Introduction

Peroral endoscopic myotomy (POEM) is emerging as a minimally invasive therapeutic option for achalasia. Data are limited in pediatric population.
To compare the efficacy and safety of POEM in pediatric and adult patients with achalasia.

Aims & Methods

A prospective study was conducted, including all patients who underwent POEM, since August/2022, in a tertiary centre. Patients aged under 18yo were included in the pediatric group and above 18yo in adult group. Procedural-related parameters, adverse advents, pre- and post-intervention clinical, manometric and radiologic outcomes were evaluated.

Results

41 patients were included, including three children (mean age: 14.3±1.2vs.51.8±19.1yo; male gender: 100%(n=3)vs.39.5%(n=15)). According to the Chicago classification v4.0, all three children had type II achalasia (adults: type I-5.3%(n=2), type II-89.4%(n=34), type III-5.3%(n=2)). No significant differences were observed between groups in relation to clinical symptoms (Eckardt score (ES): 7.6vs.0.9;ρ=0.23; average duration of symptoms: 21vs.19months;ρ=0,36), pre-POEM integrated relaxation pressure (IRP) (36.7vs.19.0;ρ=0,11), esophagogastric junction contractile integral (EGJ-CI) (105,3vs.91,2;ρ=0.72) and barium swallow study at 1/5 minutes (4.5/5.1vs.12.6/10.0;ρ=0,17/0.29) and post-POEM IRP (9.75vs.6.19;ρ=0.32), EGJ-CI (7vs25.20;ρ=0.30) and barium swallow study (3.45/2.20vs.2.65/1.43;ρ=0.57/0.56), evaluated at 4.3±1.3 and 8.5±2.1months of follow-up. Technical success was 100% in all groups with mean procedure time of 91.7±12.6minutes for children (vs.86.1±21.6 for adults;ρ=0.35). Clinical success was similar in both groups (ES: children-0±0 vs. adults-0.31±0.63;ρ=0.69). There were no significant differences between groups regarding intraprocedural complications (67%vs.66%;ρ=0.98), post-procedural complications or major adverse events. No mortality or need for surgery. Symptomatic gastroesophageal reflux disease (GERD), successfully treated with daily PPI, was only observed in 5(13.2%) adults (vs. 0% of pediatric patients;ρ=0.021).

Conclusion

POEM proved to be effective and safe for achalasia both in adults and pediatric patients, with no statistically significant differences regarding technical, clinical, manometric and imaging success or complications. Achalasia should be treated as early as possible, with apparently lower incidence of post-POEM GERD in pediatric patients.

References

1. Rui Mendo, Pedro Barreiro, José Rodrigues, Catarina Félix, Catarina O'Neill, Iala Carina, Joyce Chivia, Cristina Chagas; Peroral Endoscopic Myotomy for
Esophageal Achalasia in Portugal: Outcomes of the First Prospective Series. GE Port J Gastroenterol 30 April 2021; 28 (3): 162–169.

Introduction

Gastric cancer (GC) is the fifth most common malignancy worldwide and the fourth leading cause of cancer death. In Colombia, it ranks third in incidence and first in mortality, with a 5-year survival below 25% in advanced stages. Early detection relies on identifying premalignant lesions. OLGA and OLGIM histological staging systems enable risk stratification. While stages III–IV are known high-risk states, the role of stage II remains unclear. This study focuses on OLGA II to address this gap.

Aims & Methods

This systematic review and meta-analysis, registered on PROSPERO (CRD42024549931), adhered to PRISMA 2020 guidelines. The primary objective was to determine whether OLGA stage II confers a statistically significant risk of GC compared to stages 0–I. Secondary objectives included evaluating risks across all advanced stages (II–IV) and contrasting OLGA versus OLGIM staging.
We searched PubMed, EMBASE, and Cochrane up to 31 May 2024 using terms including "OLGA", "OLGIM", "gastric cancer", and "gastric intraepithelial neoplasia". Inclusion criteria covered cohort, case-control, and cross-sectional studies reporting GC incidence stratified by OLGA/OLGIM stage. Data extraction and quality assessment were performed independently by two reviewers using the Newcastle-Ottawa Scale, with evidence certainty assessed via GRADE. Meta-analytical synthesis used random-effects modelling, and heterogeneity was assessed with I² and Tau² statistics.

Results

Twenty-eight studies met inclusion criteria, comprising 13 cohort, 11 case-control, and 4 cross-sectional studies.

• OLGA II vs 0–I (Cross-sectional studies): A significantly increased GC risk was observed (Z = 3.14; P = 0.002; I² = 65%), suggesting OLGA II as an early but meaningful predictor of malignant transformation.
• OLGA II (Cohort studies): No statistically significant difference was found (P = 0.28; I² = 0%), though sample size was limited.
• OLGIM II: Demonstrated increased risk only in case-control settings (Z = 11.26; P < 0.00001), but not in cohort studies.

Findings for OLGA and OLGIM stages III–IV corroborated existing evidence of elevated risk. However, this is the first meta-analysis to demonstrate a potential oncogenic risk beginning at OLGA stage II, particularly evident in cross-sectional data.
Sensitivity analyses affirmed result consistency, and the certainty of evidence was rated moderate. Subgroup comparisons revealed that OLGA may outperform OLGIM in early risk discrimination.

Table 1. Summary of Gastric Cancer Risk According to OLGA and OLGIM Stages

Staging System	Stage	Study Design	Pooled Risk Estimate	95% CI	Heterogeneity (I²)	Significance (p-value)
OLGA	II vs 0–I	Cross-sectional	OR 2.34	1.36 – 4.02	65%	0.002
OLGA	II vs 0–I	Cohort	RR 1.20	0.85 – 1.69	0%	0.28
OLGA	III–IV vs 0–II	Case-control & Cohort	OR 4.87 / RR 3.12	–	88%	< 0.00001
OLGIM	II vs 0–I	Case-control	OR 1.95	1.52 – 2.50	0%	< 0.00001
OLGIM	II vs 0–I	Cohort	RR 1.10	0.85 – 1.42	0%	0.74
OLGIM	III–IV vs 0–II	Case-control & Cohort	OR 3.89 / RR 2.91	–	82%	< 0.00001

Abbreviations: OR = Odds Ratio; RR = Risk Ratio; CI = Confidence Interval

Conclusion

Our study highlights a pivotal finding: OLGA stage II—previously considered an intermediate state—emerges as a statistically significant risk factor for gastric cancer. These findings suggest that the progression to malignancy may begin earlier than currently recognised. Incorporating OLGA II into surveillance strategies could lead to improved early detection, especially in high-incidence countries. The data support a shift toward broader inclusion criteria for endoscopic follow-up and reinforce the clinical utility of histological staging in GC prevention frameworks.

References

• Yue H, Shan L, Bin L, Shi L. The OLGA and OLGIM staging systems are useful for assessing the gastric cancer risk: a systematic review and meta-analysis. Gastric Cancer. 2018;21(4):579–87. doi:10.1007/s10120-017-0779-4
• Rugge M, Genta RM, Zambon CF, et al. OLGA staging for gastritis: a tutorial. Dig Liver Dis. 2008;40(9):650–8. doi:10.1016/j.dld.2008.02.020
• Rugge M, Meggio A, Pennelli G, et al. Gastritis staging in the endoscopic follow-up for the secondary prevention of gastric cancer: a 5-year prospective study of 1755 patients. Gut. 2019;68(3):477–84. doi:10.1136/gutjnl-2017-315252
• Pimentel-Nunes P, Libânio D, Marcos-Pinto R, et al. Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group, European Society of Pathology, and Sociedade Portuguesa de Endoscopia Digestiva guidelines update 2019. Endoscopy. 2019;51(4):365–88. doi:10.1055/a-0859-0574
• Correa P. Human gastric carcinogenesis: a multistep and multifactorial process—First American Cancer Society Award Lecture on Cancer Epidemiology and Prevention. Cancer Res. 1992;52(24):6735–40.

Introduction

Endoscopic drainage is standard of care in malignant biliary obstruction (MBO).

Aims & Methods

The aim of this study was to investigate efficacy of biliary stenting in providing access to systemic chemotherapy. Patients with biliary obstruction (bilirubin >2.5 mg/dl) caused by unresectable biliary or pancreatic cancer were retrospectively analyzed with respect to use of chemotherapy and survival. Laboratory data were analyzed at baseline, 7-10 and 28-35 days following biliary stenting.

