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Background and Aims: Weight recidivism following sleeve gastrectomy (SG) is common. Adjuvant treatments include new glucagon-like peptide 1 and glucose-dependent insulinotropic peptide receptor agonists (GLP1/GIP-RA) or revisional endoscopic sleeve gastroplasty (R-ESG). We here compare the outcomes of these treatments., Methods: A retrospective study of patients ≥18 years with prior SG treated with semaglutide, tirzepatide or R-ESG for weight recidivism between January 2019 and 2023 at large academic centre. Primary outcomes were total body weight loss (TBWL) and adverse events (AEs). Secondary outcomes were changes in metabolic parameters. Tertiary outcome was to compare GLP1/GIP-RA outcomes in SG patients to matched patients with intact stomach., Results: Our study included 68 (prior SG + GLP1/GIP-RA) and 22 (prior SG + R-ESG). R-ESG offered higher TBWL% than GLP1/GIP-RA at 3 (11.2% vs. 4.3%, p < .001), 6 (13.5% vs. 6.8%, p < .001) and 12 months (13.4% vs. 9.2%, p = .07) with no significant difference in AEs or change in metabolic parameters. On subgroup analysis, tirzepatide achieved similar 12-months TBWL% as R-ESG (13.2% vs. 13.4%, p = .9) and significantly more than semaglutide (13.2% vs. 8.1%, p = .04). Compared to patients with intact stomach (n = 87), GLP1/GIP-RA achieved significantly lower TBWL% in patients with prior SG at 3 (4.3% vs. 5.7%, p = .02), 6 (6.8% vs. 9.2%, p = .02) and 12 months (9.2% vs. 12.7%, p = .03). Medication refills were difficult in 41.3% of patients., Conclusions: In a single-centre real-world experience study, R-ESG and tirzepatide appear to offer more weight loss than semaglutide in SG patients with weight recidivism although GLP1/GIP-RA were underdosed. GLP1/GIP-RA achieved higher weight loss in patients with intact stomach than those with prior SG., (© 2025 World Obesity Federation.)

Background/aims: Endoscopic ultrasound guided portosystemic pressure gradient measurement (EUS-PPG) is a novel technique to evaluate for portal hypertension (PH), a diagnosis that can prognosticate and guide therapy for patients. This study evaluated the safety and efficacy of EUS-PPG and correlation with clinical parameters and liver histology., Methods: We conducted a multi-center, retrospective study of patients undergoing EUS-PPG from January 2020 to December 2022 for suspected liver disease or PH. Linear regression was used to examine the relationship between EUS-PPG and clinical parameters of PH and the chi square test, Fisher's exact test, and Wilcoxon Rank Sums test described correlation with liver biopsy histology and non-invasive markers of fibrosis (FIB-4, APRI). Logistic regression was performed to identify the strongest predictor of histologic cirrhosis., Results: Across 8 centers, 385 patients were enrolled and 373 had successful EUS-PPG (technical success 97%). Higher median PPGs were observed in patients with than without esophageal varices (11.6mmHg vs 4.1), portal hypertensive gastropathy (10.5mmHg vs 3.3), and thrombocytopenia (7.6 mmHg vs 4.4) (p<0.001). Individuals with PH and clinically significant PH (PPG>10) were 6.7 and 3.8 times more likely to have cirrhosis on histology. EUS-PPG was the best overall predictor of biopsy proven cirrhosis (AUC 0.84) compared to FIB-4 (0.72), and APRI (0.54). There were 2 minor adverse events related to PPG (post procedural pain)., Conclusions: EUS-PPG measurement was technically feasible, safe and demonstrated strong correlation with clinical parameters of PH and liver histology. The strongest predictor of cirrhosis was EUS-PPG >5mm Hg which outperformed non-invasive markers of fibrosis., (Copyright © 2025. Published by Elsevier Inc.)

Background and Aims: Transoral incisionless fundoplication (TIF) is an established safe endoscopic technique for the management of GERD but with variable efficacy. In the past decade, the TIF technology and technique have been optimized and more widely accepted, but data on outcomes outside clinical trials are limited. We tracked patient-reported and clinical outcomes of GERD patients after TIF 2.0., Methods: Patients with body mass index <35 kg/m 2 , hiatal hernia <2 cm, and confirmed GERD with typical or atypical symptoms from 9 academic and community medical centers were enrolled in a prospective registry and underwent TIF 2.0 performed by gastroenterologists and surgeons. The primary outcomes were safety and clinical success (response in 1 subjective and at least 1 of 3 objective secondary end points). Secondary end points were symptom improvement, acid exposure time (AET), esophagitis healing, proton pump inhibitor (PPI) use, and satisfaction. Outcomes were assessed at last follow-up within 12 months., Results: A total of 85 patients underwent TIF 2.0, and 81 were included in the outcomes analysis. Clinical success was achieved in 94%, GERD Health-Related Quality of Life scores improved in 89%, and elevated Reflux Symptom Index score normalized in 85% of patients with elevated baseline. Patient satisfaction improved from 8% to 79% (P < .0001). At baseline, 81% were taking at least daily PPI, and after TIF 2.0, 80% were on no or occasional PPI (P < .0001). Esophageal AET was normal in 72%, greater with an optimized TIF 2.0 valve (defined as >300-degree circumference and >3-cm length; 94% vs 57%; P = .007). There were no TIF 2.0-related serious adverse events., Conclusions: TIF 2.0 is a safe and effective endoscopic outpatient treatment option for selected patients with GERD., Competing Interests: Disclosure The following authors disclosed financial relationships: M. I. Canto: research grant to Johns Hopkins University from EndoGastric Solutions for this investigator-initiated prospective TIF Registry (the sponsor had no influence on the design, conduct, data collection, analysis, interpretation of results, and manuscript preparation), research grants from Pentax Medical Corporation, royalties from UpToDate, and consultant for Castle Biosciences and BlueStar Genomics; P. Janu: consultant for EndoGastric Solutions, Ethicon, Johnson and Johnson, and Olympus; D. L. Diehl: speaker for EndoGastric Solutions; B. Parker: consultant for EndoGastric Solutions; B. K. Abu-Dayyeh: research support from EndoGastric Solutions, Spatz Medical, and ERBE, speaker for Endogastric Solutions, and consultant for Boston Scientific, Olympus, and Medtronic; J. Kolb: consultant for Castle Biosciences and research support from Exact Sciences; M. Murray: consultant for EndoGastric Solutions; R. Sharaiha: consultant for Olympus, Boston Scientific, Cook Medical and Surgical Intuitive and research grants from Boston Scientific and Cook Medical; O. I. Brewer Gutierrez: consultant for EndoGastric Solutions; K. Chang: consultant for and educational grants from Apollo Endosurgery, Cook, Creo, EndoGastric Solutions, Erbe, Medtronic, and Olympus, and member of the EndoGastric Solutions scientific advisory board. All other authors disclosed no financial relationships., (Copyright © 2025 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: The COVID-19 pandemic dramatically impacted endoscopy practice. Recommendations were to postpone elective cases, including procedures for removal of luminal neoplasia. This provided a natural experiment to evaluate outcomes related to these decisions and the impact of time to procedure on change in histology., Aims: The primary aim is to examine time to endoscopy for therapy of colorectal polyps and Barrett's esophagus with dysplasia and oncologic outcomes during the COVID-19 pandemic., Methods: This was a retrospective cohort study of individuals referred for endoscopic therapy of advanced colorectal polyps and dysplastic Barrett's esophagus (BE) between July 2019 and January 2022. Multivariable logistic regression was used to evaluate whether time to therapeutic exam was associated with a change in histology. Time from index to therapeutic exam before versus after the start of the pandemic (March 20, 2020) was compared using a Cox regression., Results: There were 310 patients (56% male, mean age 65) who were referred for colon polyps (n = 256) and BE-related neoplasia (n = 54). The median time to therapeutic exam was 78 days (range 4-718). Time to therapy was shorter for colon polyp cases completed after versus before the pandemic (HR: 1.49, 95% CI 1.14-1.96). The pandemic was not associated with a difference in time to exam for BE. Change in histology from index to therapeutic exam was noted in 51 cases (16.5%) and was mostly upstaging (70.6%). There was no association between time to therapeutic exam, sex, or timing related to the pandemic on the probability of being upstaged for colon polyps or BE., Conclusions: Fewer than 1 in 5 cases had a change in histology from index to therapeutic exam, and there was no delay related to the COVID-19 pandemic. These findings suggest that procedures for removal of advanced colon polyps or dysplastic BE can potentially be postponed with minimal impact, helping guide triaging decisions going forward., Competing Interests: Declarations. Conflict of interest: JMK serves as a consultant for Castle Biosciences. SW has served as a consultant for Boston Scientific, Cernostics, Interpace, Exact Sciences, and Medtronic and has received research support from Lucid, Ambu, and CDx Diagnostics. No other authors have disclosures, (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Importance: Early-onset colorectal cancer (EOCRC), defined as a diagnosis at younger than age 50 years, is increasing, and so-called red flag signs and symptoms among these individuals are often missed, leading to diagnostic delays. Improved recognition of presenting signs and symptoms associated with EOCRC could facilitate more timely diagnosis and impact clinical outcomes., Objective: To report the frequency of presenting red flag signs and symptoms among individuals with EOCRC, to examine their association with EOCRC risk, and to measure variation in time to diagnosis from sign or symptom presentation., Data Sources: PubMed/MEDLINE, Embase, CINAHL, and Web of Science were searched from database inception through May 2023., Study Selection: Studies that reported on sign and symptom presentation or time from sign and symptom presentation to diagnosis for patients younger than age 50 years diagnosed with nonhereditary CRC were included., Data Extraction and Synthesis: Data extraction and quality assessment were performed independently in duplicate for all included studies using Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guidelines. Joanna Briggs Institute Critical Appraisal tools were used to measure risk of bias. Data on frequency of signs and symptoms were pooled using a random-effects model., Main Outcomes and Measures: Outcomes of interest were pooled proportions of signs and symptoms in patients with EOCRC, estimates for association of signs and symptoms with EOCRC risk, and time from sign or symptom presentation to EOCRC diagnosis., Results: Of the 12 859 unique articles initially retrieved, 81 studies with 24 908 126 patients younger than 50 years were included. The most common presenting signs and symptoms, reported by 78 included studies, were hematochezia (pooled prevalence, 45% [95% CI, 40%-50%]), abdominal pain (pooled prevalence, 40% [95% CI, 35%-45%]), and altered bowel habits (pooled prevalence, 27% [95% CI, 22%-33%]). Hematochezia (estimate range, 5.2-54.0), abdominal pain (estimate range, 1.3-6.0), and anemia (estimate range, 2.1-10.8) were associated with higher EOCRC likelihood. Time from signs and symptoms presentation to EOCRC diagnosis was a mean (range) of 6.4 (1.8-13.7) months (23 studies) and a median (range) of 4 (2.0-8.7) months (16 studies)., Conclusions and Relevance: In this systematic review and meta-analysis of patients with EOCRC, nearly half of individuals presented with hematochezia and abdominal pain and one-quarter with altered bowel habits. Hematochezia was associated with at least 5-fold increased EOCRC risk. Delays in diagnosis of 4 to 6 months were common. These findings highlight the need to identify concerning EOCRC signs and symptoms and complete timely diagnostic workup, particularly for individuals without an alternative diagnosis or sign or symptom resolution.

Competing Interests: Competing interests: None declared.

Background and Aims: Data on how to teach endosonographers needle-based confocal laser endomicroscopy (nCLE)-guided histologic diagnosis of pancreatic cystic lesions (PCLs) are limited. Hence, we developed and tested a structured educational program to train early-career endosonographers in nCLE-guided diagnosis of PCLs., Methods: Twenty-one early-career nCLE-naïve endosonographers watched a teaching module outlining nCLE criteria for diagnosing PCLs. Participants then reviewed 80 high-yield nCLE videos, recorded diagnoses, and received expert feedback (phase 1). Observers were then randomized to a refresher feedback session or self-learning at 4 weeks. Eight weeks after training, participants independently assessed the same 80 nCLE videos without feedback and provided histologic predictions (phase 2). Diagnostic performance of nCLE to differentiate mucinous versus nonmucinous PCLs and to diagnose specific subtypes were analyzed using histopathology as the criterion standard. Learning curves were determined using cumulative sum analysis., Results: Accuracy and diagnostic confidence for differentiating mucinous versus nonmucinous PCLs improved as endosonographers progressed through nCLE videos in phase 1 (P < .001). Similar trends were observed with the diagnosis of PCL subtypes. Most participants achieved competency interpreting nCLE, requiring a median of 38 assessments (range, 9-67). During phase 2, participants independently differentiated PCLs with high accuracy (89%), high confidence (83%), and substantial interobserver agreement (κ = .63). Accuracy for nCLE-guided PCL subtype diagnoses ranged from 82% to 96%. The learned nCLE skills did not deteriorate at 8 weeks and were not impacted by a refresher session., Conclusions: We developed a practical, effective, and durable educational intervention to train early-career endosonographers in nCLE-guided diagnosis of PCLs., Competing Interests: Disclosure The following authors disclosed financial relationships: J. D. Machicado: Speaker for Mauna Kea Technologies. S. G. Krishna: Speaker for and research support from Mauna Kea Technologies. B. Napoleon: Speaker for Mauna Kea Technologies. All other authors disclosed no financial relationships., (Copyright © 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Novel, less-invasive technologies to screen for Barrett's esophagus (BE) may enable a paradigm shift in early detection strategies for esophageal adenocarcinoma (EAC). Understanding professionals' perspectives on screening is important to determine how to proceed. We aimed to explore and compare professionals' perceptions of screening for BE and EAC screening in three countries., Methods: In this study, 29 Dutch, 20 British and 18 American health care professionals (clinicians, researchers and policy makers) participated in concept mapping: a mixed-methods consensus building methodology. Statements on perceived barriers, facilitators, advantages, disadvantages, implications or worries associated with screening for BE and EAC were collected in asynchronous digital brainstorm sessions. Subsequently, participants sorted the statements into groups according to thematic similarity and assessed the relevance of each statement in evaluating the acceptability of BE and EAC screening. Multidimensional scaling and cluster analysis were used to map the associations between generated statements., Results: Professionals across three countries identified eight consistent themes that relate to their perceptions of screening for BE and EAC: (1) Benefits, (2) Harms, (3) Clinical effectiveness concerns, (4) Screening population, (5) Screening modality, (6) Resources, (7) Ownership, and (8) Public communication. Dutch and American professionals prioritized the potential health benefits of screening but also questioned clinical impact. In contrast, British participants prioritized identification of the screening population and suitable test., Conclusions: Most professionals see potential in less-invasive screening tests for BE and EAC but underline the need to define the target screening population and determine benefits and harms before widely employing them. Successful implementation will require thoughtful consideration of the involvement of general practitioners, readiness of endoscopy and pathology services, balanced public communication, and country-specific regulations., (© 2023. The Author(s).)

Background: The Eckardt score (ES) is used to assess symptom response to Per-Oral Endoscopic Myotomy (POEM), but reliable methods to assess physiologic success are needed. Functional lumen imaging probe (FLIP) panometry has a potential role in post-POEM follow-up to predict long-term outcomes. The aim of this study was to assess the correlation between clinical success and FLIP parameters following POEM to determine if short interval FLIP could predict long-term outcomes., Methods: This was a prospective study of adult patients who underwent POEM with short interval follow-up FLIP between 11/2017 and 3/2020. Clinical success was defined as post-procedure ES ≤ 3. Physiologic success was based on an esophago-gastric junction distensibility index (EGJ-DI) > 2.8 mm 2 /mmHg on FLIP., Results: 47 patients (55% female, mean age 55 years) were included in the study. Clinical success after POEM was seen in 45 (96%) patients (mean ES 6.5 ± 2.2 pre and 0.83 ± 1.0 post-POEM, p < 0.001). Physiologic success was noted in 43 (91.5%) patients (mean EGJ-DI 6.1 mm 2 /mmHg ± 2.5). Among 4 patients not meeting criteria for physiologic success, EGJ-DI was 2.5-2.6. There was no correlation between post-POEM EGJ-DI and ES in the short term or long term. Significant reflux esophagitis was seen in 6 (12.8%) patients with no difference in mean EGJ-DI with vs without esophagitis (5.9 vs 6.1, p = 0.44)., Conclusion: Post-POEM endoscopy with FLIP is useful to both assess EGJ physiology and to examine for reflux esophagitis. Short interval FLIP has limited utility to predict long-term patient outcomes or risk of acid reflux., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose of Review: Gastroesophageal reflux disease (GERD) is exceedingly common and can significantly impact quality of life through heartburn, troublesome regurgitation, or atypical symptoms. The initial approach is conservative lifestyle changes followed by medications with escalation to antireflux surgery as needed. Endoscopic therapy may represent a bridge between pharmacotherapy and surgery and represents an appropriate option for select individuals., Recent Findings: Appropriate patient selection for endoscopic antireflux therapies is critical to the success of the intervention. Candidates for endoscopic treatment with trans-oral incisionless fundoplication (TIF) include those with a small (<2 cm) or no hiatal hernia and a Hill valve grade 1 or 2. Transoral incisionless fundoplication with concomitant hiatal hernia repair (cTIF) is a safe and effective option that addresses both the crural diaphragm and gastroesophageal flap valve (GEFV)., Summary: Endoscopic interventions for GERD continue to evolve and are not all created equal. Given our current understanding of the mechanisms of GERD, the TIF procedure stands out in its ability to re-create the optimal GEFV. In those patients with altered anatomy, endoscopic approaches may offer at least partial benefit., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Variability in adherence rates to the Seattle protocol and to surveillance interval recommendations, established quality indicators (QIs) in Barrett's esophagus (BE), is unknown., Methods: We evaluated endoscopist and site-based adherence rates to these QIs from January 2018 to May 2021 using the GI Quality Improvement Consortium national registry with matched endoscopy and pathology data., Results: Across 153 practices with 572 endoscopists performing 20,155 endoscopies, adherence to the Seattle protocol varied by endoscopists (median 93.8%, IQR 18.9%) and by site (median 90.0%, IQR 20.1%). Adherence to appropriate surveillance intervals for nondysplastic BE also varied by endoscopist (median 82.4%, IQR 36.3%) and site (median 77.2%, IQR 29.8%). The overall dysplasia detection rate was 3.1% and varied among endoscopists and sites., Discussion: These US population-based results can serve as a benchmark for quality initiatives and intervention trials aimed at improving outcomes for patients with BE., (Copyright © 2022 by The American College of Gastroenterology.)

Introduction: Most patients with esophageal adenocarcinoma (EAC) do not have a previous diagnosis of Barrett's esophagus (BE), demonstrating a failure of current screening practices. An understanding of patient attitudes and barriers is essential to develop and implement interventions to improve BE screening adherence., Methods: We conducted a Web-based survey of patients aged >50 years with chronic gastroesophageal reflux disease at 3 academic medical centers and 1 affiliated safety net health systems. Survey domains included patient characteristics, endoscopy history, familiarity with screening practices, perceived BE/EAC risk, and barriers to screening., Results: We obtained a response rate of 22.6% (472/2,084) (74% men, mean age 67.9 years). Self-identified race and ethnicity of participants was 66.5% non-Hispanic White, 20.0% non-Hispanic Black, 13.4% other race, and 7.1% Hispanic. Screening for BE was recommended in only 13.2%, and only 5.3% reported previous screening. Respondents had notable gaps in knowledge about screening indications; only two-thirds correctly identified BE risk factors and only 19.5% believed BE screening was needed for gastroesophageal reflux disease. More than 1 in 5 respondents believed they would get BE (31.9%) or EAC (20.2%) but reported barriers to screening. Compared with White respondents, more Black respondents were concerned about getting BE/EAC and interested in screening but report higher barriers to screening., Discussion: Patients at risk for BE, particularly racial and ethnic minorities, are worried about developing EAC but rarely undergo screening and have poor understanding of screening recommendations., (Copyright © 2022 by The American College of Gastroenterology.)

Purpose of Review: Endoscopic eradication therapy is an effective and durable treatment for Barrett's esophagus (BE) related neoplasia, but even after achieving successful eradication, these patients remain at risk for recurrence and require ongoing routine examinations. The optimal surveillance protocol including endoscopic technique, sampling strategy, and timing are still being refined. The aim of this review is to discuss current management principles for the post ablation patient and emerging technologies to guide clinical practice., Recent Findings: There is increasing evidence to support less frequent surveillance exams in the first year after complete eradication of intestinal metaplasia and a move towards targeted biopsies of visible lesions and sampling high-risk locations such as the gastroesophageal junction. Promising technologies on the horizon that could impact management include novel biomarkers, personalized surveillance intervals, and non-endoscopic approaches., Summary: Ongoing high-quality examinations after endoscopic eradication therapy are key to limiting recurrent BE. Surveillance intervals should be based on the pretreatment grade of dysplasia. Future research should focus on technologies and surveillance practices that are most efficient for patients and the healthcare system., Competing Interests: Competing InterestsChristian Davis declares that he has no conflict of interest. Jennifer M. Kolb declares that she has no conflict of interest., (© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2023.)

