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Bouveret syndrome is a rare form of gastric outlet obstruction resulting from gallstone migration through a bilioenteric fistula. Fewer than 300 cases have been reported in the literature, to our knowledge. We present the case of a 68-year-old man with severe postprandial pain, recurrent vomiting, and significant weight loss. Laboratory tests revealed severe anemia, metabolic acidosis, and acute kidney injury. Imaging and upper endoscopy identified a large duodenal gallstone associated with a cholecystoduodenal fistula and ischemic gastric ulcers. The patient underwent endoscopic management with laser lithotripsy and fragment extraction, achieving complete resolution of the obstruction. This case highlights the feasibility and effectiveness of endoscopic therapy, particularly laser lithotripsy, as a minimally invasive alternative to surgery in patients with Bouveret syndrome who present with high surgical risk.

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Pharyngeal squamous cell carcinoma (SCC) is increasingly detected at earlier stages in Japan, largely due to routine image-enhanced endoscopy and systematic pharyngeal examination. Endoscopic submucosal dissection (ESD) is now a preferred minimally invasive treatment option for superficial SCC, with excellent outcomes. Despite this, the technique remains underutilized in the West, even though the incidence of pharyngeal cancer continues to rise. This review brings together current evidence on pharyngeal ESD, indications, technique, outcomes, and adverse events. Across contemporary series, en bloc and R0 resection rates are consistently high, with serious adverse events occurring infrequently. Nonetheless, pharyngeal ESD involves unique challenges stemming from complex anatomy, specialized anesthesia, and specific exposure techniques. We highlight practical barriers limiting adoption in the West, particularly limited knowledge in optical diagnosis, and propose targeted education to close the knowledge gap. As demand increases for minimally invasive, organ-preserving treatments, pharyngeal ESD is poised to have an important role for the treatment of early pharyngeal SCC in Western practice.

Training in flexible gastrointestinal endoscopy is increasingly challenging. Simulation tools may help impart essential skills, but existing simulators lack real-time feedback, may be unrealistic, and are not aligned with recognized key performance indicators (KPIs). As a result, translating from simulator to real-world procedures has achieved variable outcomes. The Mikoto colonoscopy simulator (R Zero Inc, Tokyo, Japan) aims to address this gap by providing real-time feedback based on procedural dynamics, including patient comfort, producing a single performance-focused score (out of a maximum possible 100; the Mikoto Simulator Score [MSS]).We sought to establish construct and user validation for the MSS, with endoscopists' KPIs and structured user feedback. Twenty endoscopists of varying experience levels were recruited and categorized into novice, training, competent, and expert experience levels, based on lifetime colonoscopy numbers (national accreditation criteria). Participants provided their United Kingdom National Endoscopy Database (NED) KPIs before using the simulator. After standardized introduction and acclimatization, each then performed 3 full colonoscopies on the simulator, with the main test parameters being cecal intubation time and MSS. User validity was determined by means of a structured feedback questionnaire assessing utility and realism. Significant differences were observed in median NED KPIs and MSS across all experience levels (n = 5 in each group, P = .046), with a linear correlation between lifetime colonoscopy numbers and MSS (P = .027). There were also highly significant correlations demonstrated between MSS and NED colonoscopy comfort score (P < .001), polyp detection rate (P < .001), and cecal intubation rate (P < .001). The Mikoto simulator demonstrates close alignment with NED KPIs for colonoscopy, with linear correlation in most cases, providing initial validation as an indicator of endoscopic competence in a nonpatient-contact setting. Further studies are warranted to assess integration into endoscopy training. The Mikoto simulator represents a promising tool for enhancing endoscopic training and improving patient outcomes.

Fully covered self-expandable metal stents (FcSEMSs) have become the mainstay of treatment for a variety of biliary pathologies. However, FcSEMSs have been associated with a greater rate of stent migration than other types of stents. A technique of anchoring double-pigtail plastic stents (DPPSs) has been proposed to minimize migration of biliary FcSEMSs. Herein, we evaluated the efficacy of anchoring DPPSs among patients treated with biliary FcSEMSs. We performed a systematic review using PubMed, EMBASE, and Web of Science from database inception through August 2023. Full-text articles comparing FcSEMSs with or without anchoring DPPSs were included. We evaluated the following outcomes: (1) stent migration; (2) stent occlusion; (3) duration of stent patency; (4) cholangitis; (5) unplanned reinterventions; and (6) adverse events. Meta-analysis was carried out using random-effect models and reported as odds ratios (ORs) with corresponding 95% confidence intervals (95% CIs). Four studies encompassing 489 patients were included. Patients with anchoring DPPSs had a 67% reduction in FcSEMS migration compared with those without anchoring DPPSs (OR: 0.33; 95% CI, 0.19-0.57; I 2 0%). Anchoring DPPSs increased the mean duration of FcSEMS patency by 83 days compared with FcSEMSs alone (95% CI, 46-120; I 2 94%). No differences in other clinical end points or adverse events were observed. Anchoring DPPSs reduced the risk of FcSEMS migration and increased the duration of FcSEMS patency without an increased risk of adverse events. Future studies are needed to corroborate these findings, determine the optimal DPPS technique, and to compare DPPS placement with other antimigratory modalities.

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Artificial intelligence (AI)-assisted colonoscopy for polyp detection is designed to improve colonoscopy quality. Although surveys have assessed staff gastroenterologists' attitudes toward AI, less is known about the views of gastroenterology (GE) fellows regarding AI during training. We conducted a nationwide survey of GE fellows from August 2024 to November 2024 to assess (1) exposure to and experience with AI in fellowship, (2) perceptions of AI's impact on colonoscopy quality, and (3) attitudes toward implementing AI into training. The survey included Likert scale questions with branching logic to tailor questions based on AI availability at the fellows' institutions. A total of 126 fellows started the survey, and 88 (69.8%) completed it. AI was available at least at 1 training site for 69.3% of respondents. In addition, 81.8% of fellows believed AI should be available during fellowship. Many fellows (43.2%) thought AI should be incorporated in the second year of training. Most fellows (60.7%) believed early exposure to AI-enhanced polyp detection skills. However, 52.5% felt neutral that AI made them better endoscopists overall. Despite this, 62.5% preferred to pursue a job with AI if they had trained with it. Our nationwide survey found that GE fellows are generally supportive of integrating AI into their training, with most advocating for its incorporation in the second year. These results should be considered by fellowship program leadership and GE practices recruiting fellows trained with AI. Further studies are required to assess the impact of training GE fellows with AI on their polyp detection competency.

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Accurate differentiation of pancreatic solid tumors, including pancreatic neuroendocrine neoplasms (pNENs) and pancreatic ductal adenocarcinomas (PDACs), is crucial because of their distinct prognoses and treatments. Contrast-enhanced endoscopic ultrasound (CE-EUS) assesses vascularization differences but is limited by subjective interpretation and low interobserver agreement. The aim of this article is to evaluate the role of quantitative CE-EUS in differentiating pNENs from PDACs. This observational study included patients with a cytological diagnosis of PDACs or pNENs undergoing CE-EUS from January to June 2024. CE-EUS videos were analyzed using software for objective contrast quantification. Vascular parameters were compared between tumor types using Mann-Whitney U tests and receiver operating characteristic analysis. Among 73 patients (51 with PDACs/22 with pNENs), pNENs had significantly greater contrast intensity, peak enhancement, and wash-in area under the curve. Receiver operating characteristic curves identified wash-in perfusion index and wash-in rate as the most discriminative parameters, achieving an area under the curve of 96.1% when combined. Quantitative CE-EUS appears to enhance pancreatic tumor differentiation by eliminating subjectivity and improving diagnostic accuracy.

Delayed gastric emptying (DGE) is a frequent adverse event after Ivor Lewis esophagectomy, negatively affecting quality of life. Although gastric peroral endoscopic pyloromyotomy (G-POEM) is effective for gastroparesis, its role in postesophagectomy DGE remains uncertain. This study evaluates the feasibility and outcomes of G-POEM in this setting. We conducted a single-center retrospective analysis of 11 patients who underwent G-POEM after Ivor Lewis esophagectomy, all of whom had symptomatic DGE confirmed by gastric-emptying studies and Gastroparesis Cardinal Symptom Index scores. All patients had confirmed DGE, with a median 49% (interquartile range, 24-80) gastric retention at 4 hours on gastric-emptying studies (normal is &#x2264;10% retention at 4 hours). After G-POEM, gastric emptying normalized in 50% of patients and improved in 37.5%, with a median retention of 13% (0-75) at 4 hours. The median Gastroparesis Cardinal Symptom Index score improved from 25 (11-33) to 11 (2-33), where a score of 0 indicates no symptoms. Prokinetic use declined from 45.5% to 9.1%. The median procedure time was 68 (33-110) minutes, hospital stay was 1 (1-5) day, and no immediate adverse events were reported. G-POEM appears to be a feasible and safe treatment for DGE after Ivor Lewis esophagectomy, associated with early symptomatic improvement and minimal hospital stay although further prospective studies are needed.

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After Roux-en-Y gastric bypass (RYGB), accessing the excluded or remnant stomach (RS) is difficult using standard endoscopy, and double-balloon enteroscopy (DBE) is often used when pathology is suspected. Data on the use of DBE for this purpose are limited. We investigated the success rate, technical factors, and findings when using DBE to access the RS after RYGB. This was a retrospective analysis of adult patients with RYGB who underwent DBE to access the RS between January 2018 and July 2023 across 3 academic medical centers. Primary aims were identifying the technical success rate of accessing the RS and associated endoscopic findings. Secondary aims were identifying patient characteristics, procedure indications, factors behind technical failures, studies preceding DBE, endoscopic therapies performed, and procedural adverse events. Eighty-nine patients underwent DBE to access the RS after RYGB for anemia/bleeding (56.2%), abdominal pain (32.6%), and abnormal imaging (44.9%). The RS was successfully accessed in 71.9% of cases. The most common reasons the RS was not accessed were proximal pathology (40%), anastomotic angulation (32%), and limb length (16%). Many (40.4%) examination results were normal. The most common findings were inflammatory (30.3%) or vascular (15.7%), 6.7% had polyps, and 5.6% had malignant neoplasm. Biopsy (50.6%) and hemostatic maneuvers (20.2%) were commonly performed. Accessing the RS was not associated with patient age, procedural indication, or time from RYGB. DBE served as definitive management in 29.2% of cases, and no procedural adverse events occurred. The RS in RYGB can be successfully and safely accessed with DBE.

Immune-mediated colitis (IMC) is a challenging adverse effect of immune checkpoint inhibitor therapy, often leading to treatment interruption or discontinuation. Current IMC endoscopic scoring systems were adapted from those used for inflammatory bowel disease but fail to fully capture IMC. The newly proposed IMC endoscopic score (IMCES) seeks to help guide prognosis and treatment. We aimed to validate IMCES and explore its association with IMC clinical severity and outcomes. This single-center retrospective study included patients with IMC who received immune checkpoint inhibitors and underwent endoscopic evaluation. IMCESs were calculated on the basis of 10 gross endoscopic features, as previously reported. Patients were divided into those with IMCES <4 and IMCES &#x2265;4. Primary end points were selective immunosuppressive therapy (SIT) use, hospitalization, and clinical and endoscopic remission. We evaluated 807 patients, including the 308 previously used to develop IMCES, with 499 in a validation cohort. We found that IMCES &#x2265;4 was associated with need for steroids and SIT (P < .05). Patients with IMCES &#x2265;4 also tended to be hospitalized more often and longer (P < .05). Including ulceration as a criterion in IMCES strengthened these associations. Clinical symptoms had lower specificities for being associated with SIT use (26.8% for diarrhea, 64.6% for colitis) compared to IMCES &#x2265;4 (91.5%). IMCES &#x2265;4 had a high specificity for the need for SIT and was associated with worse outcomes. Given the importance of risk stratification in the treatment of IMC to inform the early introduction of SIT, IMCES may be a powerful clinical tool to estimate prognosis and guide management but requires further validation.

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Endoscopic management of Zenker's diverticulum has rapidly evolved with the emergence of innovative therapeutic endoscopic approaches and the integration of novel devices. These techniques offer unprecedented precision and safety, although rare, adverse events can become catastrophic if not promptly recognized and managed. This narrative review explores recent innovations in third-space techniques and novel devices, with a focused, detailed discussion on recognizing and effectively managing adverse events.

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