Background: Glucagon-like peptide receptor agonists (GLP-1 RAs) are associated with delayed gastric emptying and may increase the risk of aspiration due to retained gastric contents. There are no guidelines on peri-endoscopic use of GLP-1 RAs, and real-world outcomes in an ambulatory setting remain unknown. This study reports real-world data from an ambulatory center associated with a large tertiary hospital. Methods: A retrospective review of electronic medical records was conducted for patients who underwent esophagogastroduodenoscopy (EGD) at a hospital-based outpatient center from January to June 2023. Exclusions included non-elective procedures, current opioid use, altered foregut anatomy, and known gastroparesis. All patients were on GLP-1 RAs before endoscopy and followed standard fasting protocols. Adverse event rates were recorded, and patients were divided into cohorts based on GLP-1 RA use. Univariate and multivariate regression analyses identified risk factors for food retention and complications. Results: A total of 1438 patients underwent elective EGD during the study period. Among the 1046 patients included, 73 (7%) were on GLP-1 RAs. The procedure was aborted in four patients (0.4%) due to gastric food retention, with two (50%) on GLP-1 RAs. Independent risk factors for food retention included GLP-1 RA use (OR: 9.19; 95% CI: 2.73–30.8; p = 0.0003) and diabetes (OR 5.6; 95% CI: 1.72–18.2; p = 0.004). Tirzepatide showed the strongest association (p = 0.0056). Factors that did not impact food retention included A1c, BMI, and gender. Protective factors were age (OR 0.96; 95% CI: 0.93–0.99; p = 0.02) and same-day colonoscopy (OR 0.18; 95% CI: 0.06–0.58; p = 0.003). Conclusions: GLP-1 RA use in diabetics increases the risk of retained gastric contents during elective EGD, particularly with tirzepatide, without increasing aspiration risk. Patients undergoing simultaneous colonoscopy had a lower risk of retained gastric contents. Further studies are needed to evaluate the impact of GLP-1 RAs on gastric food retention and procedural risk.

Video 1 Helix tack for lumen-apposing metal stent fixation in single-session EUS-directed transgastric ERCP.

EUS-guided hepaticogastrostomy (EUS-HGS) has gained traction as a reliable and safe method for definitive biliary drainage in patients who cannot undergo traditional transampullary procedures. Many of the newly developed single-stage devices are not yet approved for clinical use in Western practice. We highlight key clinical and technical aspects of EUS-HGS using devices that are currently available in Western countries. The article is a comprehensive step-by-step technical review of EUS-HGS, and the video demonstrates high-level tips to overcome commonly encountered procedural challenges. Patients with biliary obstruction underwent EUS-HGS at our center. The technical difficulties that were encountered are highlighted in the article and the accompanying video. The article and video provide a detailed review of (1) preprocedural considerations, (2) puncture site selection, (3) biliary puncture, (4) contrast injection, (5) guidewire manipulation, (6) tract dilation, and (7) stent placement. An understanding and implementation of the technical nuances highlighted in this article should help Western endoscopists navigate the complexities of EUS-HGS and ensure optimal outcomes.

Background and study aims Endoscopic weight loss procedures have gained traction as minimally invasive options for the primary treatment of obesity. Thus far, we have developed endoscopic procedures that reliably address gastric restriction but result in significantly less weight loss than surgical gastrointestinal bypass. The goal of this nonsurvival study was to assess the technical feasibility of an endoscopic procedure, that incorporates both gastric restriction and potentially reversible gastrointestinal bypass. Methods Ultrasound-assisted endoscopic gastric bypass (USA-EGB) was performed in three consecutive live swine, followed by euthanasia and necropsy. Procedure steps were: 1) balloon-assisted enteroscopy that determines the length of the bypassed limb; 2) endoscopic ultrasound-guided gastroenterostomy that creates a gastrointestinal anastomosis using a lumen apposing metal stent; 3) endoscopic pyloric exclusion that disrupts transpyloric continuity resulting in complete gastrointestinal bypass; and 4) gastric restriction that reduces gastric volume. Results Complete gastrointestinal bypass and gastric restriction was achieved in all three swine. The mean total procedure time was 131 minutes (range 113–143), mean length of the bypassed limb was 92.5 cm and 180 cm, using short and long overtubes, respectively. There were no significant complications. Conclusions We successfully described USA-EGB in three consecutive live swine. Further studies are needed to access the procedures safety, efficacy, and clinical use.

Gastrojejunal (GJ) anastomotic strictures occur in up to 30% of patients with Roux-en-Y gastric bypass. The majority of such patients require endoscopic therapy, and many will require revisional surgery after endoscopic therapy fails. We present a novel stepwise approach for definitive endoscopic management of refractory GJ strictures. A 56-year-old female with prior balloon dilatation and lumen-apposing metal stent (LAMS) placement underwent EUS-guided gastric outlet remodeling (EUS-GOR). Two LAMSs were placed in parallel, 1 across the native GJ anastomosis and 1 from the pouch into the afferent limb. After maturation of the intervening tissue tract and prophylactic suturing, a septotomy was performed using wire-guided traction. The patient tolerated the procedure well and without adverse events. The GJ anastomosis at the end of the procedure measured 20 mm at 3-month follow-up. The patient's body mass index increased from 16.5 to 22.4 kg/m² at 12 months. EUS-GOR is a feasible and minimally invasive option for carefully selected patients with a refractory GJ anastomotic stricture.