Endoscopic ultrasound-guided biliary drainage (EUS-BD) has dramatically spread and improved in the last two decades and is changing the paradigm of drainage in case of malignant biliary obstruction (MBO). EUS-BD can be achieved from different routes, including the common bile duct (choledochoduodenostomy), intrahepatic bile ducts (hepaticogastrostomy), and gallbladder as a rescue (cholecystogastrostomy/cholecystoduodenostomy). EUS-guided hepaticogastrostomy (EUS-HGS) is a valuable option for biliary drainage in MBO when ERCP fails or is not feasible. EUS-HGS has demonstrated high efficacy with a good rate of technical and clinical success. The safety profile is also overall favorable, although severe adverse events may occur in a significant proportion of patients. From a technical perspective, EUS-HGS is considered one of the most demanding procedures in biliopancreatic endoscopy, requiring multiple steps and high technical skills and experience. In this comprehensive review, technical tips and clinical outcomes of EUS-HGS are reviewed according to the latest evidence in the literature.

Several randomized clinical trials comparing different bowel preparations (BP) have shown similar efficacy; however, there is a lack of real-world studies on this topic. This study aims to identify the most effective BP regimen in a real-world setting and any predictors of inadequate BP. A retrospective single-center study was conducted over 14 months at an academic hospital including outpatient colonoscopies in which adult patients did not teach on how to perform BP before colonoscopy. Colonoscopies with 1L-PEG, 2L-PEG and picosulphate mixtures were considered. A multivariable analysis for factors associated to poor BP was fitted. Overall, 1779 patients (51 %F, 60±14) years were included. The 1L-PEG regimen provided a higher rate of BP adequacy at multivariate analysis (adjusted OR 2.30, 95 %CI 1.67-3.16,p < 0.001) and was associated with higher median Boston Bowel Preparation Scale score (p < 0.001), higher rate of right-colon cleansing (p < 0.001) and exam completion (p = 0.04). Furthermore, we identified male sex, history of constipation, active smoking, previous pelvic surgery, concomitant psychiatric/neurological or chronic kidney diseases as predictors of inadequate BP. This is the largest real-world study comparing 1L-PEG to other BP regimens. Our results suggest 1L-PEG provides better BP in a non-controlled setting, improving clinical practice quality and minimizing the need for repeated colonoscopies and saving healthcare resources.

Introduction: High-quality colonoscopy is influenced by several factors, with the adenoma detection rate (ADR) being one of the most studied indicators. A strong inverse relationship exists between ADR and the risk of developing post-colonoscopy colorectal cancer (PCCRC), prompting the European Society of Gastrointestinal Endoscopy guidelines to recommend a minimum ADR of 25%. In contrast, there is limited evidence supporting the clinical significance of the serrated polyp detection rate (SPDR), and no specific benchmark was established until a very recent update from the American societies. Main paper: This review examines the factors that influence ADR and SPDR, offering tips to improve these metrics. Effective interventions for enhancing ADR include training, colonoscopy feedback, adequate bowel preparation, longer withdrawal time, water-aided colonoscopy, right colon second look, and chromoendoscopy. The use of cap, devices, and specialized scopes also show promise, though these are often at higher costs. Artificial intelligence has generated great optimism, especially following positive results from early randomized controlled trials; however, its effectiveness has been less pronounced in real-world settings. Conclusions: Many of these approaches require further trials and meta-analyses to establish their ultimate efficacy. Moreover, future clinical head-to-head studies will help to identify the most effective interventions for reducing colorectal cancer incidence and the risk of PCCRC.

Background and Objectives: Serum alpha-fetoprotein (AFP) is a recognized affordable oncological marker in patients with hepatocellular carcinoma (HCC). However, AFP’s prognostic role has been assessed mainly after specific treatments, and no unanimously recognized cut-offs have been identified. The aim of this study is to investigate the prognostic role of different basal AFP cut-offs on survival and HCC course. Materials and Methods: In this single-center, retrospective study, all patients newly diagnosed with HCC between January 2009 and December 2021 were prospectively enrolled. Only patients suitable for curative HCC treatments were included in the analyses. Patients were stratified according to AFP cut-offs of 20, 200, 400, and 1000 ng/mL, which were correlated with survival outcomes and clinical parameters. Results: A total of 266 patients were analyzed, with a median follow-up time of 41.5 months. Median overall survival (OS) of all cohort was 43 months. At the multivariate Cox-regression analysis, AFP value ≥ 1000 ng/mL correlated with impaired OS (1-year OS: 67% vs. 88%, 5-year OS: 1% vs. 43%; p = 0.005); other risk factors were tumor dimension ≥ 5 cm (HR 1.73; p = 0.002), Child–Pugh class B–C (HR 1.72; p = 0.002), BCLC stage A (vs. 0) (HR 2.4; p = 0.011), and malignant portal vein thrombosis (HR 2.57; p = 0.007). AFP ≥ 1000 ng/mL was also associated with a reduced recurrence-free survival (HR 2.0; p = 0.038), while starting from AFP ≥ 20 ng/mL, a correlation with development of HCC metastases over time (HR 3.5; p = 0.002) was seen. AFP values ≥ 20 ng/mL significantly correlated with tumor size and higher histological grading; starting from AFP values ≥ 400 ng/mL, a significant correlation with Child–Pugh class B–C and female gender was also observed. Conclusions: Basal AFP correlates with relevant outcomes in patients with HCC. It could help identify patients at a higher risk of worse prognosis who might benefit from personalized surveillance and treatment programs. Prospective studies are needed to confirm these results.