Results

Patients with MBO (n=78) were allocated into one of three groups according to bilirubin level [mg/dl] 2.5 – 5.99 (group 1), 6.0 - 15.0 (group 2) and >15 (group 3). On first blood testing mean bilirubin declines from baseline in respective groups were: 1.19 (29.5%), 3.77 (38.5%) and 7.1 (27.3%), and on second measurement 1.61 (40%), 5.69 (58.2%) and 13.0 (50%). Chemotherapy was applied in 28 (35.8%) patients, less frequently in group 3 than in group 1 (31.2% vs 44.0%; p =0.07) and group 2 (vs 38.1%; p =0.06). Mean survival time was 4.8 ±2.8 months and was significantly shorter in group 3 as compared to group 2 (3.8 ±2.0 vs 6.2 ±3.9 months; p =0.02) and to group 1 (vs 5.4 ±2.7 months; p =0.03).

Conclusion

In two-thirds of patients with MBO endoscopic biliary drainage does not grant access to chemotherapy. Use of chemotherapy and survival time are significantly higher in patients with bilirubin level below 15 mg/dl as compared to those with greater bilirubinemia, but in patients with bilirubin level below 6 mg/dl the biliary drainage is minimally effective.

Disclosure

No.

Introduction

Common bile duct (CBD) stones are one of the most frequent indications for endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic complete sphincterotomy (EST) followed by balloon or basket extraction is widely considered the gold standard technique for the treatment of CBD stones; being successful in more than 90% of cases with approximately 5% overall rate of adverse events [1]. Endoscopic papillary large balloon dilatation (EPLBD) is an effective technique in treating large common bile duct (CBD) stones. However, the efficacy and safety of EPLBD in the setting of periampullary diverticula (PAD) are prospectively lacking.

Aims & Methods

This study aimed to compare the effectiveness and short-term safety of EPLBD after limited sphincterotomy with those of EST for extracting large CBD stones in the setting of PAD prospectively. Forty-eight patients with large CBD stone(s) > 1 cm were recruited. All patients had a PAD. Before the procedure patients were evaluated by history taking, clinical examination full investigations including proper imaging studies. During the procedure, patients were randomized to either group I; patients treated with EPLBD after limited sphincterotomy, and group II; patients treated with EST. CBD clearance was defined as a single procedure (EPLBD vs EST), single session (no repeat ERCP), and non-assisted (no lithotripsy used) stone extraction. After the procedure patients were hospitalized with clinical, laboratory, and imaging assessment.

Results

Table 1: Univariate regression of the parameters affecting stone extraction

PAD: periampullary diverticulum			* significant as P value≤ 0.05
	Odds ratio	95% CI	P value​
The used technique	5.92	1.32 to 25.3	0.009∗
Stone (s) number	0.62	0.17 to 2.25	0.468
Stone (s) diameter (mm)	2.59	0.63 to 10.56	0.187
Type of PAD​	1.32	0.65 to 2.67	0.437

The overall stone extraction rate in the current study was only 77.3% (n=34). The efficacy of stone extraction was significantly higher in the EPLBD (n= 21,87.5%) group compared to EST (n= 13, 54.17%) group (p = 0.011). The procedure-related adverse events were lower in the EPLBD group compared to the EST group. Pancreatitis was significantly higher in the EST (n=14, 58.33%) group than in the EPLBD (n=3, 12.5%) group (p= 0.001). There were no perforations or case fatalities in either group. The predictors of stone extraction were analyzed using univariate regression (Table 1), and it is noticeable that the used technique was the independent predictor of success in stone extraction (Odds Ratio: 5.92, 95% Confidence Interval: 1.38 to 25.30, p-value = 0.009).

Conclusion

The current practice guidelines of the ESGE and ASGE suggest that for large CBD stones, an EST followed by a large balloon dilatation is preferable to EST alone because combining dilatation with EST improves duct clearance and reduces the need for lithotripsy without adding risk. Our results among PAD patients seem to echo this: the EPLBD approach in comparison to EST yielded higher stone clearance on first attempt even without using lithotripsy by the study design. Hence, based on the current study these existing recommendations can be extrapolated to the PAD population based on our study which is one of the first randomized trials in the specific PAD subgroup.

References

1. Zippi M, Traversa G, Pica R, De Felici I, Cassieri C, Marzano C, et al. Efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) performed in patients with Periampullary duodenal diverticula (PAD). Clin Ter. 2014;165(4):e291-4.