Background/aims: Barrett's esophagus (BE), defined by the presence of intestinal metaplasia (IM) on histology, is thought to be the only identifiable precursor lesion for esophageal adenocarcinoma (EAC). Recent studies have suggested the possibility of an alternate, non-IM associated EAC that is a more aggressive form of EAC with worse survival. Among EAC patients, we aimed to compare survival of patients with and without IM at the time of diagnosis., Methods: This was a retrospective cohort study of all patients with histologic confirmed EAC evaluated at a tertiary care center from 2013 to 2019. Cases were categorized according to the presence or absence of IM on histologic specimens (Group I-IM-EAC and Group II-non-IM-EAC). We compared demographic characteristics, clinical stage, therapy, and survival between the 2 groups using the Chi-square and ANOVA tests (for categorical and continuous variables, respectively). We used Cox proportional hazards regression to determine the association of IM with overall survival, adjusting for sex, age at diagnosis, tumor location, histologic grade, and clinical stage., Results: A total of 475 patients were included in this analysis (mean age 64.8 years [SD 10.8], 89% white) and 109 (23.0%) had no evidence of IM. Compared with IM-EAC (Group I), individuals in the non-IM-EAC group were younger ( P = .01) and had a greater proportion of patients diagnosed with advanced disease (49.5 vs 20.2% for stage 4, P < .001). These patients were less likely to undergo endoscopic therapy alone (0.92% vs 29.78%, P < .001) or surgery alone (0 vs 9.84%, P = .001). On multivariable analysis, the presence of IM-EAC was associated with improved overall survival compared to non-IM-EAC (HR 0.69, 95% CI 0.49-0.96). Additional factors associated with poor survival was increasing stage of diagnosis (HR 6.49: 95% CI 3.77-11.15 for stage 4, HR 2.19: 95% CI 1.25-3.84 for stage 3, HR 2.04: 95% CI 0.98-4.25 for stage 2 compared to stage 1) and more advanced histologic stage (HR 2.00, 95% CI 1.26-3.19) for poorly/undifferentiated compared to well differentiated)., Conclusions: EAC without the presence of IM on histology was associated with worse survival compared to those with IM. Future prospective studies with detailed molecular sequencing are required to clarify if 2 separate phenotypes of EAC exist (IM-EAC and non-IM-EAC). If confirmed, this may have significant implications for screening and management strategies.

Surveillance guidelines following polypectomy promote cost-effective reductions in future colorectal cancer (CRC) risk, but high nonadherence rates 1 can have negative consequences on costs and effectiveness. Professional societies recommend a 3-year interval for patients with advanced colorectal polyps (ACPs), although few studies report provider adherence to surveillance intervals. 2 This study evaluated rates and predictors of guideline-discordant recommendations for patients with ACPs., (Copyright © 2022 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Efforts to assess and improve the effectiveness of Barrett's esophagus (BE) screening and surveillance are ongoing in the United States. Currently, there are limited population-based data in the United States to guide these efforts., Methods: We performed a retrospective cohort study using data from large commercial and Medicare Advantage health plans in the United States from 2004 - 2019. We identified individuals with BE and analyzed the proportion who developed EAC. EACs were classified as prevalent EAC (diagnosed within 30 days of index endoscopy), post-endoscopy esophageal adenocarcinoma (PEEC, diagnosed 30 - 365 days after index endoscopy), and incident EAC (diagnosed 365 days or more after index endoscopy). Using this cohort, we performed a nested case-control study to identify factors associated with prevalent EAC at BE diagnosis and study healthcare utilization prior to BE diagnosis., Results: We identified 50,817 individuals with incident BE. Of the 366 who developed EAC, 67.2%, 13.7%, and 19.1% were diagnosed with prevalent EAC, PEEC, and incident EAC respectively. Factors positively associated with prevalent EAC versus BE without prevalent EAC included male sex, dysphagia, weight loss, and Charlson-Deyo comorbidity score. In those with prevalent EAC, most patients with dysphagia or weight loss had their symptoms first recorded within three months of EAC diagnosis. Healthcare utilization rates were similar between those with and without prevalent EAC., Conclusions: Two-thirds of EACs among individuals with BE are diagnosed at the time of BE diagnosis. Additionally, PEEC accounts for 14% of these EACs. These results may guide future research studies that investigate novel BE diagnostic strategies that reduce the morbidity and mortality of EAC., (Copyright © 2022 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Barrett's esophagus (BE) screening is not highly utilized in the United States, and there are few data describing providers' approach to screening. To fill this gap and guide the implementation of future BE screening strategies, we studied evaluation practice patterns for gastroesophageal reflux disease (GERD) by nongastroenterologists., Methods: We performed a retrospective cohort study of patients with chronic GERD using health claims data from the United States between 2005 and 2019. We used up to 5 years of data after the diagnosis of chronic GERD to determine patient factors associated with completion of a gastroenterology encounter. We also identified patient factors associated with whether the first gastroenterology encounter was a direct-access upper endoscopy or an office visit., Results: We identified 484,023 patients diagnosed with chronic GERD by a nongastroenterology provider. The cumulative incidence of completing a gastroenterology encounter within 5 years was 38.7%. Gastrointestinal symptoms, such as dysphagia (adjusted hazard ratio [aHR] = 2.11, 95% confidence interval [CI] = 1.94-2.30), abdominal pain (aHR = 1.89, 95% CI = 1.85-1.94), and melena (aHR = 1.73, 95% CI = 1.65-1.82), were strongly associated with completion of a gastroenterology encounter. The patient factors strongly associated with direct-access upper endoscopy included dysphagia (aHR = 1.68, 95% CI = 1.52-1.85), weight loss (aHR = 1.46, 95% CI = 1.28-1.63), and melena (aHR = 1.42, 95% CI = 1.28-1.56)., Conclusion: A total of 38.7% of patients with chronic GERD complete a gastroenterology encounter within 5 years of diagnosis, and gastrointestinal alarm symptoms are the most strongly associated factors for receiving gastroenterology care. These findings highlight the importance of incorporating primary care providers in the development of new BE screening programs.

