Introduction

Sleeve gastrectomy (SG) is currently the most commonly performed bariatric surgery worldwide, attributed to its technical simplicity, effectiveness, and favorable safety profile. Despite these advantages, postoperative gastric leaks remain a serious complication, occurring in up to 5% of cases. Endoscopic stenting is a widely adopted management approach; however, the impact of stent size, small stents (SS) versus megastents (MS) on clinical outcomes remains unclear

Aims & Methods

This systematic review and meta-analysis adhered to PRISMA 2020 guidelines. A comprehensive search of PubMed, Scopus, Embase, Web of Science, and CENTRAL was conducted for studies published until January 2025. Twenty-two studies met inclusion criteria, encompassing 273 patients with SG-related leaks treated via endoscopic stenting. Primary outcome was successful leak closure. Secondary outcomes included complication rates, stent duration, number of interventions, and hospitalization length

Results

Leaks were categorized as early (58%), acute (20%), late (12%), and chronic (10%). The pooled failure rate of stenting was 20.4% (95% CI: 13–28%), with moderate heterogeneity (I² ≈ 30.2%). Subgroup analysis showed failure rates of 22.1% for SS and 17.2% for MS. The relative risk (RR) for failure with MS compared to SS was 0.78 (95% CI: 0.54–1.14; p > 0.05), indicating no statistically significant difference. Stent migration occurred in 23.4% of cases, more often with MS (30%) than SS (16%), though this difference was also not statistically significant. MS showed a significantly shorter mean stent duration (32.6 vs. 55.1 days; p < 0.05) and required fewer interventions (1.9 vs. 2.4). Sensitivity analysis and funnel plots confirmed result robustness with minimal publication bias

Conclusion

Although both small and mega endoscopic stents are effective in managing SG-related leaks, megastents may offer modest clinical advantages, particularly shorter treatment durations and fewer procedures. However, the lack of statistically significant differences in primary outcomes underscores the need for further high-quality comparative studies to define optimal stent choice

Introduction

Colonoscopy is the gold standard for diagnosing colorectal cancer (CRC)¹, with post-colonoscopy colorectal cancer (PCCRC) defined by the World Endoscopy Organization (WEO) as CRC diagnosed between 6 and 48 months after a negative colonoscopy². PCCRC rates vary from 2.5% to 7%², and the prognosis of PCCRC is generally poorer than that for CRC detected during colonoscopy³.

Aims & Methods

To evaluate the risk factors associated with PCCRC in a major tertiary medical center.
We analyzed all consecutive colonoscopic procedures conducted between 2001 and 2019. Data was retrieved from electronic medical records (EMR) and cross-referenced with the Israeli Cancer Registry. We defined PCCRC based on the WEO criteria, and two physicians independently confirmed potential PCCRC cases to ensure data accuracy. Root-cause analysis of PCCRC was performed according to the WEO algorithm as follows:
A) possible missed lesion, index examination adequate;
B) possible missed lesion, index examination inadequate;
C) detected lesion, not resected; or
D) likely incomplete resection of previously identified lesion.
We then identified colonoscopy-detected CRCs (CDCRC, controls) and compared them to the PCCRC cases at a ratio of 1:3. We assessed patient median age at the procedure, gender, religion, family history of CRC, diabetes, smoking status, body mass index (BMI), obesity (defined in the EMR or BMI > 30) and endoscopic parameters: colonoscopy indication [surveillance (follow-up colonoscopy according to recommendations), abnormal imaging, patient symptoms], adequate Boston Bowel Preparation Scale (BBPS>6 and >2 in all segments), cecal intubation rate, diverticulosis, rectal retroflection, and tumor location.
Multivariable logistic regression assessed the association of multiple factors (endoscopy indications and obesity) with PCCRC, maintaining a 95% confidence interval (CI).

