Introduction

Lumen-apposing metal stents (LAMS) have become an essential endoscopic tool for a variety of in- and off-label indications. While LAMS can provide significant clinical benefit for many patients, potential adverse events related to the procedure may occur in up to 21.3% of cases [1, 2].
International consensus recommendations on the safe use of LAMS for in- and off-label indications may reduce the overall complication rate of the related procedures.

Aims & Methods

Based on the available literature evidence statements were formulated and grouped into the following categories: general safety measures, peripancreatic fluid collections (PFC), biliary drainage (EUS-BD), gallbladder drainage (EUS-GBD), gastroenterostomy (EUS-GE) and gastric access temporary for endoscopy (GATE). The evidence level of each statement was determined using the GRADE methodology.
International LAMS experts were identified and invited to participate in a modified Delphi process to developconsensus recommendations for the safe use of LAMS. Our Delphi process consisted of three rounds. In the first two rounds, participants had the option of either agreeing or disagreeing with the statements and to add their answer rationale and comments. Statements were accepted when they reached the 80% consensus level.
When no consensus was reached, the statement was modified based on the expert feedback. The modified statement and the anonymized feedback of all colleagues were reviewed by the experts. Statements were rejected if no consensus was reached after the third Delphi round.

Results

Nineteen of the 20 invited LAMS experts completed the Delphi process. Fifty-six (93.3%) out of 60 formulated statements were accepted, of which 35 (58.3%) in the first round, an additional 17 (28.3%) in the second round and an additional 4 (6.6%) in the third round. Four statements (6.6%) did not reach the 80% consensus level and were removed from the final recommendations.
Consensus was reached on the optimal learning path, preprocedural imaging, the need for airway protection and on essential safety measures during the procedure such as the use of Doppler and measurement of the distance between the gastrointestinal lumen and the target structure.
Specific consensus recommendations were generated for the different LAMS indications, covering amongst others the careful patient selection, the preferred size of the LAMS, the need for antibiotics, the preferred anatomic location of the LAMS, the need for coaxial pigtail placement and the appropriate management of LAMS-related adverse events.

Conclusion

Through a modified international Delphi expert consensus process, we developed consensus recommendations on the safe use of LAMS, including general safety measures and recommendations for specific indications.
We hope that these consensus recommendations provide a practical and evidence-based guideline for endoscopists to minimize adverse events related to their LAMS procedures.

References

1. Choi, J.H.; Kozarek, R.A.; Larsen, M.C.; Ross, A.S.; Law, J.K.; Krishnamoorthi, R.; Irani, S. Effectiveness and safety of lumen- apposing metal stents in endoscopic interventions for off-label indications. Dig. Dis. Sci. 2021, 67, 2327–2336.
2. Hindryckx, P.; Degroote, H. Lumen-apposing metal stents for approved and off-label indications: A single-centre experience. Surg. Endosc. 2020, 35, 6013–6020.

Disclosure

1. Sebastian Stefanovic: Speaker for Medip and FujiFilm.
2. Douglas G. Adler: Consultant for Boston Scientific and Micro Tech.
3. Alexander Arlt: Nothing to disclose.
4. Todd H. Baron: Consultant and speaker for Boston Scientific, W.L. Gore, Cook Endoscopy, and Olympus America.
5. Kenneth F. Binmoeller: Consultant for Boston Scientific and an inventor of the Axios stent and electrocautery delivery system.
6. Michiel Bronswijk: Nothing to disclose.
7. Marco J. Bruno: Research support from Boston Scientific, Cook Medical, Pentax Medical, Mylan, ChiRoStim and a consultant/lecturer for Boston Scientific, Cook Medical, Pentax Medical and AMBU.
8. Jean-Baptiste Chevaux: Nothing to disclose.
9. Stefano Francesco Crino: Nothing to disclose.
10. Helena Degroote: Nothing to disclose.
11. Pierre H. Deprez: Speaker for Olympus and Erbe.
12. Peter V Draganov: Consultant for Olympus, Boston Scientific, Cook Medical, Fujifilm, and Medtronic
13. Pierre Eisendrath: Nothing to disclose.
14. Marc Giovannini: Consultant for Taewong Med Company.
15. Manuel Perez-Miranda: Consultant for Boston Scientific, Olympus, Medtronic, and M. I.Tech.
16. Ali A Siddiqui: Consultant for Boston Scientific.
17. Rogier. P. Voermans: Consultant for Boston Scientific.
18. Dennis Yang: Consultant for MicroTech, Medtronic, Olympus, Fujifilm, and Apollo Endosurgery.
19. Pieter Hindryckx: Consultant and speaker for Boston Scientific, FujiFilm, MedWork and Viatris.

Clinical Case Summary

Percutaneous endoscopic gastrostomy (PEG) tube has been frequently placed for various indications in order to provide long term enteral nutrition support[i],[ii],[iii]. Approximately 160,000 to 200,000 PEG tubes are placed each year in United States[iv]. Advancements in surgical interventions of gastrointestinal tract has resulted in increased number of anatomically altered stomachs, and so anatomically changed on endoscopic examination as well; which makes endoscopic interventions a little different[v]. Multiple case series have been reported for PEG tube placement in patients with subtotal gastrectomy [vi], however, there is scarce data available for PEG tube placement in patients with history of sleeve gastrectomy. The case that is presented here is regarding 64 years old lady with history of sleeve gastrectomy and now referred for PEG tube placement as she was advised for radiotherapy for squamous cell carcinoma of right buccal mucosa. PEG tube was successfully placed and follow up to a month showed effectively functional PEG tube with no major complications.

References

[i] Powell-Tuck J, Van Someren N. Enterostomy feeding for patients with stroke and bulbar palsy. Journal of the Royal Society of Medicine. 1992 Dec;85(12):717-9.
[ii] Richards DM, Tanikella R, Arora G, Guha S, Dekovich AA. Percutaneous endoscopic gastrostomy in cancer patients: predictors of 30-day complications, 30-day mortality, and overall mortality. Dig Dis Sci. 2013;58:768–776. doi: 10.1007/s10620-012-2397-8.
[iii] Orphanidou C, Biggs K, Johnston ME, Wright JR, Bowman A, Hotte SJ, Esau A, Myers C, Blunt V, Lafleur M, Sheehan B. Prophylactic feeding tubes for patients with locally advanced head-and-neck cancer undergoing combined chemotherapy and radiotherapy—systematic review and recommendations for clinical practice. Current oncology. 2011 Aug;18(4):e191.
[iv] Wei M, Ho E, Hegde P. An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit. J Thorac Dis. 2021 Aug;13(8):5277-5296. doi: 10.21037/jtd-19-3728. PMID: 34527366; PMCID: PMC8411178.
[v] Morrell D, Pauli E, Juza R. Endoscopy in surgically altered anatomy. Annals of Laparoscopic and Endoscopic Surgery. 2019 Apr 24;4.
[vi] Singh P, Kahn D, Greenberg R, Indaram A, Pooran N, Bank S. Feasibility and safety of percutaneous endoscopic gastrostomy in patients with subtotal gastrectomy. Endoscopy. 2003 Apr;35(4):311-4. doi: 10.1055/s-2003-38156. PMID: 12664387.

Introduction

Quality assessment is a priority in the field of gastroenterology. However, limited data are available from Greece regarding adherence to quality standards in gastrointestinal endoscopy.

Aims & Methods

This study aims at assessing the knowledge and compliance of Greek gastroenterologists with established quality standards for upper and lower digestive endoscopy, while exploring factors that may influence compliance.
​This prospective study recorded data on the quality of upper and lower digestive endoscopy performed in Greece from October 2024 to January 2025. All members of the Hellenic Society of Gastroenterology (n=668) were invited to participate via an electronic survey. The survey included a questionnaire designed specifically for this study, covering demographic and professional characteristics, as well as quality indicators for gastroscopy and colonoscopy.

Results

A total of 164 gastroenterologists participated (response rate 24.55%), of whom 107(65.24%) were male, and 102(62.2%) working in public or academic hospitals. The duration of gastroscopy was not recorded by 116(70.73%) participants, while 102(62.2%) systematically used photodocumentation. Most participants utilized the Prague and Los Angeles classifications 156(95.12%) and 159(96.95%) respectively. Additionally, 140(85.37%) followed the Seattle protocol, and 158(96.34%) conducted biopsies according to ESGE guidelines for precancerous gastric lesions. However, 83(50.61%) don’t use a registry for patients with Barrett’s esophagus. Complications were systematically recorded after gastroscopy by 103(62.8%) and after colonoscopy by 90(54.88%).
In colonoscopy, 149(90.85%) use the BBPS scale, and 158(96.34%) reported successful cecal intubation. Withdrawal times exceeded six minutes for 151(92.07%) participants. An adenoma detection rate of over 25% was achieved by 117(71.78%), while 103(62.8%) consistently used the Paris classification. Proper polypectomy techniques were employed by 111(67.68%), but 100(60.98%) recommended follow-up intervals shorter than guidelines suggest. Patient experience following gastroscopy and colonoscopy was not recorded by 126(76.83%) and 116(70.73%) participants, respectively. Overall, compliance with quality indicators for upper and lower digestive endoscopy was observed in 87(53.05%) and 75(45.73%) participants, respectively. Multivariate analysis revealed that 5-15 years of experience (p=0.05), the use of video recording (p=0.01) and use of high-resolution endoscopes (p<0.01) were associated with improved compliance with quality indicators of upper endoscopy. Whereas age above 55 (p<0.01), use of high-resolution endoscopes(p<0.01), use of video recording (p=0.02) and attendance of educational seminars relevant with quality in endoscopy (p=0.05) were associated with improved compliance with quality indicators of colonoscopy.

