Rosario Landi

Peptic ulcer disease remains one of the leading causes of non-variceal upper gastrointestinal bleeding. Despite advances in endoscopic therapy and pharmacological management, recurrent bleeding continues to represent a major cause of morbidity and mortality. Risk stratification is traditionally based on endoscopic stigmata according to the Forrest classification; however, ulcers with similar endoscopic findings may exhibit markedly different clinical outcomes. Increasing evidence suggests that ulcer-related anatomical factors, including size, location, and depth of penetration, may influence the risk of severe or recurrent hemorrhage, particularly in cases involving adjacent arterial structures. In this conceptual, hypothesis-generating review, we propose a conceptual bi-dimensional framework integrating endoscopic and anatomical determinants of bleeding risk. This approach aims to improve patient stratification by identifying a subgroup at “very-high-risk” of recurrent bleeding, in whom standard endoscopic therapy alone may be insufficient. Although this framework is hypothesis-generating and not yet validated, it may provide a conceptual basis for future studies aimed at improving individualized management strategies, including early imaging assessment and consideration of transarterial embolization in selected high-risk patients.

Endoscopic submucosal dissection (ESD) allows the en-bloc resection of large gastrointestinal lesions, enabling precise pathological evaluation and oncological radicality [1] [2]. Post-ESD wound closure can reduce delayed adverse events (AEs) [3], but standard devices struggle with large GI-defect closures. The introduction of new suturing allows for effective solutions. To date, limited studies evaluated the feasibility of hand-suturing for post-ESD wound closure [4]. We report the case of a 68-year-old male diagnosed with a 40-mm nongranular laterally spreading tumor located in the distal rectum (Paris Classification 0-IIa + IIc, IV with focal Vi Kudo Class, 2A and focal 2B JNET Class) ([Fig. 1]). ESD was performed using the GIF-H190 scope and DualKnifeJ electrosurgical knife (Olympus Medical Systems). The rich vascular pattern, intraprocedural bleedings, and patients’ need for early anticoagulation treatment reintroduction (atrial fibrillation as comorbidity) significantly increased the risk of delayed bleeding. An endoscopic needle-holder (FG-260, SutuArt; Olympus Medical Systems) and a V-Loc 180 suture, size 3–0 (Medtronic), were used for complete post-ESD wound closure ([Video 1]). Suturing followed these steps: The procedure was completed successfully ([Fig. 2], [Fig. 3]), follow-up was uneventful, and no AEs were recorded. Endoscopy_UCTN_Code_TTT_1AQ_2AK Article published online: 07 October 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

Objective Peroral endoscopic myotomy (POEM) has become standard treatment for achalasia with comparable efficacy to surgery. In most of published series, the length of myotomy is 12–13 cm. Shorter cuts could have the advantage of shorter procedure time and possibly reduced gastro-oesophageal reflux disease (GORD) rate. Design This single-centre, patient-blinded, randomised, non-inferiority clinical trial included 200 patients, who were randomly allocated, to receive either a long-POEM (13 cm; 101 patients) or a short-POEM (8 cm; 99 patients). Primary outcome was defined as an Eckardt symptom score of ≤3 at 24 months after the procedure; a non-inferiority design was chosen with an accepted success range of 6% between the two treatments. Secondary outcomes included operating time, complication rate, postoperative manometry, GORD rate and quality of life. Results In the intention-to-treat analysis, clinical success rates were 89.1% in the long-POEM and 98.0% in the short-POEM group, resulting in an absolute between-group difference of −8.9% (90% CI −14.5 to −3.3). Procedure time was significantly reduced in the short-POEM as compared with the long-POEM group (40 vs 50 min, p6% on pH monitoring study at 6 months was seen in 34.3% (long-POEM) vs 31.1% (short-POEM), while endoscopic oesophagitis was diagnosed in 37.6% vs 51.5% at 6 months and in 21% vs 24.5% at 24 months. Regular proton pump inhibitor use was not different either (36.8% vs 37.5%). Conclusions Our study demonstrates non-inferiority of a shorter cut length of POEM as compared with the standard treatment, which saved some procedural time. GORD rate was not reduced by reducing cutting length. Trial registration number NCT03450928.