Results

Out of 54,154 colonoscopies, 2,339 patients were diagnosed with CRC, of which 49 (2.1%) were confirmed PCCRCs, while 2,157 (92.2%) were detected during colonoscopy. Of patients with PCCRC, 65.4% (n=32) had adequate BBPS, and 91.8% (n=45) cecal intubation was documented. The two most common reasons for PCCRC were category A (n=29, 59.1%), and category B (n=17, 34.6%), although in a lesser extent. We then compared PCCRC cases to 150 randomly selected CDCRC cases. Significant differences in patient characteristics included BMI>30 (p = 0.041) and obesity (p=0.015). Statistically significant endoscopic factors included colonoscopy indication (p < 0.001), cecal intubation rate (p < 0.001), and tumor location (p < 0.001). As expected, PCCRC was more commonly detected in the right colon (n=24, 55.8%) or rectum (n=12, 27.9%). Multivariable logistic regression revealed that patients with abnormal imaging as a colonoscopy indication had a lower risk for PCCRC (adjusted odds ratio (aOR) = 0.148, 95% CI: 0.033-0.455), while patients that performed colonoscopy for surveillance had a higher risk (aOR = 7.334, 95% CI: 2.355-25.963). Obesity was also a significant risk factor (aOR = 3.035, 95% CI: 1.326-7.035).

Conclusion

The most frequent cause of PCCRC across various patient populations and colonoscopy indications was a possible missed lesion. Factors such as patient obesity and undergoing colonoscopy for surveillance may increase the likelihood of PCCRC. These findings highlight the importance of physician awareness regarding PCCRC risks during colonoscopy.

References

1. Bretthauer M, Løberg M, Wieszczy P, et al. Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death. N Engl J Med. 2022;387(17):1547-1556.
2. Rutter MD, Beintaris I, Valori R, et al. World Endoscopy Organization Consensus Statements on Post-Colonoscopy and Post-Imaging Colorectal Cancer. Gastroenterology. 2018;155(3):909-925.e3.
3. Govindarajan A, Rabeneck L, Yun L, Tinmouth J, Paszat LF, Baxter NN. Population-based assessment of the outcomes in patients with postcolonoscopy colorectal cancers. Gut. 2016;65(6):971-976.

Introduction

In 2018, a biennial fecal immunochemical test (FIT) screening program for colorectal cancer (CRC) was introduced in northern Portugal, targeting 1.1 million residents aged 50-74 years.

Aims & Methods

This study aimed to evaluate trends in CRC incidence, early diagnosis, and survival before and after the program's implementation.
Population-based retrospective cohort study in northern Portugal. Data on CRC cases diagnosed between 2014-2020 were retrieved from the Portuguese National Cancer Registry (RON). Early diagnosis was defined as stage I/II tumors. Net survival estimates for 2014–2016 vs. 2018-2020 were compared. Data from RON were linked to the FIT-based screening program of the Northern Portugal Regional Health Administration for the years 2018–2020 to assess screening outcomes.

Results

Between 2018 and 2020, the first 3 years of the program, 482,938 invitations for FIT screening were sent, resulting in an adherence rate of 34.4% (165,895). The negative predictive value of FIT was 99.95% (95% CI: 99.94–99.96). Overall, coverage by FIT and/or colonoscopy was 44.9%. The proportion of early cancers was significantly higher among individuals submitted to FIT screening (58.3%) or colonoscopy (62.8%) compared to unscreened individuals (49.2%) (p<0.001). Net survival rates at 1-year and 3-years were significantly higher among individuals who accepted FIT screening or underwent colonoscopy compared to those who remained unscreened (p<0.001).

Conclusion

Biennial FIT led to an increase in early diagnoses and improved survival compared to no screening shortly after its introduction. A health system's comprehensive capacity boosts population coverage and improves CRC outcomes.

Introduction

Pelvic floor dysfunction is highly prevalent. Posterior compartment disorders include fecal incontinence (FI) and obstructive defecation syndrome (ODS). Assessment of the sphincter complex's (SC) ability to resist or yield to distension may provide a valuable method for evaluating continence and defecatory function.

Aims & Methods

Women with FI, chronic constipation (CC) and suspected functional defecation disorder (FDD), as well as healthy volunteers (HV) were included. Impedance Planimetry (IP) was performed using the anal functional lumen imaging probe [EndoFLIP^TM System (Medtronic®) with an 8-cm catheter (EF-325N)]. A “stepwise” measurement protocol was applied, with bag filling from 0 to 50ml in 10-ml increments. Distensibility index (DI) was recorded at rest, voluntary squeeze, cough maneuver and during simulated evacuation at 30-, 40- and 50-ml volumes. Simulated defecation was evaluated by calculating the percentage change in the DI relative to resting values at each volume.

Results

Fifteen women were included: 4 HV (26.7%), 7 with FI (46.7%) and 4 with CC (26.7%). Women with FI were older than those in the CC and HV groups (median age: FI 72 years [66–75], CC 55 years [42-63], HV 48 years [ 43–53], p = 0.009. Median BMI was similar among groups [HV 24.0 Kg/m² (21.6 – 25.3), FI 27.0 Kg/m² (24.3 – 30.0) and CC 26.2 Kg/m² (21.5 – 30.5), p=0.367]. The DI was significantly higher in the FI group compared to CC and HV groups at rest, during squeeze and during cough maneuver across 30-, 40- and 50-ml volumes. The percentage change in DI during simulated defecation at 50 ml was significantly reduced in CC compared to HV (p=0.030). When groups were categorized based on suspected FDD (CC vs HV+FI), the percentage change in DI was significantly lower in CC at 40 ml [74% (37 – 109) vs 175% (100 – 250), p=0.037] and at 50 ml [81% (43 – 96) vs 111% (96 – 119), p=0.048].

Conclusion

Impedance planimetry proves to be a valuable tool for distinguishing pelvic floor dysfunctions, as women with FI show higher DI values, whereas those with suspected FDD exhibit reduced DI changes during simulated defecation. These findings support the hypothesis that impaired rectal distensibility is a key feature of FDD, highlighting its role in continence and evacuation disorders.

References

-Leroi AM, Melchior C, Charpentier C, et al. The diagnostic value of the functional lumen imaging probe versus high-resolution anorectal manometry in patients with fecal incontinence. Neurogastroenterol Motil. 2018;30(6):e13291. doi:10.1111/nmo.13291
-O'Connor A, Byrne CM, Vasant DH, et al. Current and future perspectives on the utility of provocative tests of anal sphincter function: A state-of-the-art summary. Neurogastroenterol Motil. 2023;35(7):e14496. doi:10.1111/nmo.14496

Introduction

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most frequent adverse event following ERCP, with an incidence of 3–10% in the general population and up to 40% in high-risk patients. Risk factors are commonly classified as patient-related (young age, female sex, suspected sphincter of Oddi dysfunction) or procedure-related (precut sphincterotomy, difficult cannulation, pancreatic duct manipulation). However, the impact of specific therapeutic maneuvers—such as stone extraction techniques and biliary drainage—on PEP risk remains uncertain. In particular, the role of mechanical lithotripsy as an independent risk factor is still poorly defined. Moreover whether the systematic use of prophylaxis has actually reduced PEP incidence over time—particularly in high-risk cases—also remains uncertain.

Aims & Methods

This study aimed to retrospectively assess both patient- and procedure-related risk factors for post-ERCP pancreatitis, with a focus on therapeutic interventions whose impact remains uncertain. Findings were also compared with existing literature to refine individual risk profiles and inform preventive strategies.
We retrospectively analyzed 678 consecutive inpatients (49% male, 51% female; mean age 72.7 ± 13.4 years) admitted to our Gastroenterology Unit treated with ERCP for various indications (e.g., choledocholithiasis, pancreatic cancer, biliary strictures) between January 2020 and December 2024. All procedures were performed by experienced interventional endoscopists. PEP incidence was compared across categorical variables using chi-squared or Fisher’s exact tests (significance threshold p < 0.001). Age was compared using the Mann–Whitney U test. Variables significant in univariate analysis were included in a multivariate logistic regression model.

Results

Thirty-six cases of PEP were identified (5.3%), including 58% mild, 34% moderate, and 8% severe. No procedure-related deaths were reported. Patients with PEP were significantly younger (median age 69 vs 76 years, p = 0.01). Independent risk factors included suspected sphincter of Oddi dysfunction (OR = 7.8, p < 0.001) and mechanical lithotripsy (OR = 4.20; 95% CI: 1.38–12.78; p = 0.007), while biliary stenting was protective (OR = 0.17; 95% CI: 0.04–0.67; p = 0.01). Nasobiliary drainage showed a non-significant trend toward protection (OR = 0.67; p = 0.34), and pancreatic stenting was not significantly associated with reduced risk (p = 0.54). No significant associations were found for stone extraction method, periampullary diverticulum, sphincterotomy, or precut. PEP incidence declined from 6.3% in 2020 to 3.8% in 2024 (p = 0.22), possibly reflecting improved prophylaxis.

Conclusion

Suspected sphincter of Oddi dysfunction and younger age were confirmed as significant PEP risk factors. Mechanical lithotripsy emerged as a high-risk maneuver, while biliary stenting appeared protective. These findings suggest procedure-specific risks should be integrated into individual preventive strategies.

Introduction

Endoscopic biliary sphincterotomy is an effective treatment for common bile duct stones. However, its success can be compromised by the presence of large stones or extensive choledochal lithiasis.
The aim of this study was to evaluate the effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) in patients with large obstructive stones (>15 mm) and those with one or two stones or choledochal lithiasis, and to identify factors influencing the success of endoscopic drainage and associated complications in the management of large bile duct stones.

Aims & Methods

This was a retrospective, descriptive, and analytical study conducted over a 19-year period, from April 2006 to February 2025, in our department.
A total of 1,011 patients who underwent ERCP for common bile duct stones were included. Choledochal lithiasis was defined as the presence of more than three stones, and a large stone was defined as an obstructive stone larger than 15 mm. Patients were divided into two groups:

• Group I (n = 143): Patients with a single obstructive stone larger than 15 mm.
• Group II (n = 868): Patients with one or two stones or choledochal lithiasis.

Results

Patients with large stones (Group I) represented 14.1% (n = 143) of the cohort, while Group II included 868 patients (85.9%).
The success rate after a single catheterization was 55.2% in Group I compared to 81% in Group II (p < 0.001). Reintervention was required in 14.7% of Group I patients versus 8% in Group II (p = 0.009). Additional procedures were performed in 46.2% of cases in Group I versus 16.1% in Group II.
The overall success rate after reintervention and/or additional procedures was 88.7% in Group I versus 92.5% in Group II (p = 0.125).
Early complication rates were higher in Group I (10.5%) compared to Group II (5.1%), with a statistically significant difference between groups (p = 0.017).
Univariate analysis identified the following factors as significantly decreasing the overall success rate of endoscopic treatment: older age, acute cholangitis, bile duct stricture, and significant bile duct dilation (diameter >15 mm).
Multivariate analysis, adjusted for age, sex, surgical history, acute pancreatitis, acute cholangitis, periampullary diverticulum, bile duct diameter, and bile duct stricture, showed that only acute cholangitis (OR: 0.295; 95% CI: [0.164 – 0.532]; p < 0.001) and bile duct stricture (OR: 0.53; 95% CI: [0.922 – 1.051]; p = 0.001) were independently associated with a decreased overall success rate of endoscopic treatment.

Conclusion

Our study found no statistically significant difference in the effectiveness of endoscopic treatment between patients with large stones and those with simple lithiasis. However, the presence of acute cholangitis and bile duct strictures appears to be associated with a reduced overall success rate of endoscopic management.

Introduction

Managing hypoxemia during procedural sedation, particularly in patients with obesity or obstructive sleep apnea (OSA), remains a significant challenge in clinical practice. This meta-analysis compared the use of positive airway pressure (PAP) with standard oxygenation therapy for patients at increased risk of hypoxemia undergoing gastrointestinal endoscopic procedures.

Aims & Methods

MEDLINE, Embase, and Cochrane databases were searched for randomized controlled studies comparing PAP systems versus standard oxygenation. Odds ratio (OR) was used for binary outcomes and mean difference (MD) for continuous outcomes with their respective 95% confidence interval (CI). Further research implications were evaluated by a trial sequential analysis (TSA).

Results

Our meta-analysis included six RCTs comprising 606 patients. Compared with standard oxygenation, PAP systems reduced the rate of hypoxemia (OR 0.21; 95%CI 0.12 to 0.38, p<0.001), and severe hypoxemia (OR 0.15; 95%CI 0.05 to 0.49, p=0.002). Additionally, the PAP group experienced fewer arrhythmic events (p=0.04), required fewer airway maneuvers (p=0.002), and had a reduced total propofol dosage (p=0.04). There was no significant difference between the groups in terms of hypotension events (p=0.39), procedure duration (p=0.62), hypoxemia episode duration (p=0.78), anesthesiologist satisfaction (p=0.44), or endoscopist satisfaction (p=0.79).

Conclusion

Overall, the use of PAP systems appears to be a promising strategy for optimizing sedation and enhancing patient safety during gastrointestinal endoscopic procedures for patients at risk of hypoxemia.