Abed Al-Lehibi

Malignant distal biliary obstruction (MDBO) is most commonly managed by endoscopic retrograde cholangiopancreatography (ERCP) with self-expandable metal stent placement. When ERCP fails or is not feasible, endoscopic ultrasound-guided biliary drainage (EUS-BD) has increasingly replaced percutaneous transhepatic biliary drainage in expert centers. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged as an indirect route for biliary decompression when the cystic duct is patent. This comprehensive narrative review focuses on the anatomical rationale, patient selection, procedural technique, comparative positioning, clinical outcomes, adverse events, and unresolved issues of EUS-GBD in MDBO. The supporting evidence is predominantly observational. Published meta-analyses report technical success generally exceeding 90%, pooled clinical success of approximately 82–89%, and overall adverse event rates of approximately 10–14%; these estimates vary with study selection, outcome definitions, assessment time points, and predominantly observational study designs. Comparative studies suggest efficacy and safety similar to EUS-guided choledochoduodenostomy after failed ERCP in anatomically selected patients, although nonrandomized allocation and confounding by indication remain major limitations. A prospective study has demonstrated feasibility as primary palliation, but this strategy cannot yet be considered standard of care. Prophylactic EUS-GBD to prevent post-stenting cholecystitis represents a separate indication and should not be conflated with EUS-GBD for biliary decompression. The key determinant of physiological success is unobstructed communication between the gallbladder and the central biliary tree; therefore, cystic duct patency, tumor relationship to the cystic duct take-off, gallbladder distension, and the absence of extensive gallbladder involvement must be assessed before intervention. EUS-GBD is best positioned as a rescue option after failed ERCP when direct EUS-BD is technically impossible, unsafe, or unsuccessful. Prospective randomized trials, standardized outcome definitions, comparative cost-effectiveness analyses, and dedicated long-term stent management protocols are needed before broader adoption.

The best endoscopic treatment for gastric varices is currently unclear. We performed a network meta-analysis combining direct and indirect comparisons among the different techniques currently in use. We identified 10 randomized controlled trials (RCTs; 760 patients) comparing endoscopic cyanoacrylate injection, endoscopic thrombin injection, endoscopic ultrasound (EUS)-guided cyanoacrylate injection, EUS-guided coil injection, EUS-guided coil+cyanoacrylate injection, and large-volume band ligation. The primary outcome was rebleeding rate, and secondary outcomes were complete obliteration of gastric varices and adverse event rate. The results were expressed in terms of risk ratio (RR) with 95%CIs. EUS-guided cyanoacrylate and EUS-guided coil+cyanoacrylate injection showed significantly lower rates of rebleeding than direct endoscopic cyanoacrylate injection (RR 0.39, 95%CI 0.27–0.58 and RR 0.15, 95%CI 0.03–0.90, respectively). None of the treatments were significantly superior in terms of complete obliteration of gastric varices but EUS-guided cyanoacrylate injection, large-volume band ligation, and thrombin injection had lower adverse event rates compared with endoscopic cyanoacrylate injection (RR 0.59, 95%CI 0.48–0.72; RR 0.38, 95%CI 0.19–0.75; and RR 0.30, 95%CI 0.15–0.61, respectively). EUS-guided cyanoacrylate injection with or without coils was associated with lower rebleeding rates than conventional endoscopic cyanoacrylate injection. However, the quality of evidence was very low and further RCTs are needed before firm conclusions can be drawn regarding the relative efficacy and safety of these treatments.

Confocal laser endomicroscopy (CLE) is an innovative diagnostic modality that facilitates real-time in vivo optical biopsies of various tissues within luminal and ductal structures. Since its introduction in 2004, the application of this tool has broadened from diagnostic purposes to encompass management and prognostic evaluation in fields such as gastroenterology, neurosurgery, urology, and dermatology. This comprehensive review examines the current applications of endomicroscopy in Barrett’s esophagus (BE), inflammatory bowel disease (IBD), and colorectal lesions. Evidence from the literature suggests that CLE offers a potential solution to the diagnostic limitations associated with white-light endoscopy and histology. With a diagnostic accuracy nearly equivalent to that of histology, CLE is emerging as a promising tool to mitigate the delays related to awaiting histology results for clinical and therapeutic decision-making. However, its use is mainly as a complementary diagnostic method rather than an alternative to histopathology or other ancillary studies. Nevertheless, its widespread adoption remains limited, and further research is necessary to ascertain its overall benefits and cost implications of integrating it into patient care.

Background: Chronic pancreatitis (CP) is a progressive inflammatory condition with regional differences in prevalence and etiology. Though alcohol and smoking are primarily the risk factors in Western populations, CP resulted from alcohol is rare in Saudi Arabia due to cultural differences. Our study aim to characterize the Etiology, clinical presentation, and complications of CP in Saudi Arabian adults who are minimally alcohol exposure. Methods: Our retrospective research highlights on patients who are 14 years of age and older that diagnosed with CP, who are treated at King Fahad Medical City from the timeline of 2013 until 2024. The Demographics, clinical presentations, laboratory, radiological and comorbidity data were obtained from the electronic records of KFMC then analysed by SPSS version 27 program. Our study is approved ethically by the KFMC Research Center, and we ensure all participants’ data remained anonymous. Results: We identified 117 CP patients (65% female, 95.7% Saudi) with a median age of 42 years and median disease duration of 4 years. Smoking was reported in 40.2% of cases. The predominant symptom was right upper quadrant pain (80.3%), followed by fever (12%), jaundice (11.1%), and pruritus (10.3%). Median laboratory values included amylase 74 U/L, lipase 39.4 U/L, calcium 2.36 mmol/L, triglycerides 1.35 mmol/L, and IgG4 0.847 g/L. Frequent complications included pancreatic leak/fistula (46.2%), pseudocysts (27.4%), bile duct obstruction (26.5%), and pancreatic carcinoma (13.7%). New-onset diabetes and duodenal obstruction each occurred in 9.5%, while metabolic bone disease and autoimmune hepatitis were rare (0.9%). Conclusion: In Saudi Arabia, CP often occurs without alcohol consumption, but with smoking emerging as a potential risk factor. Despite this non-alcoholic profile, the risk of serious complications, including pancreatic cancer, remains high. Multicentric studies are needed to clarify risk factors and optimize the management.

Three-dimensional (3D) reconstruction of ultrasound (US) images represents a novel advancement that has been extensively explored over the past three decades. This technique enables endoscopists to perform more detailed and enhanced visualizations of anatomical structures, which is not feasible using traditional ultrasound methods. The reconstructed images also facilitate navigation during endoscopy-guided procedures, such as fine-needle aspiration. Furthermore, augmented reality (AR) algorithms can overlay the reconstructed images with real-time anatomical images, thereby enhancing clinician performance during these procedures. Current evidence suggests that 3D ultrasound reconstruction has already been widely implemented in various clinical imaging studies. However, its application for generating procedural guidance and augmented reality overlays remains in the early research stages and has not yet achieved widespread adoption. Existing pre-clinical evidence suggests that 3D reconstruction has significant potential to enhance clinician performance in various ultrasound-guided procedures.

Background and aim. Gastrointestinal bleeding (GIB) is one of the most common medical emergencies. Proton pump inhibitors (PPI) are among the most widely used drugs in gastroenterology to treat various types of acid-related disorders. We aim to investigate the safety of proton pump inhibitors (PPIs) when used concurrently with anticoagulants in patients with upper and lower gastrointestinal bleeding (GIB) and assess the risk of hospitalization, GIB, and mortality in patients receiving this combined treatment. Methods. A retrospective multicenter study was conducted at two tertiary care hospitals. Patients were selected according to inclusion and exclusion criteria. Demographic data, vital signs, medical history, physical examinations, comorbid conditions, medications, laboratory investigations, endoscopy findings, management, and complications were retrieved from the medical records of all participants. Data obtained from all patients’ medical records were reviewed. Endoscopic findings and management of the bleeding site were collected according to the presenting symptoms. Statistical analyses were performed using IBM SPSS version 25.0 software. Results. Our results revealed a significant increase in acute GIB risk with the number of concurrent anticoagulants used, particularly in patients not using PPIs. Those using four anticoagulants along with PPIs had a lower likelihood of acute GIB at 6.3% (P = 0.0001). Patients taking two or three anticoagulants also experienced reduced GIB risk when PPIs were added (P ≤ 0.05). Age played a role, with a statistically significant difference between PPI users and non-users, especially in the 31-40 age group, where PPI users had a higher incidence of GIB (69.80%) compared to non-users (30.20%) (P < 0.05). Comparing patients on anticoagulants with or without PPIs, the study found a lower risk of hospitalization (adjusted hazard ratio, AHR: 1.02; 95% CI: 0.92-1.57) and mortality (AHR: 1.00; 95% CI: 0.84-1.11) in those using Rivaroxaban and PPIs concurrently. By contrast, patients using Rivaroxaban alone without PPIs faced an increased risk of hospitalization (AHR: 1.15; 95% CI: 0.98-2.35) and mortality (AHR: 1.12; 95% CI: 0.90-1.37). Conclusions. Combining PPIs with anticoagulant drugs reduced the risk of GIB, hospitalization, and mortality, particularly in older adults, thereby mitigating potential complications.

In the above-mentioned article institution 9 was corrected. This was corrected in the online version on 20.03.2025. Article published online: 19 March 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Gastroesophageal reflux (GER) and its long-term sequelae remain a concern following peroral endoscopic myotomy (POEM). POEM with fundoplication (POEM-F) is simultaneous fundoplication via pure natural orifice transluminal endoscopic surgery (NOTES). In this study, we evaluated the efficacy and safety of POEM-F in mitigating post-POEM GER. We performed a comprehensive electronic database search from January 2008 through June 2024 for studies evaluating outcomes of POEM-F performed for managing post-POEM GER. Pooled proportions were calculated using random-effects models. Heterogeneity was assessed using I² and Q statistics. We included seven studies comprising 127 patients. Pooled technical success for POEM was 96.90%; 95% confidence interval [CI] 91.40–98.90. Pooled technical success of fundoplication was 92.30%; 95% CI 85.20–96.10. Clinical success in treating achalasia was 96.40%; 95% CI 90.70–98.60. Rate of wrap integrity on follow-up was 84.00%; 95% CI 66.00–93.40. Composite clinical success of POEM-F in mitigating post-POEM GER was 86.20%; 95% CI 73.80–93.20. Mean total procedure duration and fundoplication time was 115.74 minutes; 95% CI 103.53–126.96 and 55.28 minutes; 95% CI 47.35–63.20, respectively. The overall pooled major adverse events (AE) rate was 3.60%; 95% CI 1.40–9.40. POEM-F is an effective procedure with an acceptable AE rate in expert hands. It appears to offer clinical benefit in mitigating post-POEM GER. However, further standardization for evaluating clinically significant post-POEM GER and long-term benefit of POEM-F is warranted. Received: 17 November 2024 Accepted after revision: 30 January 2025 Accepted Manuscript online: 10 February 2025 Article published online: 14 March 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

In the above-mentioned article the name of the author Roberto Leone was corrected. This was corrected in the online version on 24.10.2024. Article published online: 24 October 2024 © 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/). Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Background and study aims Although outcomes of lumen-apposing metal stents (LAMS) placement in native anatomy have been reported, data on LAMS placement in surgically altered anatomy (SAA) are sparse. We aimed to assess outcomes of LAMS placement in patients with SAA for different indications. Patients and methods This was an international, multicenter, retrospective, observational study at 25 tertiary care centers through November 2023. Consecutive patients with SAA who underwent LAMS placement were included. The primary outcome was technical success defined as correct placement of LAMS. Secondary outcomes were clinical success and safety. Results Two hundred and seventy patients (125 males; average age 61 ± 15 years) underwent LAMS placement with SAA. Procedures included EUS-directed transgastric ERCP (EDGE) and EUS-directed transenteric ERCP (EDEE) (n = 82), EUS-guided entero-enterostomy (n = 81), EUS-guided biliary drainage (n = 57), EUS-guided drainage of peri-pancreatic fluid collections (n = 48), and EUS-guided pancreaticogastrostomy (n = 2). Most cases utilized AXIOS stents (n = 255) compared with SPAXUS stents (n = 15). Overall, technical success was 98%, clinical success was 97%, and the adverse event (AE) rate was 12%. Using AGREE classification, five events were rated as Grade II, 21 events as Grade IIIa, and six events as IIIb. No difference in AEs were noted among stent types (P = 0.52). Conclusions This study shows that placement of LAMS is associated with high technical and clinical success rates in patients with SAA. However, the rate of AEs is noteworthy, and thus, these procedures should be performed by expert endoscopists at tertiary centers.