Dan Liu

Background: Based on the principle of fibrotic remodeling and stricture formation post-resection, we developed a novel endoscopic bariatric procedure, endoscopic gastric mucosal resection (EGMR), that targets the gastric body and fundus with the aim of reducing gastric volume and suppressing ghrelin levels. The aim of this study was to investigate the feasibility, efficacy, and safety of EGMR in the porcine model. Methods: Ten healthy Yorkshire pigs were randomly assigned to the experimental group ( n = 5) and the control group ( n = 5). The experimental group underwent endoscopic mucosal resection and endoscopic submucosal dissection targeting approximately 50% of the gastric body and fundus mucosa. Weight was recorded at weekly intervals over a 12-week observation period. Fasting ghrelin levels were assessed at baseline and at 4 and 8 weeks post-EGMR. Structural changes were assessed radiographically, with the findings corroborated by endoscopic evaluation and necropsy. Results: EGMR was successfully performed in all pigs in the experimental group. Both groups gained weight throughout the 12-week study period; however, from 7 weeks post-EGMR onward, body weight was significantly lower in the experimental group compared with the control group ( p < 0.05). Likewise, mean fasting ghrelin levels decreased significantly at 4 and 8 weeks compared to the control group ( p = 0.001 and p < 0.001, respectively). Gastroscopy confirmed complete ulcer healing at 8 weeks post-EGMR. Necropsy findings corroborated the structural changes observed on radiographic imaging. One intraprocedural perforation (20%) was successfully managed endoscopically using endoclips. Conclusion: In this pilot study, EGMR was technically feasible and attenuated expected weight gain in healthy juvenile pigs, rather than inducing weight loss in animals with obesity. Structural remodeling suggestive of reduced gastric volume and suppression of ghrelin provided evidence of a likely combination of mechanical and hormonal effects. All complications were managed endoscopically, but the observed perforation underscores the need for refinement before human studies.

Endoscopic retrograde appendicitis therapy (ERAT) is a minimally invasive treatment for appendicitis, widely practiced in China. Clarifying the learning curve, especially among endoscopists with varying endoscopic experience, including endoscopic retrograde cholangiopancreatography (ERCP) skills, is essential for its broader adoption. This study aimed to determine the number of cases required to achieve procedural proficiency across different experience levels, as well as to examine the disparities in technical success rates and clinical outcomes. In this multicenter retrospective study, 655 consecutive patients who had undergone ERAT between October 2021 and March 2024 in The First Affiliated Hospital of Zhengzhou University, Jingxing County Hospital, and The Affiliated Taian City Central Hospital of Qingdao University were analyzed. All ERAT procedures were performed by nine trainees from three hospitals, categorized into novice, non-ERCP experience, and ERCP experience groups. Outcomes included technical/clinical success, procedure time, pain, recurrence, length of stay, and adverse events. Learning curves were evaluated with cumulative sum (CUSUM) based on procedure time. Technical and clinical outcomes improved with increasing experience in all groups. Proficiency occurred at the 31st case in the ERCP group, the 55th in the non‑ERCP group, and the 59th in novices. The ERCP group had the highest technical (99.1%) and clinical (94.4%) success (P = 0.023 and P = 0.093), the shortest mean procedure time (20.9 minutes; P < 0.001), and the lowest recurrence (P < 0.001). Complication rates, including intraoperative and postoperative adverse events, were low and similar across groups (0.8%–2.6%, P > 0.05). Postoperative pain and hospital stay decreased with experience (P < 0.05). Endoscopists with extensive prior endoscopic experience, particularly in ERCP, achieve proficiency in ERAT more rapidly. Structured training programs tailored to different experience levels are essential to support the safe and effective global implementation of ERAT.

Appendicitis is the most common acute abdominal condition, with appendectomy being the standard treatment option [ 1]. However, stump appendicitis remains one of the most frequent complications following appendectomy, often leading to complex clinical outcomes [ 2, 3]. Stump appendicitis can be quite insidious, with the potential to rapidly progress to severe complications such as peri-appendiceal abscesses and peritonitis. The management of stump appendicitis is complex, often necessitating reoperation for debridement of the appendiceal region or even cecal resection, which poses significant risks and burdens to patients. Here, we report a successful case of endoscopic retrograde appendicitis therapy (ERAT) for appendiceal stump inflammation with peri-appendiceal abscess.

Background: Endoscopic retrograde appendicitis therapy (ERAT) has emerged as a minimally invasive approach to treating appendicitis. Objectives: This study aimed to assess the long-term safety and efficacy of ERAT and to develop a model predicting 1‑year appendicitis recurrence in patients with acute appendicitis, to guide clinical decision-making. Design: This is a multicenter retrospective study. Consecutive patients were referred to the three participating centers. Methods: A retrospective analysis was conducted on clinical data from 435 patients with acute appendicitis who underwent ERAT at three hospitals between October 2017 and October 2024. Twenty-four clinical variables were screened, and Spearman correlation analysis revealed correlation coefficients exceeding 0.6 between some variables. To address multicollinearity, LASSO regression was employed to identify key predictive factors in the training set. A predictive model was constructed using multivariate logistic regression, and a nomogram was developed. Results: All ERAT procedures were technically successful, and a clinical success rate of 92.4% was achieved. The median follow-up period was 37 months, and the overall recurrence rate was 16.1%; most recurrences (13%) were observed in the first year. Based on LASSO regression analysis, the final predictors identified were: age >60 years (odds ratio (OR) = 2.981, 95% confidence interval (CI): 1.368–6.497, p = 0.006), recurrence appendicitis (OR = 4.048, 95% CI: 1.931–8.587, p < 0.001), Alvarado score >6 (OR = 5.649, 95% CI: 2.586–12.339, p < 0.001), fecalith (OR = 2.680, 95% CI: 1.146–6.267, p = 0.023), inexperienced operator (OR = 2.286, 95% CI: 1.141–4.580, p = 0.020), procedure time >40 min (OR = 2.472, 95% CI: 1.240–4.927, p = 0.010), appendix lumen distortion (OR = 7.634, 95% CI: 1.414–41.219, p = 0.018), and stent placement (OR = 5.970, 95% CI: 0.121–0.793, p = 0.015). Based on these eight predictive factors, a nomogram model was constructed to predict recurrence risk within 1 year after ERAT. Conclusion: ERAT is a safe and effective treatment for acute appendicitis. The risk of recurrence is highest within the first year. Eight independent risk factors for recurrence within 1 year after ERAT were identified, and a recurrence risk prediction model based on these predictive factors can assist in future clinical decision-making for ERAT.

Background and Study Aim Esophageal endoscopic submucosal dissection (E-ESD) is a key treatment modality for early-stage esophageal cancer. However, data on the E-ESD learning curve remains relatively scarce. This study explores E-ESD learning patterns of endoscopists with different experience to inform training. Patients and Methods A 2014–2023 single-center retrospective study analyzed 300 E-ESDs (150 cases each performed by senior endoscopists [SE] and junior endoscopists [JE]), stratified into 3 phases (1–50, 51–100, 101–150 cases). CUSUM and moving averages assessed the learning curve, with key indicators including resection speed, en bloc/R0 rates, and perforation rate. Results As case numbers increased, both endoscopists’ key indicators improved. SE had significantly higher median resection speed than JE in Phase 1 (5.59 vs. 3.87 cm²/h, P = 0.001) and 3 (10.14 vs. 7.21 cm²/h, P < 0.001). En bloc rates rose to 96% (SE) and 94% (JE); R0 rates to 96% (SE) and 94% (JE) (no intergroup differences, P > 0.05). The perforation rate decreased from 22 to 6% for SE and from 12 to 2% for JE. CUSUM showed proficiency at 59 (SE) and 61 (JE) cases. Conclusions In our single-center study, a junior endoscopist reaches similar efficacy to a senior after about 60 cases for proficiency. Performance differs mainly in resection speed, indicating experience improves efficiency not core outcomes. These exploratory findings, derived from a limited sample of two operators, support E-ESD training but are not definitive benchmarks.

INTRODUCTION: Endoscopic retrograde appendicitis therapy (ERAT) is a new and noninvasive endoscopic technique originally developed by Liu in China for the management of acute appendicitis. Although its safety and efficacy have been extensively validated in adult populations, evidence regarding its use in pediatric patients remains scarce. The aim of this study was to evaluate the clinical outcomes of ERAT in pediatric appendicitis. METHODS: This retrospective study analyzed pediatric patients who underwent ERAT in our hospital between January 2019 and August 2022. Data collected included patient demographics, the success rate of ERAT, and the duration of hospital stay. In addition, recurrence rates were assessed during the follow-up to evaluate the safety and long-term efficacy of the procedure. RESULTS: A total of 73 patients were included in this study. Appendiceal intubation was successfully performed in 72 of 73 patients (98.63%). Among these patients, 72.22% of patients had appendiceal fecal stones or food residue, and the success rate of stone removal was 94.23%. Overall, the clinical success rate of the procedure was 91.78%. The median procedure time was 22 minutes (interquartile range 15–36.5), and the median postoperative hospital stay was 2 days (interquartile range 1–4). During the 1-year follow-up, 14.92% of the patients had recurrent appendicitis. DISCUSSION: ERAT seems to be a safe and effective alternative approach to treat appendicitis in pediatric patients, especially for obstructive appendicitis with appendicolith.

Creation of a tunnel has been deemed technically demanding for resecting large esophageal submucosal tumors (SMTs) originating from muscularis propria [1]. For lesions located at the esophageal entrance, which is known as the first physiological narrowing, there is no space to create a submucosal tunnel. As a result, endoscopic full-thickness resection (EFTR) is an imperative option [2]. Here, we present a large cervical esophageal SMT resected using EFTR, and the defect healing smoothly without closure. A 51-year-old woman had a deep SMT at the esophagus entrance ([Fig. 1] a). Endoscopic ultrasonography showed a well-demarcated, inhomogeneous and hypoechoic mass arising from the muscularis propria layer ([Fig. 1] b). After acquiring informed consent, a standard EFTR was performed ([Video 1]). To overcome the poor endoscopic maneuverability in this location, a snare was employed for traction to improve exposure and facilitate resection of the lesion while keeping the adventitia intact ([Fig. 1] c). The resected specimen measured 25 mm × 18 mm ([Fig. 1] d). Since the limited operating space made it challenging to close the defect, the procedure kept the esophageal adventitia intact ([Fig. 1] e). The intact adventitia and soft tissues around esophageal entrance kept no air and liquid leakage. Thus, we decided to keep the defect unclosed. In addition, a gastric tube was placed in the esophageal lumen for decompression. On postoperative day 7, endoscopy showed no evidence of active bleeding or fistula formation; therefore, the gastric tube was withdrawn and the liquid diet was resumed. Four months later, endoscopic examination revealed satisfactory wound healing with no signs of esophageal stenosis and sphincter dysfunction ([Fig. 1] f). This case provides a feasible option that closure is not obligatory following EFTR at esophageal entrance, when the full-thickness defect is air tight. Endoscopy_UCTN_Code_TTT_1AO_2AG_3AD Article published online: 08 December 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

A 55-year-old female was admitted to our hospital with intermittent abdominal pain for 8 months and aggravated for 1 day. Physical examination revealed a positive Murphy sign. CT scan indicated acute calculus cholecystitis ([Fig. 1] a). The patient strongly desired gallbladder preservation. Considering the patient’s severe cholecystitis and increased risks of cholecystolithotomy, we concluded that controlling inflammation and relieving biliary obstruction should be the initial priorities. Therefore, we decided to perform cystic duct stent placement. ERCP showed no dilation of the common bile duct and non-visualization of the gallbladder ([Fig. 1] b). Successful gallbladder cannulation and cholangiography were performed with a cholangioscope, which revealed multiple gallstones ([Fig. 1] c, d). To protect gallbladder physiological function (maintaining hepatobiliary circulation, gallbladder storage, and bile excretion) and ensure controlled stent retrieval, we placed an improved new type of gallbladder-cholangial plastic stent (8.5-Fr 8 cm) with a retraction thread. Firstly, the side wings of the stent were removed, and a thread about 8 cm long was threaded at the distal end of the stent ([Fig. 2]). The stent was then deployed into the biliary tract ([Video 1], [Fig. 1] e, f). Postoperatively, the patient’s abdominal pain was relieved immediately and discharged. After 3 months, a CT scan revealed complete resolution of gallbladder wall edema, and the stent remained in situ ([Fig. 1] g). Subsequent natural orifice transluminal endoscopic surgery, gallbladder-preserving cholecystolithotomy, and stent removal were performed successfully [1]. At 18-month follow-up, the patient was well ([Fig. 1] h). For patients with acute calculous cholecystitis who request gallbladder preservation, cystic duct stent placement is effective to relieve biliary obstruction and alleviate gallbladder inflammation [2]3]. The application of a gallbladder-cholangial plastic stent with a retraction thread serves as a bridging therapy. It rapidly relieves biliary obstruction, protects gallbladder physiological function, and ensures easy stent removal. This approach paves the way for definitive surgery, whether gallbladder preservation or cholecystectomy. Endoscopy_UCTN_Code_TTT_1AR_2AH Article published online: 06 November 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