Storm, Andrew C.

Abstract Background and Aims EUS-guided gastroenterostomy (EUS-GE) is an effective option to palliate symptoms of gastric outlet obstruction (GOO). While the jejunum is conventionally targeted (EUS-GJ), targeting the duodenum (EUS-GD) may offer clinical advantages. Outcomes were compared for EUS-GJ and EUS-GD. Methods Adult patients who underwent EUS-GE for GOO between 2020 and 2024 were included and categorized as an EUS-GD if the stent entered the transverse or ascending duodenum or an EUS-GJ if the stent entered more distally. The primary outcome was clinical success (soft diet tolerance at 7 days). Secondary outcomes included adverse events (AEs), stent misdeployment, and unplanned endoscopic reintervention. Baseline demographic variables and outcomes were compared with statistical significance at p < 0.05. Results Of the 139 included patients (median age 67 years (IQR 61–74); 41% female), 105 underwent EUS-GJ and 34 underwent EUS-GD. Clinical success was 98% for EUS-GJ and 94% for EUS-GD (p = 0.25). The misdeployment rate was 7% for EUS-GJ and 0% for EUS-GD (p = 0.19). The AE rate was 22% for EUS-GJ and 12% for EUS-GD (p = 0.23). There were no significant differences for stent obstruction (EUS-GJ 12% vs. EUS-GD 6%), bleeding (2% vs. 6%), perforation (4% vs. 0%), stent migration (1% vs. 0%), infection (3% vs. 0%), and unplanned reintervention (14% vs. 9%). Conclusion Both EUS-GJ and EUS-GD demonstrate high clinical success with no significant differences in adverse event rates. These data can support intraprocedural decision-making for endoscopists performing EUS-GE.

Background: Upper gastrointestinal bleeding (UGIB) is a common medical emergency associated with significant morbidity, mortality, and healthcare costs. Many patients undergo early endoscopy despite the absence of active bleeding. PillSense is a novel Food and Drug Administration (FDA)-cleared ingestible capsule that rapidly detects the presence of blood in the upper GI tract and may optimize triage decisions. Methods: We conducted a retrospective study evaluating the impact of PillSense on the management of suspected UGIB in an academic center. The primary outcome was the association between capsule results and clinical decision-making, including endoscopy deferral, prioritization, outpatient scheduling, and airway protection. Secondary outcomes included transfusion requirements, time-to-endoscopy, endoscopic intervention, and 30-day adverse events. Results: A total of 28 patients (mean age 64.4 ± 17.9 years, 82.7% male) were included. Compared with negative results, positive results were associated with higher transfusion requirements (median 3 (IQR 3–6) vs. 2 (IQR 1–3.25) units; p = 0.041) and shorter time-to-endoscopy (median 0.2 (IQR 0.01–1) vs. 2 (IQR 1–15.5) days; p = 0.017). In high-risk for sedated endoscopy patients, negative results were associated with EGD deferral in 53.8%, with no subsequent adverse events within 30 days. Endoscopic intervention was performed in 62.5% of positive-result patients versus 9.5% of negative-result patients. Conclusions: The PillSense results were associated with differences in triage and management of high-risk patients with suspected UGIB. Its rapid, accurate, and non-invasive results may reduce unnecessary urgent endoscopy procedures, improve resource utilization, and enhance patient safety, particularly in the highest-risk populations.

ABSTRACT Objectives Patients requiring long‐term enteral nutrition or continuous infusion of carbidopa/levodopa can benefit from jejunostomy tube placement. Recently, directly placed percutaneous transgastric jejunal tubes (TGJs) have been used instead of gastrostomy tubes with jejunal extensions (PEG‐Js) for enteral access. We aim to compare patient characteristics and outcomes after placement of TGJs placed via the introducer technique compared to PEG‐Js. Methods We performed a retrospective study of 141 patients (TGJ = 58, PEG‐J = 83) assessed at Mayo Clinic between 2010 and 2024. Patients were identified using a prospectively maintained procedure data registry. Demographic data, patient characteristics, procedural indications, complications, and first‐replacement date were gathered. Statistical analysis included the Wilcoxon rank sum test, chi‐square test, Fisher's exact test, and Kaplan‐Meier estimates. Patients receiving carbidopa/levodopa were excluded from complications analysis due to the carbidopa/levodopa tube's proprietary structure. A p ‐value of <0.05 was set as a threshold for significance. Results Our results demonstrated no difference in cumulative incidence of complications within 1 year for TGJs and PEG‐Js, p ‐value 0.48. Regarding time to first replacement, treating death as a competing risk factor, there was no statistically significant difference in cumulative incidence of replacement within 1 year for TGJs and PEG‐Js, p ‐value 0.389. Conclusions Our study demonstrates that both direct TGJs and PEG‐Js are safe options for long‐term jejunal feeding. More studies are needed to compare endoscopic to radiologically placed percutaneous transgastric jejunal feeding tubes.

Background: Fluorescence in situ hybridization (FISH) is recommended as part of multimodality sampling in the evaluation of biliary strictures, but can be false negative in 40%–50% cases. The aim of this study was to comprehensively assess predictors of false-negative FISH in patients with biliary strictures. Methods: Patients undergoing tissue sampling for biliary strictures from October 20 to February 22 were prospectively enrolled (NCT04572711). Procedural factors such as sampling techniques, order, and utilization of combination sampling were recorded. Results of an optimized pancreatobiliary FISH panel with locus-specific probes for 1q21, 7p12, 8q24, and 9p21 were reported per guidelines. Statistical analyses were performed using BlueSky Statistics v.10.3.1, R package v8.81. Results: Of 327 patients, 93 (28.5%) were diagnosed with malignancy. A false-negative pancreatobiliary fluorescence in situ hybridization (PB-FISH) was reported in 40 (43.1%) patients. A history of primary sclerosing cholangitis was associated with lower odds of having a false-negative PB-FISH (aOR=0.38, 95% CI=0.16–0.82, p=0.02), whereas a hilar stricture was associated with a significantly higher false-negative PB-FISH in those with cholangiocarcinoma (aOR=3.2 [1.4–7.9], p=0.009). Dilation of biliary strictures prior to brushing was not associated with a lower rate of false-negative PB-FISH. Conclusions: In this prospective study, hilar strictures were more likely to have false-negative PB-FISH. Dilation of strictures did not affect PB-FISH performance. These results can help guide PB-FISH interpretation.

ABSTRACT Weight recurrence is a late complication after Roux-en-Y gastric bypass. The transoral outlet reduction (TORe) emerged as an endoscopic alternative to revisional surgery for weight recurrence due to a dilated and incompetent gastrojejunal anastomosis. The procedure has been documented as safe and effective in clinical trials and other high-quality medical literature. Several cases of squamous metaplasia of the gastric pouch after repeated TORe procedures using argon plasma coagulation have been reported. We present a case of a late-onset adenocarcinoma of the gastrojejunal anastomosis after a TORe procedure performed using argon plasma coagulation and suturing.

Abstract Clinicians struggle to accurately classify biliary strictures as benign or malignant. Current endoscopic retrograde cholangiopancreatography (ERCP)-based sampling modalities including brush cytology and forceps biopsy have poor sensitivity for pathologic confirmation of malignancy. Cholangioscopy allows for direct visualization and sampling of biliary pathology; however, this technology is also associated with inaccurate classification of biliary disease. Previously, an artificial intelligence (AI) system that analyzes cholangioscopy footage was found to be more accurate in diagnosing biliary malignancy than ERCP sampling techniques. The aim of this study was to validate this AI system on a new series of examinations. Three academic centers collected all available unedited cholangioscopy recordings. The videos were processed by the cholangioscopy AI system. After analyzing videos, the AI system provided predictions as to whether malignancy was present. AI performance in classifying strictures was compared with the performance of brush cytology and forceps biopsy. 112 cholangioscopy examinations (containing 4 817 081 images) were generated from 99 patients. Of those examinations, 61 (54.5%) were for investigation of biliary strictures (31 [50.8%] benign, 30 [49.2%] malignant). For the correct classification of strictures, the AI system was 80.0% sensitive and 90.3% specific. It was also significantly more accurate for stricture classification (85.2%) than brush cytology (52.5%; P<0.001), forceps biopsy (68.2%; P=0.04), and the combination of brush cytology and forceps biopsy (66.7%; P=0.02). A previously developed cholangioscopy AI system was found to continually outperform standard ERCP sampling modalities for accurate identification of malignancy, without additional retraining, in a multicenter validation cohort.

Obesity is a major global health challenge associated with significant metabolic and gastrointestinal comorbidities. While metabolic and bariatric surgery remains the gold standard for durable weight loss, the desire for additional options has fueled the development of endoscopic bariatric therapies (EBTs) as another tool for weight loss. This review examines established EBTs, including endoscopic sleeve gastroplasty (ESG), intragastric balloons (IGBs), and transoral outlet reduction (TORe), alongside emerging therapies such as duodenal mucosal resurfacing (DMR), incisionless anastomosis creation, and fully automated endoscopic gastric remodeling systems. ESG has demonstrated durable weight loss, favorable safety, and superior cost-effectiveness compared to pharmacotherapy alone, while combination strategies using EBTs and anti-obesity medications (AOMs), particularly GLP-1 receptor agonists, have resulted in greater total-body weight loss than either modality alone. Genetic variation, particularly within the leptin–melanocortin pathway, may predict response to endoscopic interventions and guide personalized treatment selection. Novel investigational procedures such as DMR, automated or robotic gastric remodeling, and magnetic or ultrasound-assisted gastric bypass show promising early results. Endoscopic therapies are poised to become increasingly central to the personalized, scalable management of obesity and related metabolic diseases.

ABSTRACTIntroductionEsophageal dysmotility following metabolic bariatric surgery (MBS) may relate to decreased gastric compliance. We investigated high‐resolution esophageal manometry (HRM) and secondary peristalsis assessed by functional lumen imaging probe (FLIP) and their association with intragastric pressure after MBS.MethodsPatients undergoing HRM, FLIP, and barium esophagram (BE) after MBS were included. HRM metrics and proximal intragastric pressure at baseline (IGP baseline), during wet swallow‐induced esophagogastric junction relaxation (IGP EGJ opening), and following wet swallow‐induced esophagogastric junction opening with subsequent closure (IGP post EGJ closure) were measured. Contractile response was assessed during FLIP.ResultsForty patients (26 Roux en Y gastric bypass, 14 sleeve gastrectomy) with FLIP a median of 4 years after MBS, were identified. HRM was normal or consistent with ineffective esophageal motility (IEM) in 33 (82.5%) patients, while the contractile response on FLIP was abnormal (disordered/impaired, absent, or spastic reactive) in 28 (70%). Delayed emptying on BE was numerically more frequent with abnormal FLIP (6% vs. 0%, p = 0.08). IGP post‐EGJ closure (median 21.8 vs. 15 mmHg, p = 0.03) and ∆ IGP post‐EGJ closure—IGP baseline (median 4 vs. 0 mmHg, p = 0.02) were greater and predictive of abnormal contractility on FLIP (OR 1.11, 95% CI 1.00–1.2, p = 0.03 and OR 1.6, 95% CI 1.07–2.39, p = 0.003, respectively).DiscussionAbnormal contractility on FLIP, reflecting disordered secondary peristalsis, frequently occurs despite normal HRM findings after MBS. Secondary peristalsis may be associated with reduced gastric compliance, reflected by elevated proximal intragastric pressure. FLIP contractility could serve as an early marker for post‐MBS esophageal dysfunction.

AbstractEndoscopic sleeve gastroplasty (ESG) is an effective treatment for obesity but typically is not covered by insurance. It is not known whether patients with financial investment in their endoscopic procedure are more likely to achieve and/or maintain weight loss as compared with those who have no financial buy-in. We aimed to compare treatment adherence and outcomes between patients paying out-of-pocket (OOP) and those who underwent ESG as part of any clinical trial where costs were covered by a study protocol (no payment; NP).Data were collected via retrospective chart review. One hundred sixty-four patients who had an ESG with at least 6 months of follow-up were included. Repeated measures with generalized linear model were used to evaluate weight loss at different time points after ESG and labs values at baseline and 1-year follow-up to assess for comorbidity improvement between cohorts. Compliance was evaluated by comparing exercise adherence rates.The pattern of weight loss and change in laboratory values was not different over time between the OOP group (n = 139) and NP group (n = 25). Patients lost an average of 14% (12.2–15.9) and 12.9% (9.3–16.5) of total body weight over all time points, respectively, in both groups (6, 12 and 24 months). Treatment adherence also did not differ between the groups.Having “skin in the game” by paying for ESG OOP does not correlate with better outcomes or treatment adherence, which further supports broad insurance coverage for this procedure.