to create multipoint traction, which improves visualization of the submucosal layer and facilitates dissection. ### How REACT Works: 1. **Elastic Bands**: Orthodontic elastic bands are attached to the lesion and the endoscope to create tension. This tension lifts the lesion and exposes the submucosal layer for easier access. 2. **Customizable Setup**: The traction setup can be adjusted and repositioned during the procedure to adapt to the changing needs of the dissection process. 3. **Multipoint Traction**: Multiple bands can be used to provide traction from various angles, enhancing visibility and precision. ### Advantages of REACT-Assisted ESD Compared to Conventional ESD: 1. **Improved Submucosal Access**: REACT provides better exposure of the submucosal layer, which is crucial for safe and efficient dissection. This reduces the risk of incomplete resection or damage to surrounding tissues. 2. **Adaptability**: Unlike conventional methods, REACT can be repositioned during the procedure, allowing the operator to adapt to the lesion's morphology and location as dissection progresses. 3. **Cost-Effective**: The use of orthodontic elastic bands makes REACT a low-cost solution compared to other traction methods or advanced equipment. 4. **Reduced Technical Challenges**: By improving visibility and access, REACT minimizes the technical challenges associated with conventional ESD, which often relies solely on the operator's skill without additional traction assistance. 5. **Enhanced Precision**: Multipoint traction allows for more precise dissection, reducing the likelihood of complications such as perforation or incomplete resection. 6. **Feasibility Across Lesion Types**: REACT's customizable nature makes it applicable to a wide range of colorectal lesions, regardless of their size, shape, or location. ### Summary: REACT-assisted ESD represents a significant advancement in endoscopic techniques for colorectal lesions. By addressing the limitations of conventional ESD, such as poor visibility and difficulty in maneuvering, REACT improves the safety, efficiency, and outcomes of the procedure. Its adaptability and cost-effectiveness make it a promising option for widespread clinical use, pending further validation in multicenter studies.

ESD for upper esophageal cancer

Endoscopic submucosal dissection (ESD) is increasingly recognized as an effective and minimally invasive treatment option for superficial esophageal squamous neoplasms (ESN), including early-stage esophageal cancer. This technique is particularly suitable for treating superficial lesions confined to the mucosal or submucosal layers of the esophagus, as it allows for precise removal of the tumor while preserving the surrounding esophageal tissue. The procedure involves the use of specialized endoscopic tools to dissect and remove the cancerous lesion en bloc (in one piece), which ensures complete removal and allows for accurate pathological assessment. ESD is recommended as the standard of care for early esophageal squamous cell carcinoma (ESCC) when the lesion meets specific criteria for curative resection, such as limited depth of invasion, absence of lymphovascular invasion, and no evidence of lymph node metastasis. Key benefits of ESD for upper esophageal cancer include high rates of complete tumor removal (en bloc and R0 resection), low recurrence rates in curative resections, and the ability to preserve the esophagus, thereby avoiding more invasive surgical procedures like esophagectomy. However, patient selection is critical to ensure optimal outcomes, as deeper or more advanced lesions may require additional treatments such as surgery or chemoradiotherapy. The safety profile of ESD is generally favorable, with a low risk of complications such as bleeding or perforation, though these risks increase with larger or more complex lesions. In the Western world, data on ESD for esophageal cancer is still emerging, but studies indicate that it is a viable and effective treatment option, with outcomes comparable to those reported in Asian countries where the procedure is more established. In summary, ESD represents a safe and effective approach for the treatment of upper esophageal cancer, particularly for superficial lesions. It offers the advantages of organ preservation, accurate pathological assessment, and low recurrence rates, making it a preferred option for carefully selected patients with early-stage esophageal cancer. However, long-term follow-up and multidisciplinary care are essential to monitor for recurrence or progression, especially in cases where curative resection criteria are not met.