Esophagogastric junction (EGJ) lesions are uncommon and histologically diverse. Among these, EGJ hyperplastic lesions are rare and generally considered benign. However, their nonspecific appearance makes accurate endoscopic identification challenging. Endoscopic resection is both a diagnostic and therapeutic approach, yet risk factors for neoplastic transformation in EGJ lesions remain unclear. This study aimed to identify predictive factors for neoplastic transformation in hyperplastic EGJ lesions. This multicenter, retrospective study included patients with hyperplastic EGJ lesions endoscopically resected across 13 European hospitals. Data were collected from endoscopy and pathology reports. Neoplastic transformation was defined by presence of dysplasia or adenocarcinoma. A multivariable logistic regression model was conducted to assess predictive factors for neoplastic transformation in resected hyperplastic lesions. From January 2015 to October 2024, 91 EGJ hyperplastic lesions were included. Polypectomy/endoscopic mucosal resection (EMR) was performed in 86% of cases, endoscopic submucosal dissection (ESD) in 19%. En bloc resection was successfully achieved in 93% of cases, whereas R0 resection rates were confirmed in 84% of cases. Twenty-one lesions (23%) showed neoplastic transformation on histology. Independent predictive factors for neoplastic transformation in hyperplastic lesions included non-polypoid morphology (odds ratio [OR] 5.48; P = 0.025), presence of surface ulceration (OR 11.5; P = 0.0005) and lesion size (OR 5.48; P = 0.021). Lesion size > 12 mm was identified as a significant predictor of neoplastic transformation in hyperplastic lesions. EGJ hyperplastic lesions showed a non-negligible risk of neoplastic transformation. These findings highlight the need for careful endoscopic assessment to predict malignancy while promoting appropriate management strategies to ensure adequate R0 resection in case of undetected local malignancy.

The ileocecal valve (ICV) is one of the most difficult locations for endoscopic submucosal dissection (ESD) because of limited scope maneuverability, the presence of fatty tissue, and particular anatomic features [1[1]]. Consequently, the en bloc and R0 resection rates are reported to be lower than for other locations [2[2]] [3[3]]. Lesions covering ≥75% of the ICV, involvement of the anal lip or involvement of more than two sites on the ICV are reported to be risk factors for poor outcomes [4[4]]. Traction-assisted ESD has recently emerged as a technique that facilitates ESD, improving the rates of R0 resections in this challenging location [4[4]] [5[5]]. We report a case of a 69-year-old patient who presented with normocytic anemia and rectal bleeding. A colonoscopy was performed showing a 6-cm granular laterally spreading tumor with macronodules on the cecum (0-IIa+Is, Paris classification). The lesion extended over the ICV, involving 100% of the circumference, and involving the distal ileum. The lesion was suggestive of adenomatous histology, Kudo 4, Sano 2, and JNET 2a after evaluation with white light and narrow-band imaging. An ESD was performed that took 90 minutes, using an adaptable multitraction device (A-TRACT 2+2) ([Fig. 1Abb. 1], [Video 1Video 1]). First, a complete incision of the ileal margin was performed, followed by a complete incision on the colonic side. Traction was then placed at four points, which allowed opening of the ICV and improved the exposure of the edge of the lesion ([Fig. 2Abb. 2]). Tightening of the device allowed increased traction of the lesion outside the ileum. We resected the lesion en bloc without immediate complications. The defect was partially closed with two clips, to allow the opening of the valve. The patient developed delayed bleeding which required endoscopic thermal hemostasis and a few additional days of monitoring. The histology report showed an R0 resection of a high grade dysplastic adenoma. Endoscopy_UCTN_Code_TTT_1AQ_2AD_3AD Article published online: 06 February 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany