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CLINICAL APPLICATION EVALUATION OF NATURAL ORIFICE ENDOLUMINAL ENDOSCOPIC GALLBLADDER SURGERY (GB-NOEES): A SINGLE-CENTER RETROSPECTIVE STUDY

Jian Guo Zhang 1, Jie Zhao 2

Affiliations

1 Peking University, Beijing, China

2 China University of Geosciences, Beijing, China

Summary

AI Generated

A single-center retrospective study of 100 patients demonstrated a 99% technical success rate and 4% complication rate for gallbladder Natural Orifice Endoluminal Endoscopic Surgery (Gb-NOEES) using a per-oral cholangioscopy-guided transpapillary cystic duct approach.

Technical success rate was 99% (99/100 patients) with average operative time of 130±59 minutes across gallstones, gallbladder polyps, and acute cholecystitis cases
Complication rate was 4%: three gallbladder perforations (one managed conservatively, two required laparoscopic conversion) and one postoperative bleeding case (managed conservatively), with no severe pancreatitis or deaths
Gallstone clearance rate was 98% (78/80) with largest stone 4.0 cm and up to 52 stones removed in a single operation; complete excision of polyps achieved in 100% (15/15) with polyp diameters 4–15 mm
During follow-up (2–26 months), stone recurrence rate was 2.5% (2/80) with no polyp recurrence; one early-stage gallbladder cancer was incidentally detected
Authors conclude the technique offers organ preservation but requires multi-center validation; all procedures performed by experts with ≥10 years endoscopy experience

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Abstract

Introduction

Although Endoscopic Retrograde Cholangiopancreatography (ERCP) has played an important role in the diagnosis and treatment of biliary and pancreatic diseases since its inception, the gallbladder is still considered a “blind spot” or inaccessible area for ERCP.

Aims & Methods

This study was intended to evaluate the technical success rate, safety, and clinical application value of per-oral cholangioscopy-guided transpapillary cystic duct approach for Gb-NOEES, and to explore the feasibility of Natural Orifice Endoluminal Endoscopic Surgery (NOEES) in the diagnosis and treatment of gallbladder diseases.
Patients with gallbladder diseases who received Gb-NOEES treatment from January 2023 to November 2024 were retrospectively included in a single-center study. Inclusion criteria: Patients are preoperatively diagnosed with gallstones, gallstones combined with common bile duct stones, gallstones combined with intrahepatic stones, acute cholecystitis, and gallbladder polyps. Exclusion criteria: patients with asymptomatic gallstones, patients with gallbladder cancer, and patients at risk of gallbladder cancer. All procedures were performed by experts with ≥10 years of experience in digestive endoscopy, and postoperative follow-up period ranged from 2 to 26 months.

Results

A total of 100 patients were included (58 males and 42 females, with an average age of 47±15.1). The disease distribution is shown in Table 1. The technical success rate of Gb-NOEES was 99% (99/100), and the average operative time was 130±59 minutes. The complication rate was 4%: 3 cases of gallbladder perforation (1 case of successful conservative treatment, and 2 cases of conversion to laparoscopic surgery), and 1 case of postoperative bleeding (successful conservative treatment). No severe pancreatitis or death occurred. Treatment outcomes: Gallstone clearance rate was 98% (78/80), with the largest stone measuring 4.0 cm, and up to 52 stones removed in a single operation. Complete excision rate of gallbladder polyps was achieved in 100% (15/15), with long diameter of polyps ranging from 4 mm to 15 mm, and up to 8 polyps excised in a single operation. Drainage success rate for acute cholecystitis was 100% (4/4). One case of early-stage gallbladder cancer was incidentally detected. During the follow-up period, the recurrence rate of stones was 2.5% (2/80), and there was no recurrence of polyps.

Conclusion

Gb-NOEES demonstrated favorable safety profile (complication rate was 4%) and high efficacy (overall success rate was 98%) in the diagnosis and treatment of gallbladder diseases. This technique has advantages of both lesion removal and organ preservation, offering a new minimally-invasive treatment option for gallbladder diseases. However, its clinical application value requires further validation through multi-center studies.

Table 1. Disease Distribution of Patients

Disease Type	Number of Cases (n=100)
Gallstones	69
Combined with Common Bile Duct Stones	10
Combined with Intrahepatic Bile Duct Stones	1
Gallbladder Polyps	15
Acute Cholecystitis	4
Early-Stage Gallbladder Cancer	1

Disclosure

There is no conflict of interest.

Conference

UEG Week Berlin 2025

Topics

Hepatobiliary

Submission format

Abstract

Session

The rolling stone: How to catch? (Posters)

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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For the medical oncologist

Francesco Sclafani 1

Affiliations

1 Université libre de Bruxelles, Bruxelles, Belgium

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Abstract

Event

UEG Week Berlin 2025

Topics

Digestive Oncology Endoscopy Surgery

Session

Game changers in lower GI over the past decade: Neoplasm

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Francesco Sclafani

RESECTION DEPTH OF UNDERWATER ENDOSCOPIC MUCOSAL RESECTION COMPARED WITH CONVENTIONAL ENDOSCOPIC MUCOSAL RESECTION FOR INTERMEDIATE-SIZE COLORECTAL TUMORS: A MULTICENTER, RANDOMIZED, NONINFERIORITY TRIAL

Hiroki Kamada

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A NOVEL DEEP LEARNING MODEL FOR PREDICTING COLORECTAL ANASTOMOTIC DEHISCENCE: A PIONEER MULTICENTER TRANSATLANTIC STUDY

Manuel Limbert

UEG Presentation

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RESECTION DEPTH OF UNDERWATER ENDOSCOPIC MUCOSAL RESECTION COMPARED WITH CONVENTIONAL ENDOSCOPIC MUCOSAL RESECTION FOR INTERMEDIATE-SIZE COLORECTAL TUMORS: A MULTICENTER, RANDOMIZED, NONINFERIORITY TRIAL

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RESECTION DEPTH OF UNDERWATER ENDOSCOPIC MUCOSAL RESECTION COMPARED WITH CONVENTIONAL ENDOSCOPIC MUCOSAL RESECTION FOR INTERMEDIATE-SIZE COLORECTAL TUMORS: A MULTICENTER, RANDOMIZED, NONINFERIORITY TRIAL

Yuzuru Tamaru 1, Akihiro Miyakawa 2, Takuya Yamada 3, Yorinobu Sumida 4, Keitaro Sekimoto 1, Minori Yasui 1, Hiroki Kamada 1, Shigeaki Semba 1, Kazuki Nakamura 1, Yuji Teraoka 1, Takeshi Mizumoto 1, Akihito Okazaki 1, Tsuyoshi Hatakeyama 1, Shintaro Takaki 1, Shigeto Yoshida 1, Toshio Kuwai 5

Affiliations

1 NHO Kure Medical Center and Chugoku Cancer Center, Kure, Japan

2 Asahi General Hospital, Asahi, Japan

3 Osaka Rosai Hospital, Sakai, Japan

4 Kitakyushu Municipal Medical Center, Kitakyushu, Japan

5 Hiroshima University Hospital, Hiroshima, Japan

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Abstract

Introduction

Underwater endoscopic mucosal resection (UEMR) is an alternative to conventional EMR (CEMR) offering consistent negative horizontal margins. However, UEMR does not involve submucosal injection; thus, its ability to achieve a sufficient resection depth comparable to that of CEMR remains uncertain. This randomized controlled trial (RCT) aimed to compare UEMR and CEMR in terms of resection depth.

Aims & Methods

This multicenter, parallel two-arm, open-label, noninferiority RCT was conducted across four Japanese institutions enrolling patients with colorectal tumors measuring 10–20 mm. Participants were randomly assigned in a 1:1 ratio to either to UEMR or CEMR group, using a computerized random-number generator. The primary outcome was the resection depth, which is the distance from the lower edge of the muscularis mucosa to the deep margin of the resected specimen, analyzed based on per-protocol (PP) principles (noninferiority margin of 400 µm).

Results

This study screened 217 patients from September 21, 2022, to December 2, 2024, and randomly assigned them to the UEMR (n =109) or CEMR (n =108) group. The PP analysis revealed that the mean resection depths of the UEMR and CEMR groups were 1688.9 ± 1510.0 µm and 1432.3 ± 1294.2 µm, respectively (mean difference: 256.6 µm, 95% confidence interval: -119.9 µm to 633.1 µm; P = 0.18), indicating the noninferiority of UEMR compared with CEMR in terms of resection depth. Subgroup analyses revealed that the resection depth of lesions by UEMR, especially at the cecum/ascending colon (1822.4 ± 1469.7 µm vs. 1096.5 ± 1007.6 µm; P = 0.01), and those with superficial morphology (1238.7 ± 862.2 µm vs. 731.6 ± 376.1 µm; P < 0.01), was significantly deeper than that achieved by CEMR. Moreover, even for nonexperts, UEMR tended to provide adequate resection depth compared with CEMR, approaching the proficiency level exhibited by experts (1786.6 ± 1471.6 µm vs. 1192.4 ± 1074.7 µm; P = 0.07). There were no significant differences in adverse events between the two groups, including one case of intraoperative perforation (0.9%) in the CEMR group and one case of delayed bleeding (0.9%) in the UEMR group. No EMR-related deaths were reported.

Conclusion

UEMR maintains the equivalent resection depth as CEMR and could become the gold standard endoscopic resection technique for intermediate-size colorectal tumors. UEMR is strongly recommended, especially for lesions at the cecum, ascending colon, and superficial lesions, because it could resect significantly deeper than CEMR. Furthermore, UEMR is recommended for nonexperts as a resection method that provides sufficient resection depth (Clinical trial registration number: UMIN000047432).

Event

UEG Week Berlin 2025

Topics

Colorectal Endoscopy Surgery

Submission format

Abstract

Session

Improving decision-making in colorectal lesions

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Manuel Limbert

UEG Presentation

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Pathophysiology: Microbiota T-2D and MASLD

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Pathophysiology: Microbiota T-2D and MASLD

Onno Holleboom 1

Affiliations

1 Amsterdam UMC, Amsterdam, Netherlands

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Abstract

Event

UEG Postgraduate Teaching Programme Berlin 2025

Topics

Gut Microbiota Hepatobiliary Mechanisms & Personalised Medicine

Session

Diabetes in GI disorders

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Hiroki Kamada

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A NOVEL DEEP LEARNING MODEL FOR PREDICTING COLORECTAL ANASTOMOTIC DEHISCENCE: A PIONEER MULTICENTER TRANSATLANTIC STUDY

Manuel Limbert

UEG Presentation

Share via Email Share on Facebook Share on X Share on LinkedIn Share on Bluesky

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Training with simulators

Ulrike Beilenhoff 1

Affiliations

1 ESGENA Scientific Secretary, Ulm, Germany

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Abstract

Event

UEG Week Berlin 2025

Topics

Nurses

Session

Education: Important tool for quality in endoscopy

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Francesco Sclafani

RESECTION DEPTH OF UNDERWATER ENDOSCOPIC MUCOSAL RESECTION COMPARED WITH CONVENTIONAL ENDOSCOPIC MUCOSAL RESECTION FOR INTERMEDIATE-SIZE COLORECTAL TUMORS: A MULTICENTER, RANDOMIZED, NONINFERIORITY TRIAL

Hiroki Kamada

Pathophysiology: Microbiota T-2D and MASLD

Onno Holleboom

Training with simulators

Ulrike Beilenhoff

EUS-CDS WITH LAMS AND COAXIAL STENT VERSUS ERCP WITH FCSEMS FOR PRIMARY DRAINAGE OF DISTAL MALIGNANT BILIARY OBSTRUCTION: A POST-HOC ANALYSIS OF TWO PROSPECTIVE COHORTS

Rogier P. Voermans

A NOVEL DEEP LEARNING MODEL FOR PREDICTING COLORECTAL ANASTOMOTIC DEHISCENCE: A PIONEER MULTICENTER TRANSATLANTIC STUDY

Manuel Limbert

UEG Presentation

Share via Email Share on Facebook Share on X Share on LinkedIn Share on Bluesky

EUS-CDS WITH LAMS AND COAXIAL STENT VERSUS ERCP WITH FCSEMS FOR PRIMARY DRAINAGE OF DISTAL MALIGNANT BILIARY OBSTRUCTION: A POST-HOC ANALYSIS OF TWO PROSPECTIVE COHORTS

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EUS-CDS WITH LAMS AND COAXIAL STENT VERSUS ERCP WITH FCSEMS FOR PRIMARY DRAINAGE OF DISTAL MALIGNANT BILIARY OBSTRUCTION: A POST-HOC ANALYSIS OF TWO PROSPECTIVE COHORTS

Anke Onnekink 1, Jeska A. Fritzsche 2, Esmée Smit 2, Marc G. Besselink 3, Paul Fockens 2, Akin Inderson 1, Mattheus Carolus Benignus Wielenga 2, Roy .L.J Van Wanrooij 4, Jeanin van Hooft 1, Rogier P. Voermans 3

Affiliations

1 Leiden University Medical Center, Leiden, Netherlands

2 Amsterdam UMC, location University of Amsterdam, Amsterdam, Netherlands|||Cancer Center Amsterdam, Amsterdam, Netherlands

3 Cancer Center Amsterdam, Amsterdam, Netherlands|||Amsterdam UMC, location University of Amsterdam, Amsterdam, Netherlands

4 Amsterdam UMC, location Vrije Universiteit, Amsterdam, Netherlands|||Cancer Center Amsterdam, Amsterdam, Netherlands

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Abstract

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the current standard for drainage of distal malignant biliary obstruction (MBO), but carries a significant risk of post-procedural pancreatitis.[1] EUS-guided choledochoduodenostomy (EUS-CDS) is increasingly used as a promising alternative, but comparative studies are still scarce.[2,3] While previous studies have mainly focused on stent patency, the current study aims to evaluate whether EUS-CDS is superior to ERCP in achieving a textbook outcome for the patients, indicating an optimal post-procedural course.

Aims & Methods

This single-center study included patients with distal MBO who underwent technically successful (1) EUS-CDS with a lumen apposing metal stent (LAMS) plus additional coaxial stent or (2) ERCP with fully covered self-expandable metal stent (FCSEMS) as part of the prospective SCORPION studies and SPHINX trial, respectively.[1,4] The primary endpoint was textbook outcome, defined as the absence of procedure- or stent-related adverse events (AEs), reinterventions, or hospital readmissions within 30 days of the procedure. Secondary endpoints included individual components of the primary outcome, mortality, time to initiation of treatment (e.g., systemic therapy or surgery), and textbook outcome at 90 days.

Results

A total of 144 patients were enrolled for EUS-CDS (n=49) or ERCP (n=95). Primary etiologies included pancreatic cancer (n=117, 81%) and distal cholangiocarcinoma (n=14, 10%). Coaxial stents used in the EUS-CDS group were FCSEMS (n=20) or double pigtail plastic stents (n=29). Textbook outcome was achieved in 44 patients (90%) in the EUS-CDS group and in 67 patients (71%) in the ERCP group at 30 days (RR 1.27, 95% CI 1.08-1.50). EUS-CDS led to fewer procedure- or stent-related AEs (RR 0.35, 95% CI 0.14-0.84) compared with ERCP, particularly post-procedure pancreatitis (0% vs. 23%). Other AEs, including perforation (2% vs. 0%), bleeding (0% vs. 0%), stent dysfunction with or without cholangitis (4% vs. 6%), and cholecystitis (4% vs. 3%) were similar between groups. Hospital readmission rate was lower in the EUS-CDS group (6% vs. 30%, RR 0.21, 95% CI 0.07-0.65), as was the length of hospital stay (mean 0.3 days [SD 1.3] vs. 1.8 days [SD 4.0], P=0.01). In-hospital mortality (8% vs. 5%), need for reinterventions (8% vs. 6%), and time to treatment initiation, either surgery or chemotherapy, did not differ (median 33 days [IQR 23-42] vs. 30 days [IQR 18-41]). At 90 days, textbook outcome was more often present in the EUS-CDS group when compared to ERCP however the difference was no longer significant (78% vs. 69%, RR 1.22, 95% CI 1.02-1.44).

Conclusion

EUS-CDS with LAMS and additional coaxial stent was superior to ERCP with FCSEMS in achieving textbook outcome at 30 days post-procedure. EUS-CDS resulted in less procedure- or stent-related AEs, particularly post-procedure pancreatitis, and consequently in fewer hospital readmissions and shorter hospital stay. Therefore, when expertise is available, EUS-CDS with coaxial stent placement could be considered as primary biliary drainage technique in patients with distal MBO.

References

1. Onnekink, A. M., Gorris, M., Bekkali, N. L., et al (2024). Endoscopic sphincterotomy to prevent post-ERCP pancreatitis after self-expandable metal stent placement for distal malignant biliary obstruction (SPHINX): a multicentre, randomised controlled trial. Gut, gutjnl-332695. https://doi.org/10.1136/gutjnl-2024-332695
2. Teoh, A. Y. B., Napoleon, B., Kunda, R et al (2023). EUS-Guided choledocho-duodenostomy using lumen apposing stent versus ERCP with covered metallic stents in patients with unresectable malignant distal biliary obstruction: a multicenter randomized controlled trial (DRA-MBO trial). Gastroenterology, 165(2), 473-482.e2. https://doi.org/10.1053/j.gastro.2023.04.016
3. Chen, Y., Sahai, A., Donatelli, G. et al (2023). Endoscopic Ultrasound-Guided Biliary Drainage of First Intent With a Lumen-Apposing Metal Stent vs Endoscopic Retrograde Cholangiopancreatography in Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Study (ELEMENT Trial). Gastroenterology, 165(5), 1249-1261.e5. https://doi.org/10.1053/j.gastro.2023.07.024
4. Fritzsche, J. A., Fockens, P., Besselink, M. G. et al (2024). Optimizing EUS-guided choledochoduodenostomy with lumen-apposing metal stents for primary drainage of malignant distal biliary obstruction (SCORPION-IIp): a prospective pilot study. Gastrointestinal Endoscopy. https://doi.org/10.1016/j.gie.2024.10.012

Disclosure

Paul Fockens acted as a consultant for Cook Endoscopy and Olympus, outside the submitted work.
Roy L.J. van Wanrooij acted as a consultant for Boston Scientific. Jeanin E. van Hooft has received research support from Cook Medical and acted as lecturer for Cook Medical, Boston Scientific and Falk, and as consultant for Olympus. Rogier P. Voermans received a research grant and acted as consultant for Boston Scientific. All outside the submitted work. All other authors declare that they have no competing financial interests or personal relationships that could have appeared to influence the work reported in this abstract.

Event

UEG Week Berlin 2025

Topics

Endoscopy Hepatobiliary

Submission format

Abstract

Session

Endoscopic solutions to malignant biliary obstruction

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Rogier P. Voermans

A NOVEL DEEP LEARNING MODEL FOR PREDICTING COLORECTAL ANASTOMOTIC DEHISCENCE: A PIONEER MULTICENTER TRANSATLANTIC STUDY

Manuel Limbert

UEG Presentation

Share via Email Share on Facebook Share on X Share on LinkedIn Share on Bluesky

A NOVEL DEEP LEARNING MODEL FOR PREDICTING COLORECTAL ANASTOMOTIC DEHISCENCE: A PIONEER MULTICENTER TRANSATLANTIC STUDY

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A NOVEL DEEP LEARNING MODEL FOR PREDICTING COLORECTAL ANASTOMOTIC DEHISCENCE: A PIONEER MULTICENTER TRANSATLANTIC STUDY

Miguel Mascarenhas-Saraiva 1, Francisco Mendes 1, André Martins dos Santos 2, António Miguel Martins Pinto da Costa 3, Filipa Fonseca 4, Eduardo Carvalho 5, Nilza Ramião 5, Guilherme Barbosa 5, Maisa Vasconcellos 6, Abdullah Bunaiyan 7, Maria Almeida 1, Joana Mota 1, Tiago Ribeiro 1, Miguel Martins 1, João Afonso 1, Pedro Cardoso 1, Francisca Pinheiro 2, Matheus Carvalho 3, Marcos Eduardo Lera dos Santos 3, Eduardo De Moura 3, Marley Feitosa 6, Ahsan Javed 7, Guilherme Macedo 1, Manuel Limbert 4

Affiliations

1 Centro Hospitalar Universitário de São João, Porto, Portugal

2 Faculdade de Medicina da Universidade do Porto, Porto, Portugal

3 Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil

4 Instituto Português de Oncologia IPO, Lisboa, Portugal

5 INEGI – Institute of Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal

6 Hospital das Clínicas da Faculdade de Medicina de USP - Ribeirão Preto, São Paulo, Brazil

7 Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom

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Abstract

Introduction

Colorectal anastomotic dehiscence (CAD) is one of the most severe postoperative complications in colorectal surgery, significantly impacting patient morbidity and mortality. Current risk assessment methods rely on clinical and intraoperative factors, but no real-time predictive tool exists. This study aimed to develop an artificial intelligence model based on intraoperative recording of the anastomosis for CAD prediction.

Aims & Methods

A convolutional neural network (CNN) was trained using a dataset of annotated frames from colorectal surgery videos across three international high-volume centers: IPO Lisboa, Hospital das Clínicas de Ribeirão Preto, São Paulo, Brazil and Royal Liverpool University Hospital. The dataset included a total of 5,356 annotated frames from 25 patients, 2,007 frames classified as CAD-positive and 3,349 as CAD-negative. Four CNN architectures (EfficientNetB0, EfficientNetB7, ResNet50, and MobileNetV2) were tested. Performance was evaluated using sensitivity, specificity, accuracy, and area under the receiver operating characteristic (AUROC) curve. Heatmaps were generated to identify key regions influencing predictions.

Results

The best-performing model achieved an accuracy of 99.55%, AUROC of 99.60%, sensitivity of 99.21%, specificity of 100%, PPV of 100%, and NPV of 98.94%. The model reliably identified CAD-positive frames and provided visual explanations through heatmaps.

Conclusion

To our knowledge, this is the first AI model developed to predict CAD using intraoperative video analysis. Its accuracy suggests the potential to redefine surgical decision-making by providing real-time risk assessment. Further refinement with a larger dataset and diverse surgical techniques could enable intraoperative interventions to prevent CAD before it occurs, marking a paradigm shift in colorectal surgery.

Event

UEG Week Berlin 2025

Topics

Colorectal Endoscopy Surgery

Submission format

Abstract

Session

Lower GI: Surgical considerations

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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For the medical oncologist

Francesco Sclafani

RESECTION DEPTH OF UNDERWATER ENDOSCOPIC MUCOSAL RESECTION COMPARED WITH CONVENTIONAL ENDOSCOPIC MUCOSAL RESECTION FOR INTERMEDIATE-SIZE COLORECTAL TUMORS: A MULTICENTER, RANDOMIZED, NONINFERIORITY TRIAL

Hiroki Kamada

Pathophysiology: Microbiota T-2D and MASLD

Onno Holleboom

Training with simulators

Ulrike Beilenhoff

EUS-CDS WITH LAMS AND COAXIAL STENT VERSUS ERCP WITH FCSEMS FOR PRIMARY DRAINAGE OF DISTAL MALIGNANT BILIARY OBSTRUCTION: A POST-HOC ANALYSIS OF TWO PROSPECTIVE COHORTS

Rogier P. Voermans

A NOVEL DEEP LEARNING MODEL FOR PREDICTING COLORECTAL ANASTOMOTIC DEHISCENCE: A PIONEER MULTICENTER TRANSATLANTIC STUDY

Manuel Limbert

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