Background and Aims: Gastric peroral endoscopic pyloromyotomy (G-POEM) is emerging as a treatment option for patients with gastroparesis. The most technically difficult part of the procedure is creating a submucosal tunnel in the gastric antrum, which can be directionally challenging. We describe a novel navigational tunneling method that guides submucosal dissection in the direction of the pylorus and helps to identify the pyloric landmarks., Methods: Consecutive patients from September to December 2020 who underwent G-POEM for symptomatic gastroparesis were included. All cases were confirmed by prolonged gastric emptying study. The navigational tunnel technique was performed as follows: (1) mucosal cautery markings were made to outline the tunnel starting 3 to 4 cm proximal to the pylorus, (2) submucosal injection was done at the level of the pylorus and extended backward to the incision point, and (3) submucosal dissection was carried out after the prior submucosal injection straight to the pylorus., Results: Six patients with gastroparesis underwent G-POEM with the navigational tunneling technique. The average time for submucosal injection was 2 minutes and 42 seconds, and the average tunnel time was 15 minutes and 36 seconds. There were no adverse events. All patients reported significant improvement (50%-85%) in symptoms., Conclusions: This novel navigational tunneling technique appears to guide and facilitate G-POEM by providing a visual path for submucosal dissection straight to the pylorus. It may increase efficiency, decreasing the need to repeatedly exit the tunnel to check direction and preventing nonproductive wandering. It may also help identify the pyloric ring within the tunnel., (© 2022 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Background & Aims: Incidence and mortality associated with early-age onset colorectal cancer (EAO-CRC) is increasing, prompting professional society recommendations to lower the screening age in average-risk individuals. The yield of screening individuals younger than 50 years is not known., Methods: A systematic review of 3 databases from inception through July 2020 was performed in all languages that reported colonoscopy findings in average-risk individuals younger than 50 years. The primary outcomes were EAO colorectal neoplasia (CRN) and advanced colorectal neoplasia (aCRN) prevalence. Subgroup analyses were performed based on sex, geographic location, time period, and age, including comparison with those aged 50-59 years. Generalized linear mixed model with random intercept logistic regression and fixed subgroup effects were performed., Results: Of 10,123 unique articles, 17 studies published between 2002 and 2020, including 51,811 average-risk individuals from 4 continents, were included. The pooled rate of EAO-CRN was 13.7% (95% confidence interval [CI], 0.112%-0.168%) and EAO-aCRN was 2.2% (95% CI, 0.016%-0.031%). Prevalence of CRC was 0.05% (95% CI, 0.00029%-0.0008%). Rates of EAO-CRN were higher in men compared with women (relative risk, 1.71%; 95% CI, 1.49%-1.98%), and highest in the United States (15.6%; 95% CI, 12.2%-19.7%) compared with Europe (14.9%; 95% CI, 6.9%-29.3%), East Asia (13.4%; 95% CI, 10.3%-17.2%), and the Middle East (9.8%; 95% CI, 7.8%-12.2%) (P = .04) The rate of EAO-CRN in age groups 45-49 years and 50-59 years was 17.8% (95% CI, 14.5%-21.6%) and 24.8% (95% CI, 19.5%-30.8%), respectively (P = .04). The rate of EAO-aCRN in age group 45-49 years was 3.6% (95% CI, 1.9%-6.7%) and 4.2% (95% CI, 3.2%-5.7%), respectively (P = .69)., Conclusions: The rate of aCRN in individuals aged 45-49 years was similar to the rate observed in individual aged 50-59 years, suggesting that expanding screening to this population could yield a similar impact on colorectal cancer risk reduction., (Copyright © 2021 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: The prevalence and significance of digestive manifestations in coronavirus disease 2019 (COVID-19) remain uncertain. We aimed to assess the prevalence, spectrum, severity, and significance of digestive manifestations in patients hospitalized with COVID-19., Methods: Consecutive patients hospitalized with COVID-19 were identified across a geographically diverse alliance of medical centers in North America. Data pertaining to baseline characteristics, symptomatology, laboratory assessment, imaging, and endoscopic findings from the time of symptom onset until discharge or death were abstracted manually from electronic health records to characterize the prevalence, spectrum, and severity of digestive manifestations. Regression analyses were performed to evaluate the association between digestive manifestations and severe outcomes related to COVID-19., Results: A total of 1992 patients across 36 centers met eligibility criteria and were included. Overall, 53% of patients experienced at least 1 gastrointestinal symptom at any time during their illness, most commonly diarrhea (34%), nausea (27%), vomiting (16%), and abdominal pain (11%). In 74% of cases, gastrointestinal symptoms were judged to be mild. In total, 35% of patients developed an abnormal alanine aminotransferase or total bilirubin level; these were increased to less than 5 times the upper limit of normal in 77% of cases. After adjusting for potential confounders, the presence of gastrointestinal symptoms at any time (odds ratio, 0.93; 95% CI, 0.76-1.15) or liver test abnormalities on admission (odds ratio, 1.31; 95% CI, 0.80-2.12) were not associated independently with mechanical ventilation or death., Conclusions: Among patients hospitalized with COVID-19, gastrointestinal symptoms and liver test abnormalities were common, but the majority were mild and their presence was not associated with a more severe clinical course., (Copyright © 2021 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Video 1Hybrid APC for Barrett's esophagus., (© 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Competing Interests: Competing interests: None declared.

Introduction: Using the National Cancer Database, we assessed the relationship between facility overall esophageal adenocarcinoma (EAC) case volume and survival., Methods: We categorized facilities into volume quintiles based on annual EAC patient volume and performed a multivariable Cox proportional hazards regression between facility patient volume and survival., Results: In a cohort of 116,675 patients, facilities with higher vs lower (≥25 vs 1-4 cases) annual EAC patient volume demonstrated improved survival (adjusted hazard ratio: 0.80. 95% confidence interval: 0.70-0.91)., Discussion: This robust volume-outcome effect calls for centralization of care for EAC patients at high annual case volume facilities.

Competing Interests: S. Wani is a consultant for Medtronic, Boston Scientific, and Interpace. R. Soetikno is a consultant for Olympus and Fujifilm. H. Hammad is a consultant for Olympus, Medtronic, and Cook Medical. The remaining authors declare that they have no conflict of interest.

Background: Transoral incisionless fundoplication (TIF) is an endoscopic alternative for the treatment of GERD. However, TIF does not address the hiatal hernia (HH). We present a novel approach with a laparoscopic HH repair followed by same-session TIF, coined concomitant transoral incisionless fundoplication (cTIF). The aim of this study was to assess the efficacy, safety, and feasibility of cTIF in a collaborative approach between Gastroenterology and surgery., Study Design: Patients with confirmed GERD and >2 cm HH who underwent cTIF between 2018 and 2020 were included. Symptoms were assessed using the Reflux Disease Questionnaire, GERD Health-Related Quality of Life Index, and the Reflux Symptom Index pre and post cTIF. One-way ANOVA and paired samples t-test were used for statistical analysis., Results: Sixty patients underwent cTIF (53% were men, mean age was 59.3 years) with 100% technical success. Mean ± SD HH measurement on endoscopy was 2.9 ± 1.5 cm. Scores on Reflux Disease Questionnaire for symptom frequency and symptom severity improved significantly from before to 6 months after cTIF (17.4 to 4.72; p < 0.01 and 16.7 to 4.56; p < 0.05, respectively). According to the GERD Health-Related Quality of Life Index, significant decreases were seen post cTIF in heartburn (23.26 to 7.37; p < 0.01) and regurgitation (14.26 to 0; p = 0.05). Reflux Symptom Index similarly decreased after cTIF (17.7 to 8.1 post cTIF; p < 0.01). Mean DeMeester score decreased from 43.7 to 4.9 and acid exposure time decreased from 12.7% to 1.28% post cTIF (p = 0.06)., Conclusions: We present a novel multidisciplinary approach to GERD using a combined endoscopic and surgical approach with close collaboration between Gastroenterology and surgery. Our results suggest that cTIF is safe and effective in reducing reflux symptoms in a large spectrum of GERD patients., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Esophageal adenocarcinoma (EAC) continues to be one of the fastest rising incident cancers in the Western population with the majority of patients presenting with late stage disease and associated with a dismal 5-year survival rate. Barrett's esophagus (BE) is the only identifiable precursor lesion to EAC. Strategies to screen for and survey BE are critical to detect earlier cancers and reduce morbidity and mortality related to EAC. A high-quality endoscopic examination with careful inspection of the Barrett's segment and adherence to the Seattle protocol for tissue sampling are critical. Advanced imaging modalities offer the potential to improve dysplasia detection, predict histopathology in real time and guide endoscopic eradication therapy (EET). Several technologies have been studied and although most are not yet recommended for routine clinical practice, high definition white light endoscopy (HD-WLE) as well as chromoendoscopy (including virtual chromoendoscopy) improved dysplasia detection in numerous studies supporting their use. Future studies should evaluate the role of artificial intelligence in optimizing detection of dysplasia in BE patients., Competing Interests: Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tgh.2020.02.10). The series “Advanced Endoscopic Imaging of the GI Tract” was commissioned by the editorial office without any funding or sponsorship. JM Kolb received funding from the National Institutes of Health (NIH) T32-DK007038. S Wani is supported in part by the Department of Medicine Outstanding Early Scholars Program, and is a consultant for Medtronic, Boston Scientific, and Interspace., (2021 Translational Gastroenterology and Hepatology. All rights reserved.)

Background: Per-oral endoscopic myotomy (POEM) is safe and effective for the treatment of achalasia. There is limited data on performance of POEM in patients with altered upper gastrointestinal anatomy, especially after bariatric surgery. Outcomes in patients with prior sleeve gastrectomy have not been reported., Aim: To assess the efficacy and safety of POEM in patients with prior bariatric surgery., Methods: A prospective POEM database was reviewed from 3/2017-5/2020 to identify patients who underwent POEM after prior bariatric surgery. Efficacy was assessed by technical success (defined as the ability to successfully complete the procedure) and clinical success [decrease in Eckardt score (ES) to ≤ 3 post procedure]. Safety was evaluated by recording adverse events., Results: Six patients (50% male, mean age 48 years) with a history of prior bariatric surgery who underwent POEM were included. Three had prior sleeve gastrectomy (SG) and three prior Roux-en-Y gastric bypass (RYGB). Four patients had achalasia subtype II and 2 had type I. Most (4) patients had undergone previous achalasia therapy. Technical success was 100%. Clinical success was achieved in 4 (67%) patients at mean follow-up of 21 mo. In one of the clinical failures, EndoFLIP evaluation demonstrated adequate treatment and candida esophagitis was noted as the likely cause of dysphagia. There were no major adverse events., Conclusion: POEM is technically feasible after both RYGB and SG and offers an effective treatment for this rare group of patients where surgical options for achalasia are limited., Competing Interests: Conflict-of-interest statement: Wagh MS is a consultant for Boston Scientific, Medtronic and Olympus; Hammad H is a consultant for Olympus, Boston Scientific, and Covidien; Kolb JM, Jonas D, Funari MP, Menard-Katcher P have no conflict of interest., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

The most commonly recognized high-risk group for colorectal cancer (CRC) is individuals with a positive family history. It is generally recognized that those with a first-degree relative (FDR) with CRC are at a 2-fold or higher risk of CRC or advanced neoplasia. FDRs of patients with advanced adenomas have a similarly increased risk. Accordingly, all major US guidelines recommend starting CRC screening by age 40 in these groups. Barriers to screening this group include patient lack of knowledge on family and polyp history, provider limitations in collecting family history, and insufficient application of guidelines., Competing Interests: Disclosure None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Advanced adenomas represent a subset of colorectal polyps that are known to confer an increased risk of colorectal neoplasia to the affected individual and their first-degree relatives (FDRs). Accordingly, professional guidelines suggest earlier and more intensive screening for FDRs of those with advanced adenomas similar to FDRs of those with colorectal cancer (CRC). Although the risk to family members is less clear among patients with advanced serrated polyps, they are often considered in the same category. Unfortunately, there is a growing concern that patients, endoscopists, and primary care providers are unaware of the familial risk associated with these polyps, leaving a wide gap in screening these high-risk individuals. Herein, we propose a standardized language around advanced colorectal polyps and present a detailed review of the literature on associated familial risk. We outline the challenges to implementing the current screening recommendations and suggest approaches to overcome these limitations, including a proposed new colonoscopy quality metric to capture communication of familial CRC risk. Improving screening in these high-risk groups has the potential to substantially reduce the burden of CRC.

Purpose of Review: Barrett's oesophagus is the only identifiable precursor lesion to oesophageal adenocarcinoma. The stepwise progression of Barrett's oesophagus to dysplasia and invasive carcinoma provides the opportunity to intervene and reduce the morbidity and mortality associated with this lethal cancer. Several studies have demonstrated the efficacy and safety of endoscopic eradication therapy (EET) for the management of Barrett's oesophagus related neoplasia. The primary goal of EET is to achieve complete eradication of intestinal metaplasia (CE-IM) followed by enrolment of patients in surveillance protocols to detect recurrence of Barrett's oesophagus and Barrett's oesophagus related neoplasia., Recent Findings: EET depends on early and accurate detection and diagnosis of Barrett's oesophagus related neoplasia. All visible lesions should be resected followed by ablation of the remaining Barrett's epithelium. After treatment, patients should be enrolled in endoscopic surveillance programmes. For nondysplastic Barrett's oesophagus, surveillance alone is recommended. For low-grade dysplasia, both surveillance and ablation are reasonable options and should be decided on an individual basis according to patient risk factors and preferences. EET is preferred for high-grade dysplasia and intramucosal carcinoma. For T1b oesophageal adenocarcinoma, esophagectomy remains the standard of care, but endoscopic therapy can be considered in select cases., Summary: EET is now standard of care and endorsed by societal guidelines for the treatment of Barrett's oesophagus related neoplasia. Future studies should focus on risk stratification models using a combination of clinical data and biomarkers to identify ideal candidates for EET, and to predict recurrence. Optimal therapy for T1b cancer and surveillance strategy after CE-IM are topics that require further study.

Endoscopic resection of luminal gastrointestinal neoplasia offers a minimally invasive, lower risk alternative that can be successful in the appropriate setting. Bleeding and perforation can occur with endoscopic mucosal resection and endoscopic submucosal dissection. Defect closure with conventional endoclips or modified technique using endoloops can decrease the risk of adverse events. The Overstitch (Apollo Endosurgery, Austin, TX) endoscopic suturing device is designed for tissue apposition and thus can effectively close a large resection defect. Herein we describe our technique. Our and other groups' initial experience with suturing for closure of the resection defect demonstrates high procedural success rates and safety., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Endoscopic treatment of lower gastrointestinal bleeding can be challenging. This article reports on the use of the endoscopic clipping over the scope technique to treat acute severe lower gastrointestinal bleeding. In particular, it describes the approaches and outcomes of using the technique for acute severe bleeding in the colon and the anal transition zone. The following synopsis is the one that you supplied, but lightly copyedited. Please confirm OK. Please note that the synopsis will appear in PubMed: Endoscopic treatment of lower gastrointestinal bleeding can be challenging. This article reports on the use of the endoscopic clipping over the scope technique to treat acute severe lower gastrointestinal bleeding. In particular, it describes the approaches and outcomes of using the technique for acute severe bleeding in the colon and the anal transition zone., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background & Aims: For patients with branch duct intraductal papillary mucinous neoplasms (BD-IPMNs, cysts), it is a challenge to identify those at high risk for malignant lesions. We sought to identify factors associated with development of pancreatic cancer, focusing on neoplasm growth rate., Methods: We performed a retrospective study of 189 patients with BD-IPMNs who underwent at least 2 contrast-enhanced cross-sectional imaging studies, 1 year or more apart, at a tertiary referral center from January 2003 through 2013. Patients with cysts that had Fukuoka worrisome or high-risk features were excluded. Two radiologists reviewed all images. Cyst size was recorded at the initial and final imaging studies and growth rate was calculated. We collected patient demographic data, cyst characteristics, and clinical outcomes; univariate logistic regression models were used to determine the odds of developing worrisome features. The primary outcomes were to determine growth rate of low-risk BD-IPMNs and to assess whether cyst growth rate correlates high-risk features of IPMNs., Results: Based on image analyses, cysts were initially a median 11 mm (range, 3-31 mm) and their final size was 12.5 mm (range, 3-42 mm). After a median follow-up time of 56 months (range, 12-163 months), the median cyst growth rate was 0.29 mm/year. Twelve patients developed worrisome features, no patients developed high-risk features, 4 patients had surgical resection, and no cancers developed. The rate of BD-IPMN growth was greater in patients who developed worrisome features than those who did not (2.84 mm/year vs 0.23 mm/year; P < .001). The odds of developing worrisome features increased for each unit (mm) increase in cyst size (odds ratio, 1.149; 95% CI, 1.035-1.276, P = .009)., Conclusion: In a retrospective analysis of images from patients with BD-IPMN, we found low-risk BD-IPMNs to grow at an extremely low rate (less than 0.3 mm/year). BD-IPMNs in only about 6% of patients developed worrisome features, and none developed high-risk features or invasive cancers. BD-IPMNs that developed worrisome features were associated with a significantly higher rate of growth than lesions with low-risk features. Low risk BD-IPMNs that grow more than 2.5 mm/year might require surveillance., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)