Rakesh Kalapala

Aims: Colorectal cancer (CRC) remains a major cause of cancer mortality, with up to 26% of adenomas missed on conventional colonoscopy. Artificial intelligence (AI)–based computer‐aided detection (CADe) systems may reduce these miss rates. We aimed to validate the iIDEAS‐C CADe module in a prospective cohort, with co‐primary endpoints of adenomas per colonoscopy (APC) and lesion‐level miss rate. Methods and Results: In this prospective, nonrandomized, single‐center study (NCT05784935), consecutive adults (18–75 years) undergoing screening, surveillance, or diagnostic colonoscopy were enrolled between February and May 2023. Each colon segment was inspected twice: an initial blinded withdrawal without CADe, followed by a second inspection with iIDEAS‐C. Missed lesions were those identified by CADe during the second inspection and confirmed endoscopically. Secondary outcomes included PDR, ADR, PPC, lesion characteristics, and procedural times. Two hundred patients (mean age 44.1 ± 12.7 years; 64% male) were included. Eighty‐two polyps were detected across 42 patients (PDR = 21%). Endoscopists detected 61/82 polyps (74.4%), yielding a per‐polyp miss rate of 25.6%. The iIDEAS‐C module detected all 82 lesions, achieving 0% per‐polyp and per‐adenoma miss rate. Missed lesions were mostly diminutive and proximal. PPC increased from 0.305 to 0.410 ( p < 0.0001), PDR from 17.5% to 21.0% ( p = 0.016), and APC from 0.115 to 0.140 ( p = 0.029). No adverse events occurred. Conclusion: The iIDEAS‐C module demonstrated a 0% lesion‐level miss rate and significantly improved key detection metrics, especially for small proximal lesions. Larger multicenter studies are warranted to confirm these findings and assess long‐term outcomes. ClinicalTrials.gov : NCT05784935. Trial Registration: ClinicalTrials.gov identifier: NCT05784935.

INTRODUCTION: Health care accounts for nearly 5% of global greenhouse gas emissions, and medical imaging is among its most energy-intensive activities. For intermediate-likelihood common bile duct stones, endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are both guideline-endorsed with comparable diagnostic accuracy, yet their environmental costs have never been directly compared. METHODS: In this prospective study, we measured the per-procedure carbon footprint of EUS and MRCP using the Greenhouse Gas Protocol and India's grid emission factor. We recorded EUS procedure times individually; MRCP emissions were derived from a validated power model that captures the continuous cryocooler load maintaining magnet superconductivity around the clock, with shared infrastructure allocated by real case volume. We performed sensitivity analyses across scanner utilization, energy-allocation method, scan duration, and grid carbon intensity. The study followed the European Society of Gastrointestinal Endoscopy Endoscopic Sustainability PrimAry Reporting Essentials reporting standard. RESULTS: EUS generated 4.53 kg CO ₂ e per procedure and MRCP 18.90 kg CO ₂ e per procedure, making MRCP 4.2 times more carbon-intensive. The continuously running cryocooler was the single largest fixed contributor to MRCP emissions (23.4% in standby alone), a 24/7 load absent in EUS. Choosing EUS for 108 patients saved 1,552 kg CO ₂ e, equivalent to the annual carbon uptake of 74 mature trees. EUS remained the lower-carbon option across sensitivity analyses, although the advantage narrowed and could reverse on low-carbon grids. DISCUSSION: For bile duct stone evaluation, EUS offers the same diagnostic answer at substantially lower carbon cost where grid electricity is carbon-intensive, adding environmental impact to accuracy, safety, and cost in the decision.

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Gastro-oesophageal reflux disease (GORD) is among the most commonly diagnosed gastrointestinal disorders, with a substantial impact on quality of life, mental health, sleep and healthcare costs. Although proton pump inhibitors (PPIs) remain first-line therapy, a sizeable minority of patients are PPI-dependent or PPI-refractory and many wish to avoid lifelong pharmacotherapy without committing to laparoscopic fundoplication. Endoscopic antireflux therapies (EARTs) bridge this therapeutic gap. The currently relevant modalities—transoral incisionless fundoplication (TIF V.2.0) and concomitant TIF with hiatal hernia repair (cTIF), endoscopic full-thickness plication (GERD-X), the mucosal interventions antireflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA) and radiofrequency ablation (Stretta)—work through distinct mechanisms but share the goal of reinforcing the gastro-oesophageal junction. The 2025 American Society for Gastrointestinal Endoscopy (ASGE) guideline now formally endorses TIF and cTIF as evidence-based alternatives to chronic medical therapy in selected patients. The first sham-controlled randomised controlled trials of ARMA, published in 2026, have refined our understanding of its niche: ARMA appears effective in reflux-predominant GORD characterised by an acid exposure time (AET) 80 reflux episodes per 24 hours but provides no benefit over sham in conventional acid-predominant disease. Magnetic sphincter augmentation (LINX) has matured as a minimally invasive surgical alternative. This review synthesises the contemporary evidence using Lyon Consensus V.2.0 phenotyping as the framework for patient selection, discusses training, safety and cost considerations and offers a practical algorithm for choosing among EARTs and identifying patients best referred for surgery.

Background: The optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in patients with mild-to-moderate acute cholangitis remains uncertain. Objective: To compare the clinical outcomes of urgent ERCP performed within 24 hours vs early ERCP performed within 24–48 hours in patients with mild to moderate acute cholangitis. Design: Single-centre, open-label, randomised controlled trial. The primary outcome was 30-day mortality. Secondary outcomes included organ failure at day 3 and day 30, in-hospital mortality, length of hospital stay, reintervention rates, readmission rates and post-ERCP adverse events. The sample size calculation was based on a superiority hypothesis, assuming event rates of 8% versus 19% in favour of urgent ERCP. Results: A total of 304 patients (mean age 55.58±14.10 years; 218 men) were randomised, with 152 assigned to urgent ERCP and 152 to early ERCP. Baseline characteristics were similar between the two groups. There was no significant difference in 30-day mortality between the urgent and early ERCP groups (3.95% vs 6.58%; hazard ratio 0.70, 95% CI 0.25 to 1.93; p=0.47). Likewise, there were no significant differences in in-hospital mortality (1.97% vs 3.28%; relative risk (RR) 1.67, 95% CI 0.40 to 7.20), organ failure at day 3 (9.2% vs 11.2%; RR 1.24, 95% CI 0.59 to 2.62), organ failure at day 30 (11.8% vs 17.1%; RR 1.54, 95% CI 0.80 to 2.94), reintervention rates or readmission rates. The median length of hospital stay was also similar between the groups (6.94 days vs 7.84 days). However, post-ERCP adverse events were more frequent in the urgent ERCP group than in the early ERCP group (17.1% vs 9.2%; RR 2.03, 95% CI 1.02 to 4.07) in the unadjusted analysis. Conclusion: In patients with mild-to-moderate acute cholangitis, urgent ERCP within 24 hours was not superior to early ERCP within 24–48 hours with respect to mortality or organ failure and is associated with a higher rate of procedure-related adverse events. Trial registration number: NCT05920954 .

Background and Objectives Obesity is a leading risk factor for fatty liver disease and weight loss has been shown to improve liver parameters. This study evaluates the efficacy of oral semaglutide for weight loss in individuals with overweight or obesity, excluding those with diabetes mellitus. Methods A randomized, open-label, controlled trial was conducted at the Asian Institute of Gastroenterology, Hyderabad, from June 2022 to December 2023. Adults (≥ 18 years) with a body mass index (BMI) ≥ 30 or ≥ 27 with comorbidities (pre-diabetes, hypertension, dyslipidemia, obstructive sleep apnea or cardiovascular disease) were randomized into two groups. Both groups received counselling on a reduced-calorie diet and increased physical activity. Group 1 also received oral semaglutide, starting at 3 mg/day and titrated to 14 mg/day over two to four weeks. The objectives were to assess the effects of semaglutide on weight loss, non-invasive markers of liver fibrosis and cardiometabolic parameters. (ClinicalTrials.gov ID: NCT05442450). Results Total 116 participants (58 per group) completed the study. At 28 weeks, the mean percentage weight reduction was -10.47% (SD 5.3) in the Semaglutide group vs. -2.4% (SD 4.5) in the control group (p < 0.001). Semaglutide treatment significantly improved alanine aminotransferase (ALT) (serum glutamic-pyruvic transaminase [SGPT]) levels, along with reductions in the aspartate aminotransferase to platelet ratio index (APRI) score, liver fat content and liver stiffness. However, NFS (NAFLD fibrosis score) and FIB-4 (fibrosis-4 index) did not show significant reductions. Improvements in BMI, waist circumference, HbA1c, fasting insulin and C-reactive protein (CRP) were significantly greater with semaglutide (p < 0.001). Total fat mass decreased by 7.3 kg vs. 1.74 kg (p < 0.0001) in controls, while visceral fat ratings dropped by 3.67 vs. 0.6 (p < 0.0001). Conclusions In adults with overweight or obesity without diabetes, oral semaglutide, combined with dietary and lifestyle modifications, led to significant and clinically meaningful weight loss and metabolic improvements compared to lifestyle modifications alone. Graphical Abstract

Background and Objectives Anti-reflux mucosal ablation (ARMA) is a minimally invasive therapy for patients with proton pump inhibitor (PPI) controlled gastro-esophageal reflux disease (GERD). This study evaluated the safety and efficacy of ARMA over 12 months. Methods This single-center prospective study included PPI-dependent GERD patients (acid exposure time [AET] > 6% or AET > 4.2% with reflux episodes > 80 on 24-h-pH-impedance monitoring). ARMA was performed in a standardized fashion using hybrid technique (sub-mucosal lift followed by ablation). Patients were evaluated using the GERD health-related quality of life questionnaire (HRQL) at baseline, three months and 12 months, with 24-h-pH-impedance monitoring at baseline and 12 months. Results Total 216 patients (67.1% males, mean age = 38.7 years) underwent ARMA. At baseline, 123 (56.9%) patients had Hill’s grade I and 93 (43.1%) had Hill’s grade II on endoscopy. Ninety (41.7%) patients had Los Angeles (LA) grade A and 2 (0.93%) had LA grade B. There was a significant improvement in GERD-HRQL score from 43.8 (12.6) at baseline to 20.6 (13.8) at three months and to 8.3 (12.3) at 12 months (p = 0.001). The mean (SD) heartburn and regurgitation scores improved from 22.9 (10.8) and 20.6 (9.4) at baseline to 11.1 (8.7) and 9.5 (8.7) at three months and 3.9 (6.9) and 3.9 (6.9) at 12 months, respectively (p = 0.001). The AET (median [IQR]) decreased from 11.9 (15.9) to 7.6 (10.8) (n = 125, p = 0.009) at 12 months and the median DeMeester score reduced from 42.4 (47.1) to 26.2 (32.3) (p = 0.001). There was also a significant decrease in number of patients with AET 4% to 6% and > 6% and reflux episodes 40–80 and > 80 and DeMeester score > 14.72, as well as an increase in patients with AET < 4% and reflux episodes < 40. There was a significant improvement in Hill’s grading and endoscopic esophagitis at one year. No major adverse events were observed. Conclusion In PPI-dependent GERD patients, ARMA resulted in sustained symptom reduction and improved quality of life at 12 months. This procedure is relatively simple, widely accessible and has a good safety profile. Clinical trial registration ClinicalTrials.gov (NCT04243668). Graphical Abstract

Background: Given the imperative to combat climate change, reducing the healthcare sector’s implications on the environment is crucial. Objective: This study aims to offer a comprehensive assessment of the environmental impact of gastrointestinal endoscopy (GIE) procedures, specifically focusing on greenhouse gas (GHG) emissions and waste generation. Design: A prospective study was conducted at the Asian Institute of Gastroenterology (AIG Hospitals), Hyderabad, India, from 29 May to 10 June 2023, including all consecutive GIE procedures. Carbon emissions for various variables involved were calculated with specific emission factors using ‘The GHG Protocol’. Results: Based on data from 3244 consecutive patients undergoing 3873 procedures, the study revealed a total carbon footprint of 148 947.32 kg CO₂e or 38.45 kg CO₂e per procedure. Excluding patient travel, the emissions were 6.50 kg CO₂e per procedure. The total waste generated was 1952.50 kg, averaging 0.504 kg per procedure, far less than 2–3 kg per procedure in the West. The waste disposal breakdown was 9.5% direct landfilling, 64.8% incineration, then landfilling and 25.7% recycling, which saved 380 kg CO₂e. India effectively recycles 25.7% of hospital-related waste, which undergoes landfilling in the West. The primary contributors to GHG emissions were patient travel (83.09%), electricity consumption (10.42%), medical gas transport and usage (3.63%) and water consumption (1.86%). Diagnostic procedures generate less waste and lower carbon footprint than therapeutic procedures. Conclusion: This study highlights the significant environmental footprint of GIE procedures, emphasising the importance of optimising practices to reduce patient travel and repeat procedures, alongside improving electricity and water management for sustainable healthcare.

Gastric and duodenal perforation from ingested organic and inorganic foreign bodies, such as sewing needles, toothpick, metallic wires, fish and chicken bone, are uncommon incidents as most foreign bodies pass in the faeces. The perforated foreign body can at times migrate and either penetrate causing traumatic injury or incite inflammation with formation of abscesses or pseudo-tumours in the adjacent organs such as the liver and pancreas. We report one such case of pancreatitis in a child resulting from a metallic wire perforating the posterior gastric wall and penetrating the pancreas. The findings were detected on CT and the foreign body was extracted endoscopically. We also present review of literature on similar case reports.