Trending Topics in Gastroenterology | GastroAGI

EndoBarrier Improves Diabetes and Weight Loss: Ann Surg | July 2026

Introduction: Endoscopic metabolic therapies have emerged as less invasive alternatives to bariatric surgery for patients with obesity and poorly controlled type 2 diabetes mellitus (T2DM). The EndoBarrier duodenal-jejunal bypass liner (DJBL) is an endoscopically placed device that temporarily excludes the proximal small intestine, aiming to improve glucose metabolism through both weight-dependent and weight-independent mechanisms. Why was this study needed?: . Many patients with obesity and uncontrolled T2DM do not achieve adequate control with medications and lifestyle modification. . Bariatric surgery is highly effective but is not suitable or acceptable for all patients. . Evidence from large randomized sham-controlled trials evaluating the EndoBarrier device has been limited. . The balance between metabolic benefits and device-related safety required confirmation before wider adoption. Results: In this multicenter double-blind randomized sham-controlled trial, the EndoBarrier significantly improved glycemic control compared with sham treatment, with greater reductions in HbA1c and significantly higher rates of achieving target glycemic control. Patients receiving the device also experienced substantially greater weight loss and were more likely to achieve clinically meaningful weight reduction. Although device-related serious adverse events occurred, including gastrointestinal bleeding, intolerance, and hepatic abscess, the overall safety profile met the predefined study criteria and was considered acceptable with appropriate monitoring. Clinical Impact: The EndoBarrier offers an effective minimally invasive metabolic intervention for patients with obesity and poorly controlled T2DM who are not candidates for or decline bariatric surgery. While its metabolic benefits are clinically meaningful, careful patient selection and close surveillance are essential because of device-related complications, particularly hepatic abscess. The device may serve as an important bridge between pharmacotherapy and surgery in specialized centers. Bottom Line: The EndoBarrier significantly improved glycemic control and weight loss compared with sham treatment, supporting its role as an effective endoscopic metabolic therapy for selected patients with obesity and poorly controlled type 2 diabetes, provided appropriate safety monitoring is ensured.

Immediate Endoscopic Necrosectomy in Necrotizing Pancreatitis: Gastroenterology | July 2026

Introduction: Endoscopic ultrasound (EUS)-guided transmural drainage is the standard minimally invasive treatment for symptomatic necrotizing pancreatitis. However, the optimal timing of direct endoscopic necrosectomy (DEN) following drainage remains uncertain. While the conventional step-up approach reserves DEN for patients with inadequate clinical response, immediate DEN may accelerate recovery by achieving earlier clearance of necrotic material. Why was this study needed?: The ideal timing of DEN after EUS-guided drainage has not been established. The drainage-oriented step-up approach delays necrosectomy until clinically indicated. Earlier necrotic tissue removal may shorten recovery without increasing complications. Randomized evidence comparing immediate versus on-demand DEN has been lacking. Results: In the multicenter WONDER-01 randomized trial, immediate DEN significantly shortened the time to clinical success compared with the conventional drainage-oriented step-up strategy. Technical success was similarly high in both groups, and rates of procedure-related adverse events and mortality were comparable. However, all patients assigned to immediate DEN underwent necrosectomy, whereas fewer than half of those managed with the step-up approach ultimately required the procedure, highlighting that many patients can recover with drainage alone. Clinical Impact: Immediate DEN offers faster clinical resolution without compromising safety, making it an attractive option for patients in whom rapid recovery is desirable. However, because the step-up approach avoids unnecessary necrosectomy in a substantial proportion of patients, it remains an efficient and less invasive strategy. Treatment decisions should therefore be individualized based on disease severity, clinical response, and local expertise. Bottom Line: Immediate endoscopic necrosectomy after EUS-guided drainage accelerates recovery without increasing adverse events but results in more necrosectomy procedures, supporting individualized selection between immediate and step-up treatment strategies.