Conclusion

In this study, discrepancies were observed in the compliance of Greek endoscopists with endoscopic quality indicators, highlighting the need for further improvement. The systematic recording of these quality indicators is essential, underlining the important role of scientific societies in this process.

Introduction

The increasing prevalence of antibiotic resistance and the scarcity of therapeutic options for patients with penicillin allergy have highlighted the necessity for novel treatment regimens. Keverprazan, a novel potassium-competitive acid blocker, provides potent and sustained gastric acid suppression.

Aims & Methods

This study was designed to evaluate the efficacy and safety of keverprazan-minocycline (KM) dual therapy compared with keverprazan-amoxicillin (KA) dual therapy in patients with Helicobacter pylori (H. pylori) infection. From October 2024 to April 2025, a total of 240 patients with H. pylori infection were recruited from six hospitals in Fujian province and randomly assigned to receive either KA dual therapy (amoxicillin 1 g three times daily plus keverprazan 20 mg once daily) or KM dual therapy (minocycline 100 mg twice daily plus keverprazan 20 mg once daily) for a duration of 14 days. The primary endpoint was the H. pylori eradication rate assessed at 4 weeks post-treatment. Secondary endpoints included the symptom relief rate, incidence of adverse events, and patient compliance.

Results

In the intention-to-treat (ITT) analysis, the H. pylori eradication rates were 85.83% (103/120) in the KA group and 87.50% (105/120) in the KM group. In the per-protocol (PP) analysis, the eradication rates were 86.95% (100/115) in the KA group and 90.35% (102/113) in the KM group. No statistically significant differences were observed between the two groups (P = 0.704 for ITT and P = 0.421 for PP analysis). Additionally, symptom remission rates (73.88% vs. 82.50%) and treatment adherence rates (97.01% vs. 97.50%) also showed no significant intergroup differences (both P > 0.05). However, the KM group exhibited a significantly higher overall incidence of adverse events compared with the KA group (38.33% vs. 17.16%, P < 0.001), primarily driven by mild dizziness (25.83% vs. 2.23%, P < 0.001). However, these adverse reactions were mild and did not affect treatment adherence.

Conclusion

The keverprazan-minocycline dual regimen demonstrated high eradication efficacy and acceptable safety in patients with H. pylori infection, with eradication effectiveness comparable to that of the keverprazan-amoxicillin dual therapy and mild adverse reactions. This regimen is recommended for the clinical treatment of H. pylori infection, particularly in patients with penicillin allergy.

Disclosure

There is no conflict of interest.

Introduction

ESD of the colorectal lesions involving the appendiceal orifice (AO) is technically challenging because of the thin wall and narrow working space. On the other hand, even if the lesions are small and benign, it is difficult to perform EMR because of the narrow snaring space. We previously reported strip biopsy (SB) resection of the AO lesion. The SB technique is as follows (1) Insert a 2-channel scope and check the lesion. (2) Insert a snare and grasping forceps into each channel, and hold the grasping forceps in the snare. (3) Grasp the appendiceal end of the lesion with the grasping forceps, open the snare, grasp the lesion, and resect it. This method makes it possible to snare the lesion after confirming the distal border of the AO. In the present study, we evaluated the feasibility of SB for AO lesions.

Aims & Methods

This was a retrospective study in which SB for AO lesions was performed on 10 patients at our hospital. Inclusion criteria for the study cohort were (1) the lesion less than 15 mm, and (2) visible lesion margin on the appendicular side. Polyps suspected to be cancerous were excluded.

Results

Male to female ratio was 8:2, median age (range) was 76 years (44-89). The median tumor size was 10 mm (10-15). The pathological findings were 8 cases of SSL and 2 cases of low-grade tubular adenoma. All lesions were resected en bloc, with a median treatment time of 10 minutes (range (5-10)). No complications were observed. Pathology results were negative for 8 cases and unknown for 2 cases. All lesions were resected endoscopically with no residuals.

Conclusion

SB technique for AO lesions is safe and it appeared that this could be one option for endoscopic treatment of AO lesions.^​