Trending Topics in Gastroenterology | GastroAGI

Cyanoacrylate Glue for Gastric Varices

Cyanoacrylate glue is a medical adhesive commonly used in the treatment of gastric varices, particularly in patients with cirrhosis who are experiencing variceal bleeding. Gastric varices are dilated veins in the stomach, which can rupture and lead to life-threatening bleeding. Cyanoacrylate glue is injected endoscopically into the varices to achieve hemostasis by rapidly solidifying upon contact with blood, thereby sealing the bleeding vessels. A randomized controlled trial compared two strategies for cyanoacrylate therapy in patients with cirrhosis and large gastric varices experiencing their first variceal bleed: aggressive and conservative approaches. In the aggressive approach, all visible gastric varices were obliterated with cyanoacrylate glue, while in the conservative approach, only varices with high-risk features or signs of recent bleeding were treated. The study found that both approaches had similar outcomes in terms of 1-year variceal rebleeding rates (18.2% for aggressive vs. 15.0% for conservative) and all-cause mortality (22.2% vs. 32.9%, respectively). Aggressive therapy, however, achieved faster obliteration of varices and required fewer endoscopic sessions. Adverse event rates were comparable between the two groups. In conclusion, while aggressive cyanoacrylate therapy may expedite variceal obliteration, its clinical outcomes are similar to those of conservative therapy, making both approaches viable options depending on patient needs.

EPOC trial

The EPOC trial (Prophylactic clip closure after ESD of large flat and sessile polyps) is a multicenter randomized controlled trial conducted to evaluate the effectiveness of prophylactic clip closure in reducing delayed bleeding rates following colorectal endoscopic submucosal dissection (ESD) of flat and sessile polyps measuring 20–50 mm. The trial was conducted across four institutions in Japan and aimed to address the lack of evidence regarding the efficacy of clip closure in colorectal ESD, as opposed to endoscopic mucosal resection (EMR), where its benefits are better established. ### Key Details of the EPOC Trial: #### **Objective:** To compare the clinically significant delayed bleeding rates between a prophylactic clip closure group and a control group following ESD for colorectal polyps. #### **Design:** - Multicenter randomized controlled trial. - Patients were randomly assigned to two groups: - **Closure group:** Underwent prophylactic clip closure after ESD. - **Control group:** Did not receive clip closure after ESD. - The trial included both intention-to-treat (ITT) and per-protocol (PP) analyses. #### **Primary Endpoint:** The delayed bleeding rate after colorectal ESD. #### **Secondary Endpoints:** - Severe delayed bleeding rates. - Delayed perforation rates. - Post-ESD coagulation syndrome rates. #### **Results:** 1. **Delayed Bleeding Rates:** - ITT analysis showed delayed bleeding rates of **6.7%** in the closure group and **20.1%** in the control group. - The absolute risk difference (ARD) for delayed bleeding was **13.5%** (95% CI: 5.6% to 20.9%), with an odds ratio (OR) of **0.28** (95% CI: 0.13 to 0.60; p<0.001). 2. **Severe Delayed Bleeding Rates:** - Severe delayed bleeding rates were **1.3%** in the closure group and **8.7%** in the control group. - ARD was **7.4%** (95% CI: 2.2% to 12.4%), with an OR of **0.14** (95% CI: 0.03 to 0.64; p=0.003). 3. **Multivariate Analysis:** - Prophylactic clip closure was identified as a significant independent preventive factor for both delayed bleeding (OR: **0.22**; 95% CI: 0.08 to 0.50; p<0.001) and severe delayed bleeding (OR: **0.22**; 95% CI: 0.05 to 0.76; p=0.015). 4. **Other Findings:** - No cases of delayed perforation were observed. - Post-ESD coagulation syndrome rates were not significantly different between the closure and control groups. - Clip closure was successfully achieved in approximately **90% of cases**. #### **Conclusion:** Prophylactic clip closure significantly reduced delayed bleeding rates following colorectal ESD for polyps measuring 20–50 mm. It was recommended as a preventive measure to improve safety outcomes in colorectal ESD procedures. #### **Implications for Practice and Policy:** The study supports the adoption of prophylactic clip closure as a standard practice after colorectal ESD to mitigate the risk of delayed bleeding, which is a common and serious complication.

Laterally spreading tumors

Laterally spreading tumors (LSTs) are a distinct category of colorectal lesions characterized by their nonpolypoid, flat appearance and their lateral growth pattern rather than vertical growth. These lesions are defined as being at least 1 cm in size and are considered precancerous or potentially cancerous. LSTs are important to identify and classify due to their unique growth behavior and varying risks of malignancy. They are generally detected during colonoscopy and are often more challenging to identify compared to polypoid lesions due to their flat morphology. Early detection and removal of LSTs are critical to prevent progression to colorectal cancer. ### Categories of LSTs: LSTs are broadly divided into two main categories: granular (LST-G) and non-granular (LST-NG). These subtypes are differentiated based on their surface appearance and histological features, and each has distinct clinical implications. 1. **Granular (LST-G):** LST-G lesions are characterized by a granular surface, often appearing as a collection of small nodules or granules. These lesions are more common and generally have a lower risk of malignant transformation, with approximately 10% containing cancer. LST-Gs are further subcategorized into homogeneous and nodular mixed types. Homogeneous LST-Gs have a uniform granular appearance, while nodular mixed types have areas of larger nodules. Although the overall risk of malignancy is low, larger lesions or those with mixed nodular patterns may carry a slightly higher risk. 2. **Non-Granular (LST-NG):** LST-NG lesions have a smooth or flat surface without granularity. They are less common but are associated with a significantly higher risk of malignancy, with up to 33% of these lesions containing cancer. LST-NGs are further classified into flat-elevated and pseudo-depressed types. The pseudo-depressed subtype, in particular, is highly suspicious for malignancy and requires careful evaluation and management. Due to their higher cancer risk, LST-NG lesions are often prioritized for removal and histopathological examination. ### Clinical Significance: The distinction between LST-G and LST-NG is essential for determining the appropriate management strategy. LST-G lesions, especially smaller ones, may be managed conservatively or with endoscopic resection, while LST-NG lesions often warrant more aggressive intervention due to their higher potential for malignancy. Advanced endoscopic techniques, such as endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR), are commonly used for the complete removal of these lesions. Regular surveillance and follow-up are also critical for preventing recurrence or progression to colorectal cancer.

Endoscopic Submucosal Dissection for Early Gastric Cancer Using a Novel Bending Attachment

Endoscopic submucosal dissection (ESD) is a minimally invasive technique used for the removal of early-stage gastrointestinal cancers, including early gastric cancer. This procedure allows for precise en bloc resection of lesions while preserving healthy tissue. However, ESD can be technically challenging, particularly in areas where access and visualization are limited, such as the lesser curvature of the upper gastric body. In this context, a novel single-use bending attachment, called the AttachBend, has been successfully utilized to enhance the ESD procedure for a patient with early gastric cancer. The AttachBend is a lightweight accessory designed to provide an additional bending function to a standard thin therapeutic endoscope, addressing the limitations of conventional multibending endoscopes. Traditional multibending endoscopes, while effective, can be expensive, heavier, and may increase operator burden, making them less practical for routine use. ### Case Description The patient presented with early gastric cancer located in the lesser curvature of the upper gastric body. During the ESD procedure, the operator faced technical difficulties due to the orientation of the muscle layer, which was directly facing the endoscope. This positioning made it challenging to maintain a clear view of the submucosal layer and perform safe dissection. To overcome these challenges, the AttachBend was mounted onto the endoscope. This attachment allowed the operator to manually adjust the bending angle of the endoscope, enabling a parallel approach to the muscle layer. This adjustment significantly improved visualization of the submucosal space and facilitated effective countertraction using the endoscopic hood. ### Advantages of the AttachBend 1. **Enhanced Visualization**: The added bending capability provided a better view of the submucosal layer, which is critical for safe and precise dissection. 2. **Improved Maneuverability**: The attachment allowed for more precise positioning of the dissection knife, enabling controlled and smooth dissection of the lesion. 3. **Safety**: The improved access and visualization reduced the risk of complications, such as perforation or incomplete resection. 4. **Cost-Effectiveness**: Unlike multibending endoscopes, the AttachBend is a single-use accessory, offering a more affordable and lightweight alternative without requiring specialized equipment. ### Outcome The use of the AttachBend resulted in successful en bloc resection of the lesion without any adverse events. Pathological examination confirmed complete removal of the cancerous tissue with negative margins, indicating no residual disease. This outcome highlights the practical advantages of the AttachBend in overcoming technical difficulties during gastric ESD. ### Conclusion The AttachBend represents a promising innovation for enhancing the safety, efficiency, and accessibility of gastric ESD in routine clinical practice. By improving access, visualization, and maneuverability, this novel attachment addresses common challenges associated with conventional techniques, offering a cost-effective and operator-friendly solution. Its successful application in this case suggests that it may be a valuable tool for managing early gastric cancer and potentially other gastrointestinal lesions requiring ESD.