Endoscopy After Bevacizumab Appears Safe: GIE | July 2026

Introduction: Bevacizumab is widely used in metastatic colorectal cancer (mCRC) because of its survival benefits but is associated with impaired wound healing, gastrointestinal perforation, and bleeding. These concerns often lead clinicians to delay endoscopic procedures after bevacizumab therapy, despite limited evidence supporting this practice. Why was this study needed?: The optimal timing of endoscopy after recent bevacizumab exposure remains uncertain. Clinicians are concerned about increased risks of gastrointestinal perforation and postprocedural bleeding. Existing evidence is limited and largely based on small observational studies. Better data are needed to guide the safety of diagnostic and therapeutic endoscopic procedures in patients receiving bevacizumab. Results: In this large propensity score–matched analysis, recent bevacizumab use was not associated with an increased risk of gastrointestinal perforation within 30 days after either diagnostic or therapeutic endoscopy compared with other active chemotherapy. However, patients receiving bevacizumab had a significantly higher risk of postprocedural bleeding, particularly after therapeutic endoscopic interventions, with the excess risk largely driven by upper gastrointestinal procedures. Diagnostic endoscopy alone did not demonstrate an increased bleeding risk. Clinical Impact: These findings suggest that recent bevacizumab therapy should not automatically delay necessary endoscopic evaluation because the feared increase in perforation risk was not observed. However, therapeutic endoscopic procedures, especially upper GI interventions, should be undertaken with greater caution, balancing procedural benefits against the elevated bleeding risk. Careful procedural planning and post-procedure monitoring remain essential. Bottom Line: Recent bevacizumab exposure does not increase post-endoscopy perforation risk but is associated with higher bleeding risk after therapeutic endoscopic procedures, supporting individualized procedural planning rather than routine postponement of endoscopy.

Colorectal ESD Perforation: Endoscopy | July 2026

Introduction: Endoscopic submucosal dissection (ESD) enables en bloc resection of large colorectal neoplasms with excellent oncological outcomes. However, concerns about perforation have limited its widespread adoption. This large prospective multicenter study evaluated the incidence, risk factors, and clinical outcomes of colorectal ESD-related perforations. Why was this study needed? • Perforation is the most feared complication of colorectal ESD. • Real-world Western data on perforation outcomes are limited. • Predictors of perforation and need for surgery remain poorly defined. • Better risk stratification can improve patient counseling and procedural planning. • Understanding delayed perforation is essential for post-ESD surveillance. Results: • More than 90% of ESD-related perforations were successfully managed conservatively, particularly intraprocedural perforations, avoiding surgery in most patients. • Delayed perforation was uncommon but carried a high likelihood of emergency surgery, making early recognition and close post-procedure monitoring critical. • Large lesions, severe fibrosis, previous resection, poor endoscope maneuverability, and proximal colonic location significantly increased the risk of perforation. Clinical Impact: These findings reassure endoscopists that most intraprocedural perforations can be safely managed endoscopically without surgery. However, delayed perforation remains a serious complication requiring prompt diagnosis and surgical evaluation. Careful patient selection and recognition of high-risk lesions are essential to optimize ESD outcomes. Bottom Line: Colorectal ESD perforation is usually manageable without surgery, but delayed perforation remains the major clinical challenge. Patients with large, fibrotic, previously treated, or proximal colonic lesions require heightened procedural caution and close post-procedure surveillance.

Duodenal Mucosal Resurfacing REMAIN-1 Study: DDW | 2026

Introduction: Obesity has become one of the greatest global health challenges. New incretin-based therapies—including semaglutide, tirzepatide, resmetirom, and SGLT2 inhibitors such as empagliflozin—have transformed the treatment of obesity, diabetes, and MASLD. However, many patients discontinue these therapies within 1–2 years because of cost, adverse effects, or limited access, often leading to rapid weight regain. Why was this study needed? • Weight regain commonly occurs after GLP-1 receptor agonist discontinuation. • Long-term maintenance strategies after stopping GLP-1 therapy are lacking. • A non-pharmacological approach may help sustain metabolic benefits. • The duodenum plays a central role in glucose metabolism and insulin resistance. • Endoscopic metabolic therapies are emerging as less invasive alternatives to surgery. Results: • A single session of Duodenal Mucosal Resurfacing (DMR) helped maintain weight loss and metabolic improvements after GLP-1 discontinuation. • DMR appears to function as an "off-ramp" therapy, reducing early rebound weight gain after stopping GLP-1 treatment. • These findings support the concept that combining pharmacological and endoscopic metabolic therapies may provide more durable long-term outcomes than either approach alone. Clinical Impact: DMR is a minimally invasive endoscopic procedure that uses hydrothermal ablation to regenerate the duodenal mucosa, targeting abnormal metabolic signaling rather than simply reducing caloric intake. If confirmed in larger studies, DMR may become an attractive strategy for maintaining weight loss after GLP-1 withdrawal and reducing lifelong dependence on medication. Bottom Line: The future of obesity treatment may not be lifelong medication alone. Combining GLP-1 therapy for weight loss induction with Duodenal Mucosal Resurfacing for long-term maintenance could represent a new paradigm in metabolic disease management.

EUS-FNAB for Solid Pancreatic Lesions: GIE | July 2026

Introduction: Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is the standard technique for diagnosing solid pancreatic lesions. Traditionally, biopsy specimens are processed for cytology, often requiring on-site cytopathology support. This multicenter prospective study evaluated whether directly placing FNB tissue in formalin for histopathology could provide comparable diagnostic performance. Why was this study needed? • Many centers lack rapid on-site cytopathology (ROSE) or dedicated cytopathologists. • Histopathology may better preserve tissue architecture for diagnosis and ancillary testing. • The optimal processing method for EUS-FNB specimens remains uncertain. • Simplifying specimen handling could improve workflow and reduce procedure time. • Prospective data comparing histopathology with conventional cytology are limited. Results: • Histopathologic evaluation of EUS-FNB specimens achieved diagnostic accuracy comparable to conventional cytology for solid pancreatic lesions. • Histopathology required fewer needle passes, potentially reducing procedure time and improving efficiency. • With macroscopic on-site evaluation (MOSE), all histopathology specimens were adequate for analysis, supporting its reliability even without on-site cytopathologists. Clinical Impact: This study supports direct formalin submission of EUS-FNB specimens for histopathology as a practical alternative to cytology, particularly in centers without ROSE or cytopathology services. It may simplify specimen processing while maintaining excellent diagnostic performance. Bottom Line: Histopathology with MOSE is a reliable alternative to cytology for EUS-FNB of solid pancreatic lesions. It provides comparable diagnostic accuracy with fewer needle passes, making it an attractive approach for routine clinical practice, especially in resource-limited settings.

Durable Endoscopic Partial Reversal of Roux-en-Y Gastric Bypass Using Parallel LAMS Septotomy: GIE | July 2026

Introduction: Although Roux-en-Y gastric bypass (RYGB) is an effective bariatric procedure, a small proportion of patients develop severe nutritional complications, refractory dumping syndrome, or other debilitating adverse events requiring reversal. This study describes a novel endoscopic technique that offers a minimally invasive alternative to surgical reversal. Why was this technique needed? Surgical reversal of RYGB carries substantial morbidity, particularly in malnourished or medically complex patients. Conventional EUS-guided gastrogastric fistulas created with lumen-apposing metal stents (LAMS) often close after stent removal, limiting long-term success. What did the study show? • Six patients underwent endoscopic partial RYGB reversal using the parallel LAMS septotomy technique. • Technical and clinical success was achieved in 100% of patients. • Durable gastrogastric anastomosis was maintained after stent removal in all patients during follow-up. • No major procedure-related adverse events were reported. • The technique eliminates the need for permanent indwelling LAMS while maintaining long-term luminal patency. • Patients experienced sustained restoration of gastric continuity without requiring surgical reversal. Clinical Impact: Parallel LAMS septotomy represents an important advance in third-space endoscopy, providing a minimally invasive option for selected patients requiring RYGB reversal. The technique may reduce surgical morbidity while offering durable anatomical restoration. Take-Home Message: Parallel LAMS septotomy enables durable endoscopic partial reversal of Roux-en-Y gastric bypass without permanent stent dependence. Although early results are highly encouraging, larger studies with longer follow-up are needed before widespread adoption.

EUS Double Drainage for Malignant Dual Obstruction : Gut | Jul 2026

Introduction: Simultaneous malignant distal biliary obstruction (MDBO) and gastric outlet obstruction (GOO), commonly caused by advanced pancreatic, biliary, or duodenal cancers, presents a major palliative challenge. Conventional endoscopic approaches often require repeated interventions and may be technically difficult when both obstructions coexist. Endoscopic ultrasound (EUS)-guided double drainage has emerged as an innovative minimally invasive strategy to address both obstructions in a single therapeutic approach. Problem Statement: Traditional management with ERCP and enteral stenting is frequently limited by anatomical distortion, stent dysfunction, and the need for repeat procedures. Surgical bypass remains effective but is associated with greater morbidity, particularly in frail patients with advanced malignancy. A durable, less invasive alternative is needed to improve symptom control and quality of life. Summary: This review highlights the growing role of EUS-guided double drainage (EUS-DD), combining EUS-guided gastroenterostomy (EUS-GE) and EUS-guided biliary drainage (EUS-BD), for patients with synchronous malignant gastric outlet and distal biliary obstruction. EUS-GE restores enteral passage by creating a bypass to the small bowel, while EUS-BD provides internal biliary drainage when ERCP is unsuccessful or not feasible. Together, these procedures offer effective relief of obstructive symptoms without the need for surgery. Compared with conventional endoscopic techniques, EUS-DD is associated with improved long-term patency, fewer reinterventions, and durable palliation, while achieving outcomes comparable to surgical bypass in selected patients. The approach is particularly valuable for patients with advanced malignancy who are poor surgical candidates. However, EUS-DD is technically demanding and should currently be performed only in experienced, high-volume centers with multidisciplinary interventional and surgical support. Successful implementation requires advanced EUS expertise, dedicated training, and careful patient selection. As procedural experience, training pathways, and supporting evidence continue to expand, EUS-guided double drainage is expected to become the preferred endoscopic palliative strategy for malignant dual obstruction in appropriately equipped centers.

Endoscopic Mucosal and Submucosal Cutting in benign esophageal stricture: Gut | July 2026

Introduction: Long benign esophageal strictures remain one of the most difficult benign conditions to manage. Although endoscopic dilation and incision techniques provide temporary relief, recurrence is common, often requiring repeated interventions. This study introduces a novel endoscopic approach designed to achieve more durable stricture release. Why was this technique needed? Conventional balloon dilation and radial incision frequently result in restenosis, especially in long, complex strictures. There is a need for a technique that provides more complete scar release while minimizing repeated procedures. What did the study show? • The technique combines methylene blue-guided visualization of scar tissue with longitudinal mucosal and submucosal cutting down to the muscularis propria, followed by triamcinolone injection. • Eleven patients with long benign esophageal strictures underwent the procedure, with eight receiving it as primary treatment. • Short-term clinical success was achieved in nearly all patients. • Only one patient required repeat treatment during follow-up. • The technique appeared feasible and safe, with encouraging outcomes over a mean follow-up of approximately 11 months. Clinical Impact: This novel endoscopic approach offers a promising alternative for patients with long or refractory benign esophageal strictures, particularly when conventional dilation or incision techniques have failed. Larger prospective studies are needed to confirm long-term efficacy and safety. Take-Home Message: Endoscopic mucosal and submucosal cutting represents an innovative third-space endoscopic technique that may provide more durable relief for long benign esophageal strictures, potentially reducing recurrence and the need for repeated endoscopic interventions.

Economic Impact of POEM and ESD: GIE | June 2026

Introduction: Peroral endoscopic myotomy (POEM) and endoscopic submucosal dissection (ESD) have revolutionized the management of esophageal motility disorders and early gastrointestinal neoplasia. Despite their proven clinical benefits, widespread adoption has been limited by concerns regarding procedure costs and relatively low reimbursement. Why was this study needed? Hospital administrators often view POEM and ESD as financially unattractive because of their complexity and low procedural reimbursement. This study evaluated whether these advanced endoscopic procedures generate broader economic value through downstream healthcare utilization. What did the study show? • The study analyzed 825 patients undergoing POEM or ESD at a high-volume tertiary center between 2018 and 2024. • Although direct procedural reimbursement was relatively low (15.5%–22.4%), the program generated $73.5 million in total physician and hospital charges. • Downstream care accounted for $39.9 million in additional healthcare charges. • Overall reimbursement reached $15.7 million during the study period. • The program attracted 349 new referral patients, generating an additional $28.5 million in healthcare charges and $5.8 million in reimbursements. • The financial benefits extended well beyond the endoscopic procedures themselves through referrals, follow-up care, imaging, surgery, and multidisciplinary services. Clinical Impact: The value of POEM and ESD should be assessed across the entire healthcare system rather than by procedural reimbursement alone. Investment in third-space endoscopy programs can strengthen referral networks, improve patient access to advanced therapies, and generate substantial long-term institutional revenue. Take-Home Message: POEM and ESD are not only clinically transformative but also economically valuable. While direct procedural reimbursement remains modest, the substantial downstream revenue and referral growth make advanced endoscopy programs a worthwhile investment for healthcare systems.