Endoscopic Gastroplasty and weight loss

Endoscopic Gastroplasty (EG) is a minimally invasive procedure designed to help manage obesity by reducing the size of the stomach without requiring traditional surgical methods. It is classified as an Endoscopic Bariatric Therapy (EBT), which serves as an alternative to more invasive bariatric surgeries like gastric bypass or sleeve gastrectomy. EG is performed using advanced endoscopic tools that allow the reshaping and suturing of the stomach from within, thereby limiting its capacity and promoting early satiety. ### Techniques of Endoscopic Gastroplasty There are three primary techniques for performing Endoscopic Gastroplasty: 1. **Endoscopic Sleeve Gastroplasty (ESG):** This technique uses the Apollo Overstitch Sx device (Boston Scientific) to place sutures along the stomach, creating a sleeve-like structure that reduces its volume. 2. **Endoluminal Vertical Gastroplasty (EVG):** This method employs the Endomina system (EndoTools Therapeutics) to perform vertical suturing inside the stomach for size reduction. 3. **Primary Obesity Surgery Endoluminal-2 (POSE-2):** Using the Incisionless Operating Platform (USGI Medical), this technique involves placing anchors or sutures to reduce stomach volume and alter its shape. ### Effectiveness of Endoscopic Gastroplasty A clinical study conducted between April 2021 and May 2023 evaluated the outcomes of these three techniques on weight loss among 184 obese patients. The results demonstrated that all three methods were equally effective in achieving weight loss, with no statistically significant differences among the techniques. The primary findings include: - **Total Body Weight Loss (TBWL):** Patients achieved an average of 15.5% at 6 months, 14.5% at 12 months, and 17.1% at 18 months. - **Excess Weight Loss (EWL):** Patients experienced an average EWL of 39.3% at 6 months, 36.7% at 12 months, and 43.0% at 18 months. ### Safety and Feasibility Endoscopic Gastroplasty was found to be a safe and feasible procedure with a 100% technical success rate and a low serious adverse event rate of 1.1%. The minimally invasive nature of the procedure contributes to quicker recovery times and reduced risks compared to traditional bariatric surgery. ### Additional Benefits Beyond weight loss, EG showed significant improvements in: - **Anthropometric Measurements:** Reduction in waist circumference and overall body fat percentage. - **Body Composition:** Improved muscle-to-fat ratio. - **Fatty Liver Disease and Hyperlipidemia:** Marked improvements in liver health and lipid profiles. - **Quality of Life:** Enhanced scores on the Bariatric Analysis and Reporting Outcome System (BAROS) and the Total Self-Development Obesity Control (TSD-OC) test, indicating better physical, emotional, and social well-being. ### Limitations The study had incomplete follow-up rates, with only 56% of patients followed at 6 months, 32% at 12 months, and 15% at 18 months. This limitation may have impacted the robustness of the long-term data, although the researchers assumed missing data were random. ### Conclusion Endoscopic Gastroplasty through ESG, EVG, and POSE-2 is a promising intervention for managing obesity. It provides effective weight loss, improves metabolic health, and enhances quality of life in the medium-term follow-up. Its minimally invasive nature makes it a safer and more feasible option for patients seeking alternatives to surgical bariatric procedures.

ESD, Esophageal Stricture and steroid

**ESD (Endoscopic Submucosal Dissection):** Endoscopic Submucosal Dissection (ESD) is a minimally invasive endoscopic procedure used to treat superficial esophageal cancer. It allows for the precise removal of cancerous lesions while preserving the surrounding healthy tissue. ESD has become the standard treatment for early-stage esophageal cancer due to its favorable outcomes, such as reduced complications and improved prognosis when compared to more invasive surgical options. However, despite its advantages, one of the major challenges following ESD is the development of **esophageal strictures**, particularly after extensive or circumferential ESD (cESD). --- **Esophageal Stricture After ESD:** An esophageal stricture refers to a narrowing of the esophagus, which can lead to difficulty swallowing (dysphagia). This complication is most common after large or circumferential resections during ESD, as the wound healing process often leads to fibrotic scar tissue formation and contraction of the esophageal wall. Patients with esophageal strictures can experience significant discomfort, reduced quality of life, and may require multiple interventions, such as endoscopic balloon dilations, to manage the condition. Preventing esophageal strictures is a critical concern in patients undergoing cESD, as it directly impacts their recovery and long-term outcomes. Various strategies have been explored to reduce the risk of stricture formation, with steroid therapy being one of the most effective approaches. --- **Role of Steroids in Preventing Esophageal Stricture:** Steroids, such as **triamcinolone acetonide (TA)** and **oral prednisone**, are used to prevent esophageal stricture formation by reducing inflammation and inhibiting the excessive production of fibrotic tissue during the healing process. Steroids help modulate the immune response and minimize the risk of scar tissue formation that leads to esophageal narrowing. Two main steroid-based approaches are commonly used: 1. **Combined Steroid Therapy (CST):** This approach involves injecting triamcinolone acetonide (TA) directly into the esophageal wall immediately after cESD, followed by a prolonged course of oral prednisone. CST has shown effectiveness in reducing stricture rates, but it is not always sufficient, especially in cases of extensive resections. 2. **Submucosal Steroid Preinjection Strategy (SSPS):** SSPS is a novel approach where triamcinolone acetonide is pre-injected into the submucosal layer of the esophagus before cESD, creating a "steroid water cushion" to reduce trauma during the procedure. Additional steroid injections are administered postoperatively to further suppress inflammation and fibrosis. SSPS has demonstrated promising clinical outcomes, with better prevention of esophageal strictures compared to CST. --- **Key Clinical Outcomes of Steroid Use:** Steroid therapy, whether CST or SSPS, aims to achieve the following outcomes: - **Reduced stricture rates:** Lower incidence of esophageal narrowing and dysphagia. - **Improved swallowing ability:** Patients experience fewer difficulties in eating and drinking post-procedure. - **Fewer endoscopic interventions:** Stricture prevention reduces the need for repeated balloon dilation sessions. - **Shorter hospitalization and recovery time:** Effective prevention strategies minimize complications and improve overall recovery. - **Cost-effectiveness:** Fewer complications lead to reduced medical expenses and unscheduled visits. --- **Conclusion:** Steroid therapy plays a crucial role in managing esophageal strictures after ESD, particularly circumferential ESD. While CST has been widely used, the novel SSPS approach shows promising results in further improving outcomes by integrating pre-procedural steroid injections. Both strategies aim to enhance patient recovery, reduce complications, and improve quality of life following treatment for superficial esophageal cancer.

Endoscopic Billary Drainage in surgically altered anatomy

Endoscopic biliary drainage (BD) in patients with surgically altered anatomy (SAA) is a complex and challenging medical procedure. SAA refers to patients who have undergone surgeries that change the normal anatomy of the gastrointestinal tract, such as Billroth-II gastrectomy, Roux-en-Y reconstruction, or other similar procedures. These anatomical changes make it difficult to access the bile ducts endoscopically, which is necessary for drainage in cases of biliary obstruction caused by conditions like stones, strictures, or malignancies. ### Why Endoscopic Biliary Drainage is Necessary: Biliary drainage is essential for relieving obstruction in the bile ducts, which can lead to serious complications like infection (cholangitis), jaundice, and liver damage. While BD is a routine procedure in patients with normal anatomy, SAA presents unique challenges due to altered pathways that make the bile ducts harder to reach. Traditional endoscopic retrograde cholangiopancreatography (ERCP), the standard approach for BD, is often not feasible in these patients. Therefore, alternative techniques and specialized approaches are required. ### Techniques for Biliary Drainage in SAA: Several approaches are used for BD in patients with SAA, depending on the type of surgical reconstruction and the expertise available at the medical center. These include: 1. **Device-Assisted Enteroscopy ERCP**: This involves the use of specialized enteroscopes, such as balloon-assisted or spiral-assisted enteroscopes, to navigate the altered anatomy and reach the bile ducts. 2. **Interventional Endoscopic Ultrasound (EUS)**: This technique uses ultrasound guidance to access the bile ducts through the stomach or intestines. It has gained popularity in recent years due to its high success rate and lower need for repeat interventions. 3. **Percutaneous or Surgical Drainage**: In cases where endoscopic techniques fail, percutaneous or surgical approaches may be used as a last resort. ### Findings from Recent Studies: A recent multicenter study involving 432 patients with SAA evaluated the outcomes of different BD techniques. The study found that: - The overall technical success rate of endoscopic BD was 80.3%, and clinical success was 79.9%. - Outcomes were similar across different types of surgical reconstructions, but patients with Billroth-II reconstruction experienced a higher rate of adverse events (14.4%). - Roux-en-Y reconstruction required more advanced techniques, such as device-assisted enteroscopy ERCP and interventional EUS. - Interventional EUS has become increasingly popular in the last two years, showing significantly better clinical outcomes compared to other techniques. It also reduced the need for repeat interventions during follow-up. ### Conclusion: Endoscopic biliary drainage in patients with surgically altered anatomy remains a challenging procedure with suboptimal success rates. However, advancements in interventional EUS techniques have significantly improved outcomes, making it a promising approach for managing these complex cases. The choice of technique depends on the type of surgical reconstruction, the clinical scenario, and the expertise available at the treating center.

EUS-guided gallbladder drainage in acute cholecystitis

EUS-guided gallbladder drainage (EUS-GBD) has emerged as a valuable and reliable treatment option for patients with acute cholecystitis who are considered high-risk for surgical intervention. Acute cholecystitis, an inflammation of the gallbladder typically caused by gallstones, can lead to serious complications if untreated. While surgery remains the standard treatment, certain patients, such as those with significant comorbidities or poor overall health, may not be suitable candidates for surgical procedures. In these cases, EUS-GBD provides an effective alternative. EUS-GBD involves the use of endoscopic ultrasound to place a stent, creating a drainage pathway from the gallbladder to the gastrointestinal tract. This approach eliminates the need for external drainage, as seen in percutaneous transhepatic gallbladder drainage, and offers a minimally invasive solution with fewer complications. Guidelines now recommend EUS-GBD over percutaneous drainage due to its safety and efficacy. Studies have shown that EUS-GBD achieves high rates of technical and clinical success, with durable outcomes over long-term follow-up. It is associated with low rates of adverse events, such as stent obstruction or infection, and provides effective symptom relief while reducing the need for repeat interventions or hospital readmissions. Overall, EUS-GBD represents a transformative option for managing acute cholecystitis in high-risk surgical patients.

EUS-guided Gallbladder drainage in malignant biliary obstruction

EUS-guided gallbladder drainage (EUS-GBD) is an emerging endoscopic technique used in the management of malignant biliary obstruction (MBO), particularly in cases where conventional approaches like endoscopic retrograde cholangiopancreatography (ERCP) are not feasible or have failed. Malignant biliary obstruction commonly occurs due to cancers such as pancreatic cancer, cholangiocarcinoma, or other malignancies that block the bile ducts, leading to complications like jaundice, cholangitis, and liver dysfunction. Effective biliary drainage is critical to relieve symptoms, improve quality of life, and prepare patients for further treatments like chemotherapy or surgery. ### Why EUS-GBD is Important: EUS-GBD has gained attention as a minimally invasive alternative to traditional methods for biliary drainage. It is particularly valuable in cases where the bile ducts are inaccessible or when patients have anatomical or technical challenges that make other approaches difficult. EUS-GBD involves using endoscopic ultrasound to access the gallbladder and place a lumen-apposing metal stent (LAMS) to establish drainage. This approach can be especially beneficial in patients who have not undergone a prior cholecystectomy and have a patent cystic duct, allowing for effective drainage through the gallbladder. ### Key Findings from the recent literature: 1. **Clinical Success**: EUS-GBD was shown to have a high rate of clinical success, meaning it effectively relieved symptoms and resolved biliary obstruction in the majority of patients. Its efficacy was found to be comparable to EUS-guided choledochoduodenostomy (EUS-CDS), another advanced technique for biliary drainage. 2. **Technical Success**: The technical success rate of EUS-GBD was also high, indicating that the procedure could be performed successfully in most cases without significant technical challenges. 3. **Safety**: EUS-GBD demonstrated a favorable safety profile, with a similar rate of adverse events compared to EUS-CDS. Serious complications were relatively rare in both groups. 4. **Patient Selection**: EUS-GBD may be particularly suitable for patients with distal malignant biliary obstruction who have not undergone a cholecystectomy and have a clearly patent cystic duct. This makes it a viable first-line option in carefully selected patients. ### Advantages of EUS-GBD: - Minimally invasive and can be performed endoscopically without the need for surgery. - Provides effective biliary drainage, relieving symptoms such as jaundice and cholangitis. - Avoids the need for percutaneous drainage, which can be associated with higher morbidity and discomfort. - Can be an alternative to EUS-CDS in certain clinical scenarios. ### Limitations: - EUS-GBD requires specialized expertise and equipment, which may not be available in all centers. - It is not suitable for patients who have undergone a cholecystectomy or those with an obstructed cystic duct. - Long-term outcomes and durability of the stent placement require further study. ### Conclusion: EUS-guided gallbladder drainage represents a promising and effective option for managing malignant biliary obstruction, particularly in patients who are not candidates for traditional approaches like ERCP. The study demonstrated that EUS-GBD is comparable to EUS-CDS in terms of efficacy and safety, making it a valuable addition to the therapeutic arsenal for biliary drainage in patients with distal malignant biliary obstruction. Careful patient selection and expertise in advanced endoscopic techniques are critical to achieving optimal outcomes.

EUS - Performance matrix by ESGE

Key takeaways from the European Society of Gastrointestinal Endoscopy (ESGE) guidelines for the performance matrix in endoscopic ultrasound (EUS): 1. **Informed Patient Consent**: ESGE mandates that informed patient consent must be obtained for 100% of EUS procedures to ensure ethical and legal compliance. 2. **Adequate Documentation of Landmarks**: At least 90% of EUS procedures should include detailed documentation of anatomical landmarks to maintain high-quality diagnostic standards. 3. **Structured Training and Supervision**: ESGE recommends structured training programs for EUS trainees, with at least 20% of procedures involving supervised training using assessment tools to ensure competency development. 4. **Standardized Description of Pancreatic Cystic Lesions**: A standardized description of pancreatic cystic lesions should be provided in at least 85% of cases to ensure uniform reporting and clinical decision-making. 5. **Diagnostic Tissue Acquisition**: ESGE emphasizes diagnostic tissue acquisition using EUS-guided fine-needle aspiration (FNA) or fine-needle biopsy (FNB) for solid lesions, with a success rate of ≥85% of procedures. 6. **Adverse Events Monitoring**: Adverse events should be kept below 5% for procedures involving cystic lesions and below 3% for solid lesions, ensuring patient safety. 7. **Updated Antibiotic Use for Cystic Lesions**: The previous recommendation to administer antibiotics for EUS-guided puncture of cystic lesions has been omitted in the current guideline due to recent evidence suggesting it may not be necessary. 8. **Quality Assessment at Center Level**: ESGE emphasizes the importance of monitoring and evaluating EUS performance metrics at both the center and individual endoscopist levels to ensure consistent quality. 9. **Landmark Documentation as a Quality Indicator**: Proper documentation of anatomical landmarks serves as a critical quality indicator for the accuracy and reliability of EUS procedures. 10. **Training and Assessment Tools**: ESGE advocates for the use of structured assessment tools during EUS training to objectively evaluate the skills of trainees and improve their proficiency. 11. **Focus on Pancreatic Lesions**: Special attention is given to standardizing the description and management of pancreatic cystic lesions, reflecting the importance of accurate diagnosis in this area. 12. **Diagnostic Yield Optimization**: The guideline underscores the importance of optimizing diagnostic tissue acquisition using EUS-guided fine-needle techniques to improve diagnostic yield for solid lesions. 13. **Minimizing Adverse Events**: ESGE sets clear benchmarks for minimizing adverse events in EUS procedures to prioritize patient safety and procedural efficacy. 14. **Evidence-Based Updates**: The guideline reflects recent evidence in its recommendations, such as omitting the routine use of antibiotics for puncturing cystic lesions, showcasing ESGE's commitment to evidence-based practice. 15. **Continuous Quality Improvement**: ESGE encourages centers to adopt these performance measures as part of their continuous quality improvement initiatives, ensuring better outcomes for patients undergoing EUS procedures. These takeaways highlight ESGE's commitment to improving the quality, safety, and effectiveness of endoscopic ultrasound practices across Europe.

Endoscopic papillectomy for laterally spreading lesions of the papilla

Endoscopic papillectomy is a recognized treatment for ampullary lesions, including the rare subtype of laterally spreading lesions (LSLs) of the papilla of Vater. LSLs are characterized by their extensive involvement of the duodenal mucosa, making them distinct and more challenging to treat compared to non-LSL ampullary lesions. A recent study compared the outcomes of endoscopic papillectomy for LSLs versus non-LSLs in matched patient cohorts. The study included 1422 endoscopic papillectomies, with a subset of 232 matched patients (116 LSLs and 116 non-LSLs) based on factors such as age, sex, co-morbidities, and histologic subtype. The primary outcome, complete resection (R0) after the first intervention, was significantly lower in the LSL group (54.3%) compared to the non-LSL group (69.0%). However, after repeated endoscopic interventions, technical success rates were similar for both groups (82.8%). Despite achieving comparable technical success, LSLs exhibited a significantly higher recurrence rate (41.3%) compared to non-LSLs (15.0%) during a median follow-up of 22 months. Additionally, disease-free survival rates at 1 and 3 years were notably lower in the LSL group (61.1% and 44.0%, respectively) compared to the non-LSL group (86.1% and 81.6%, respectively). Complication rates, however, were not significantly different between the two groups (32.8% for LSLs vs. 26.7% for non-LSLs). In conclusion, endoscopic papillectomy is a safe and viable option for treating LSLs of the papilla of Vater, but it often requires multiple interventions to achieve complete resection. The higher recurrence rates associated with LSLs highlight the need for vigilant post-procedure surveillance and follow-up care.