Local Recurrence Risk After Horizontal Margin–Positive En Bloc Colorectal ESD

The systematic review and meta-analysis you are referencing provides an in-depth evaluation of the local recurrence risk after en bloc colorectal endoscopic submucosal dissection (ESD) with positive or indeterminate horizontal margins (HM1/x). Here is a detailed breakdown of the findings: ### Key Findings: 1. **Pooled Recurrence Rate**: - Across 11 studies and 441 cases of HM1/x en bloc colorectal ESD, the pooled recurrence rate was found to be **4.3%**. - This indicates that while the recurrence risk is elevated compared to cases with negative horizontal margins (HM0), the absolute risk remains relatively low. 2. **Nature of Recurrences**: - Recurrence typically occurred at a **median of 14 months** post-procedure. - Among the histologically characterized recurrences, the majority (13 out of 16) were **benign (dysplasia)** rather than invasive cancer. - Invasive recurrences were associated with lesions initially classified as having invasive or high-grade dysplasia. 3. **Management of Recurrences**: - Most benign recurrences were successfully treated with **repeat endoscopic procedures**. - Invasive recurrences, however, required **surgical intervention**. 4. **Comparative Risk**: - The recurrence risk was significantly higher in HM1/x cases compared to HM0 cases, with a pooled odds ratio of **8.04**. - Despite this, the recurrence risk for noninvasive lesions was still relatively low, suggesting that the presence of HM1/x margins does not universally indicate a high recurrence risk. 5. **Implications for Surveillance**: - The findings suggest that current surveillance recommendations, which are largely based on data from piecemeal endoscopic mucosal resection, may be overly cautious for en bloc ESD cases with HM1/x margins. - Surveillance strategies could potentially be refined to balance early detection of recurrences with the avoidance of unnecessary interventions, especially for cases with low-risk pathology. ### Contextual Significance: - The study highlights the importance of distinguishing between benign and invasive recurrences when managing patients with HM1/x margins after en bloc ESD. - It also underscores the need for individualized surveillance protocols that take into account the specific pathology and recurrence risk of the lesion. ### Conclusion: The local recurrence risk after en bloc colorectal ESD with positive or indeterminate horizontal margins (HM1/x) is low, at 4.3%, and is predominantly associated with benign dysplasia. Surveillance strategies may need to be adjusted to reflect this low absolute risk, especially for noninvasive lesions, while still ensuring the timely detection and management of any invasive recurrences.

EUS-Guided Gallbladder vs Bile Duct Drainage for Malignant Biliary Obstruction: Multicenter Trial

The study you are referring to is an international multicenter trial that compared two endoscopic ultrasound (EUS)-guided procedures for managing distal malignant biliary obstruction (MBO): EUS-guided gallbladder drainage (EUS-GBD) and EUS-guided choledochoduodenostomy (EUS-CDS). Traditionally, such conditions are managed using endoscopic retrograde cholangiopancreatography (ERCP), but this study explored alternative primary drainage strategies using EUS-guided techniques with lumen-apposing metal stents. ### Key Details of the Study: 1. **Study Design**: - Retrospective observational trial conducted across 28 tertiary care centers. - Timeframe: April 2017 to August 2024. 2. **Participants**: - A total of 291 patients with distal malignant biliary obstruction were included. - The majority of cases (84%) were due to pancreatic cancer. - 82 patients underwent EUS-GBD, while 209 underwent EUS-CDS. 3. **Methodology**: - To minimize selection bias, the study employed 1-to-1 propensity score matching, resulting in 154 matched patients (77 in each group). - Both procedures utilized lumen-apposing metal stents. 4. **Outcomes Compared**: - **Primary Outcome**: Clinical success (defined as effective biliary drainage and resolution of symptoms). - **Secondary Outcomes**: Technical success, adverse events, and overall survival. ### Results: 1. **Technical Success**: - EUS-GBD: 96%. - EUS-CDS: 99%. - Both procedures showed high and comparable rates of technical success. 2. **Clinical Success**: - Clinical success rates were similar between the two groups. 3. **Adverse Events**: - Both procedures had comparable adverse event profiles, indicating similar levels of safety. 4. **Overall Survival**: - No significant difference in overall survival was observed between the two groups. ### Conclusion: The study concluded that EUS-GBD is a viable and effective alternative to EUS-CDS as a first-line therapy for distal malignant biliary obstruction. Both approaches demonstrated high technical and clinical success rates, comparable safety profiles, and similar survival outcomes. This suggests that the choice between EUS-GBD and EUS-CDS can be guided by factors such as anatomical considerations, operator expertise, and patient-specific characteristics. ### Implications: This trial supports the use of EUS-guided procedures as effective alternatives to ERCP in managing distal MBO. The findings reinforce the flexibility in choosing between EUS-GBD and EUS-CDS, allowing clinicians to tailor their approach to the individual needs of the patient.

Prophylactic Rectal ESD Defect Closure and Post-ESD Outcomes

The study explored the impact of prophylactic closure of rectal ESD (endoscopic submucosal dissection) defects on post-ESD outcomes, focusing on delayed adverse events (DAEs) and post-procedure hospitalization. Here are the key findings: ### Study Details: - **Objective**: To determine whether closing rectal ESD defects prophylactically improves short-term clinical outcomes, particularly reducing delayed bleeding, perforation, and hospitalization. - **Population**: 385 patients who underwent rectal ESD between 2016 and 2023 across 12 centers in North America and Europe. Patients with intraprocedural perforation were excluded. - **Intervention**: Defect closure was achieved in 166 patients (43%) using techniques like endoscopic suturing, clips, or other closure devices. - **Outcome Measures**: Delayed adverse events (DAEs) — defined as bleeding or perforation within two weeks — and post-procedure hospitalization rates were analyzed. ### Key Findings: 1. **Delayed Adverse Events (DAEs)**: - Overall, DAEs occurred in **5.5%** of patients. - Risk factors for DAEs included chronic anticoagulant use, NICE 3 lesions (high-risk features), and incomplete resections. - Prophylactic defect closure did not significantly reduce the overall rate of DAEs compared to leaving defects open. - **Delayed perforations** were observed exclusively in the open-defect group, while no perforations occurred in patients with closed defects. 2. **Hospitalization and Recovery**: - Patients with defect closure had significantly lower rates of overnight hospital admission or observation following ESD. - This suggests that defect closure may improve post-procedure recovery and reduce healthcare resource utilization. 3. **High-Risk Subgroups**: - In patients with higher risk factors (e.g., anticoagulant use or challenging lesions), defect closure showed a numerical reduction in DAEs, though the difference was not statistically significant. ### Clinical Implications: - **Routine Closure**: The study indicates that prophylactic closure may not be necessary for all rectal ESD cases. - **Selective Closure**: Closure is recommended for high-risk patients (e.g., those on anticoagulants or with high-risk lesions) to reduce complications like delayed perforation and hospitalization. ### Conclusion: Prophylactic closure of rectal ESD defects has nuanced benefits. While it may not universally reduce delayed adverse events, it prevents delayed perforation and improves post-procedure recovery, particularly in high-risk patients. The findings suggest a tailored approach, focusing on selective closure for patients with elevated risk profiles to optimize outcomes and resource utilization.

Efficacy of PEG–Ascorbic Acid Plus Linaclotide vs Senna for Bowel Preparation (APPLE Trial)

The APPLE trial (Efficacy of PEG–Ascorbic Acid Plus Linaclotide vs Senna for Bowel Preparation) was a multicenter, endoscopist-blinded, randomized controlled trial conducted across five centers in Japan. The study aimed to evaluate whether adding linaclotide to a low-volume bowel preparation regimen (polyethylene glycol plus ascorbic acid, 1L-PEG) improves bowel cleansing efficacy compared to senna. ### Study Design: - **Participants**: A total of 1,464 outpatients scheduled for colonoscopy. - **Intervention Groups**: 1. **1L-PEG/AL**: 1 L polyethylene glycol plus ascorbic acid with 0.5 mg linaclotide. 2. **1L-PEG/AS**: The same regimen with 24 mg senna. - **Primary Endpoint**: Adequate bowel preparation assessed using the Boston Bowel Preparation Scale (BBPS). ### Key Findings: 1. **Efficacy**: - The linaclotide regimen (1L-PEG/AL) achieved significantly higher rates of adequate bowel preparation compared to the senna regimen (1L-PEG/AS): **92% vs 86%**. - Linaclotide showed superior overall and segmental BBPS scores. - The benefit of linaclotide was most pronounced in **high-risk patients** for inadequate bowel preparation, where adequacy reached **94%** with linaclotide compared to **86%** with senna. - In **low-risk patients**, both regimens performed equally well. 2. **Tolerability and Safety**: - Both regimens had similar tolerability, with comparable rates of side effects such as nausea, abdominal pain, sleep disturbances, and willingness to repeat the preparation. - Linaclotide led to an earlier onset of bowel movements and increased defecation before the intake of PEG, without increasing adverse events. 3. **Colonoscopy Outcomes**: - Colonoscopy completion rates, procedure times, and lesion detection rates were comparable between the two regimens. ### Conclusion: The APPLE trial demonstrated that the linaclotide-enhanced low-volume bowel preparation regimen (1L-PEG/AL) provides **superior cleansing efficacy** compared to the senna regimen (1L-PEG/AS), particularly in high-risk patients, while maintaining similar safety and patient acceptability. Linaclotide represents a promising option for improving bowel preparation, especially in patients at high risk of inadequate cleansing.

Spray vs Forced Coagulation in ESD for Early Gastric Neoplasms

The comparison between Spray Coagulation Mode (SCM) and Forced Coagulation Mode (FCM) in Endoscopic Submucosal Dissection (ESD) for early gastric neoplasms has been thoroughly investigated in a multicenter randomized controlled trial conducted across five Japanese institutions. Below is a detailed summary of the findings: ### 1. **Primary Challenge in ESD** - Intraoperative bleeding is a major technical challenge during ESD for early gastric neoplasms, often requiring the use of hemostatic forceps. ### 2. **Study Objective** - The trial aimed to compare the hemostatic effectiveness of SCM-ESD and FCM-ESD in controlling bleeding during ESD. ### 3. **Study Design** - The study was a prospective, multicenter, randomized controlled trial with balanced randomization (1:1). Stratification was based on tumor location, size, and antithrombotic use to ensure validity and generalizability. ### 4. **Key Findings** #### a. **Knife-Only Completion Rate** - SCM-ESD achieved a significantly higher rate of successful ESD completion using only the knife without the need for hemostatic forceps compared to FCM-ESD. #### b. **Reduced Dependence on Hemostatic Forceps** - SCM-ESD markedly decreased both the number and duration of hemostatic forceps use, streamlining the procedure and reducing interruptions. #### c. **Improved Hemostasis** - Spray coagulation provided broader and more stable coagulation, which enhanced bleeding control during submucosal dissection. #### d. **Procedure Time and Dissection Speed** - Despite better bleeding control, the total procedure time and submucosal dissection speed were similar between SCM-ESD and FCM-ESD groups. #### e. **Oncologic Outcomes** - Both groups achieved high rates of en-bloc resection (removal of the tumor in a single piece) and complete (R0) resection, with no significant differences observed. - Curative resection rates were also comparable, indicating that SCM-ESD did not compromise oncologic efficacy. #### f. **Injection Volume** - SCM-ESD required significantly less submucosal injection volume compared to FCM-ESD, which may contribute to procedural efficiency and cost reduction. #### g. **Safety Profile** - Adverse event rates, including intraoperative bleeding and perforation, were low and comparable between the two groups. - SCM-ESD did not increase thermal damage, ensuring that pathological margin assessments were not impaired. #### h. **Benefit for Nonexperts** - SCM-ESD demonstrated improved hemostasis outcomes even when performed by less experienced endoscopists, highlighting its potential to benefit a wider range of practitioners. #### i. **Antithrombotic Use** - The benefits of SCM-ESD were less pronounced in patients receiving antithrombotic agents, suggesting that caution is needed in this subgroup. #### j. **Workflow Efficiency** - SCM-ESD simplified the workflow by reducing the need for device exchanges, thereby minimizing procedural interruptions and enhancing efficiency. ### 5. **Clinical Implications** - SCM-ESD is a promising technique for ESD in early gastric neoplasms, offering several advantages: - Improved bleeding control. - Reduced dependence on hemostatic forceps. - Streamlined workflow and reduced procedural costs. - Preservation of safety and oncologic efficacy. - These benefits make SCM-ESD particularly appealing for less experienced endoscopists and in settings where procedural efficiency is a priority. ### 6. **Limitations** - The benefits of SCM-ESD were less pronounced in patients on antithrombotic therapy, which may require additional strategies for optimal bleeding control in this subgroup. ### 7. **Conclusion** - Spray coagulation mode (SCM) represents a significant advancement in ESD for early gastric neoplasms, addressing the challenge of intraoperative bleeding while maintaining safety, efficacy, and efficiency. It is a valuable technique for improving outcomes and simplifying the procedure for both expert and nonexpert endoscopists.

Impact of the S–O Clip on Endoscopic Submucosal Dissection Outcomes: A Meta-Analysis

The meta-analysis on the impact of the S–O clip on Endoscopic Submucosal Dissection (ESD) outcomes provides compelling evidence supporting the clinical benefits of this traction device. Below is a detailed summary of the findings: ### **Background and Challenges in ESD** Endoscopic submucosal dissection (ESD) is a highly effective technique for removing early gastrointestinal (GI) neoplasms with en-bloc resection. However, it is technically demanding and associated with challenges such as: 1. **Poor submucosal visibility** during dissection. 2. **Long procedure times**, increasing operator fatigue and potential complications. 3. **Risk of complications** such as bleeding and perforation. To address these limitations, traction devices like the S–O clip have been developed to improve procedural efficiency and safety. ### **Role and Mechanism of the S–O Clip** The S–O clip is a specialized traction device designed to enhance submucosal exposure during ESD. Its **spring-and-loop mechanism** provides stable counter-traction, enabling better visibility of submucosal layers and facilitating precise dissection. Importantly, the design minimizes obstruction of the endoscopic field, allowing for uninterrupted visualization and manipulation. ### **Meta-Analysis Design** This meta-analysis followed the **PRISMA guidelines** and synthesized evidence from 17 studies involving 1,449 patients. The included studies compared ESD outcomes with and without S–O clip assistance, focusing on procedure efficiency, safety, and resection quality. ### **Key Findings** #### **1. Procedure Time Reduction** The use of the S–O clip significantly shortened ESD procedure times compared to conventional techniques. This is attributed to improved submucosal exposure, which allows for faster and more precise dissection. The reduction in procedure time may also decrease operator fatigue, enhancing technical precision and overall safety. #### **2. Improved Dissection Speed** Dissection speed was consistently higher with S–O clip assistance across studies. This reflects the device's ability to provide stable traction and optimize the efficiency of submucosal dissection. #### **3. Higher En-bloc Resection Rates** The S–O clip modestly but significantly increased **en-bloc resection rates**, which is critical for achieving complete removal of neoplastic tissue and minimizing recurrence risk. This advantage was particularly evident in colorectal ESD. #### **4. Comparable Complete Resection (R0) Rates** Complete resection rates (R0) were similar between S–O clip-assisted and conventional ESD groups, indicating that the device does not compromise the quality of resection. #### **5. Maintained Safety Profile** No significant increase in intraoperative perforation rates was observed with S–O clip use, demonstrating its safety during ESD. Additionally, post-ESD bleeding rates were comparable between S–O clip-assisted and conventional techniques. #### **6. Lesion-Specific Benefits** - **Gastric Lesions**: The S–O clip significantly reduced procedure time and improved dissection speed for gastric neoplasms. - **Colorectal Lesions**: In colorectal ESD, the device resulted in higher en-bloc resection rates and faster dissection. - **Duodenal Lesions**: Evidence for duodenal lesions was limited, though procedure time appeared reduced with S–O clip use. ### **Additional Advantages** #### **1. Reduced Operator Fatigue** Shorter procedure times with the S–O clip may alleviate operator fatigue, which is particularly important for lengthy and complex ESD cases. Reduced fatigue can improve technical precision and minimize the risk of errors. #### **2. Training Implications** The S–O clip may facilitate safer and more efficient ESD performance by less experienced endoscopists. Its ability to enhance submucosal exposure and simplify dissection may serve as a valuable training tool. #### **3. Cost-Effectiveness** While the S–O clip adds to procedural costs, its ability to reduce procedure time and complications may offset device expenses, particularly in high-volume centers. ### **Evidence Quality** The majority of included studies were assessed as **low risk of bias**, with moderate-to-high certainty of evidence for key outcomes such as procedure time, dissection speed, and en-bloc resection rates. ### **Clinical Recommendations** Based on the meta-analysis findings, the S–O clip is a valuable adjunct for ESD, particularly for gastric and colorectal lesions. It improves procedural efficiency without compromising safety or resection quality. While evidence for duodenal lesions is limited, preliminary data suggest potential benefits. The device is recommended for routine use in ESD, especially in high-volume centers and training programs. ### **Conclusion** The S–O clip significantly enhances ESD outcomes by improving submucosal visibility, reducing procedure time, increasing dissection speed, and modestly improving en-bloc resection rates. Its safety profile is comparable to conventional techniques, with no increased risk of perforation or bleeding. These findings support the widespread adoption of the S–O clip as a valuable tool for optimizing ESD performance.