Aims Zenker’s diverticulum (ZD) may be responsible of dysphagia, regurgitation, cough and potentially life-threatening conditions, such as ab-ingestis pneumonia. Peroral endoscopic myotomy (Z-POEM) has been recently used for the management of ZD as an alternative to flexible endoscope septotomy and to the open or transoral surgery. We report on the results of Z-POEM in a consecutive series of patients treated in a single tertiary-referral centre. Methods All the patients who underwent Z-POEM in our department between October 2020 and November 2022 were retrospectively identified. Demographics, clinical and technical aspects were retrieved from a prospectively collected database. After treatment, patients underwent a close clinical and endoscopic follow-up: technical success, incidence of adverse events and symptoms recurrence were calculated 1, 6 and 12 months after treatment. Results 41 Z-POEM were performed on 40 patients (mean diverticulum size 15.4±9.1 mm, mean procedure time 17.6±6.6 minutes). Technical success rate was 95.1% (39/41). Intraprocedural mild complications occurred in two patients (one bleeding and one mucosal perforation) and were treated intraoperatively. A severe complication (oesophageal perforation) occurred in one patient (2.4%) and required surgery. A substantial decrease in Kothari-Haber score was observed 1, 6 and 12 months after treatment. Clinical success was achieved in 85.3% of patients. Three patients underwent a successful endoscopic retreatment (2 septotomies and 1 Z-POEM) after a mean of 7.7±1.7 months. Conclusions Z-POEM is a promising technique for the treatment of ZD. Larger studies with a long follow-up and comparative trials are necessary to assess its role in the management of ZD. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Text A 74 year-old lady underwent endoscopic papillectomy. At the end of en-bloc resection severe bleeding occurred. A 25-gauge needle was advanced to perform a submucosal injection of diluted epinephrine (1:10000). The presence of abundant amount of blood in the duodenum reduced the visibility and an excessive pression on the needle tip led to duodenal wall perforation. Two 16 mm endoclips were placed and promptly closed the duodenal wall defect. The patient was referred for urgent CT scan, confirming the presence of free air in the retroperitoneum. After 7 days a control CT scan showed reduction of the retropeumoperitoneum without collections. Clinical course was uneventful. The patient is free of recurrence after 2 year. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Aims The aim of this study is to report the experience of a high-volume endoscopy center in the use of single-use EXALT Model D duodenoscope (Boston Scientific Corporation, USA). Methods This is a retrospective observational study. All consecutive patients undergoing ERCP performed with EXALT single-use duodenoscope by expert endoscopists from April 2010 to November 2022 were reviewed from a prospectively maintained ERCP database. Demographic and technical data, indications, AEs, and ERCP success rate were recorded. Descriptive data are reported as mean/median ± standard deviation/range, or percentage. Results 19 were included. Patients’ characteristics in Table 1. Post-Liver transplantation immunodeficiency was the most common indication for the use of disposable duodenoscope (9, 47.3%), followed by SARS-CoV2 infection (6, 31.5%) and immunodeficiency (4, 21%). Twelve native papillae were recorded (63.1%) undergoing biliary sphincterotomy in 10 cases (52.6%) and pancreatic sphincterotomy in 1 case (5.2%). In 1 case (5.2%) precut was needed after cross-over to reusable duodenoscope. Seven cases of non-native papilla were recorded (36.8%). ERCP was completed with the single use duodenoscope in 17 cases (87.4%). One case of delayed bleeding (5.2%) managed endoscopically, and 1 case of post-ERCP pancreatitis (5.2%) managed conservatively, were recorded. Conclusions EXALT single use duodenoscope resulted efficient and safe in the management of bilio-pancreatic diseases. However, the advantages and environmental/cost impact of disposable duodenoscope and the are still controversial issues ([Fig. 1]). Patients characteristics (n: number, LT: liver transplantation, AEs: adverse events). Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Aims The aim of this study is to perform a case-control study to evaluate the risk for post-ERCP pancreatitis (PEP) in post-liver transplantation (LT) patients Methods This is a case-control retrospective study. All consecutive patients undergoing ERCP for the first time (native papilla) for post-LT biliary complications from January 2015 to September 2022, were included. The control group consisted of patients with native papilla undergoing ERCP for other indications from January 2019 to December 2019. Demographic data, technical data, and post-ERCP AEs were recorded. Rectal indomethacin was administrated in all cases as PEP prophylaxis. Descriptive data are reported as mean/median ± standard deviation/range, or percentage. Categorical data were compared using the χ₂ test. P values <0.05 were considered statistically significant. Results 106 post-LT patients were included in the “case” group and 452 in the “control” group. Patients’ characteristics in ([Table 1]). PEP prevalence was significantly higher in the case group (8/106, 7.5%) compared with the control group (15/452, 3.5%) (OR: 2.37, 95% CI: 0.98-5.75, P= 0.048). Double guide-wire cannulation prevalence was significantly higher in the case group (21/106, 19.8% vs. 54/442, 12.2%) (OR: 1.78, 95% CI: 1.02-3.10, P= 0.041). Conclusions LT patients are at higher risk of PEP when compared with patients undergoing ERCP for other indication. Biliary cannulation seems to be more difficult in LT patients and this could explain the higher risk of PEP. The main limitations of this study are the retrospective design and the presence of a historic cohort group as controls. Prospective studies are needed to confirm these data. Patients characteristics (n: number, LT: liver transplantation, AEs: adverse events, PEP: post-ERCP pancreatitis). Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany