We report the case of a 65-year-old man who was referred to our unit with a diagnosis of a large early Barrett’s esophagus adenocarcinoma, extending for about 10 cm and involving two-thirds of the esophageal circumference. CT scan revealed a moderate esophageal variceal ectasia not visible at endoscopic evaluation; however, no sign of liver cirrhosis had been identified at abdominal ultrasound, elastography, and laboratory examinations. Therefore, after a preliminary discussion with the tumor board, we performed endoscopic submucosal dissection (ESD). An ultraslim therapeutic endoscope (EG-840 TP Slim Treatment Gastroscope, Fujifilm, Tokyo, Japan) was used. This gastroscope has a 7.9-mm insertion tube endowed with a large 3.2-mm working channel and powered by an expanded angulation (210° up/160° down) that significantly improves maneuverability. Moreover, the latest-generation hybrid-knife (HYBRIDknife flex I-Type, Erbe, Tübingen, Germany) was used, further improving the cut and coagulate precision. The procedure was performed under amber-red-color imaging (Fujifilm) mode, specifically designed to enhance the visibility of deep vessels and submucosal space/muscle. Following significant bleeding after first mucosal incision at the distal margin, the initial therapeutic plan of tunnel creation method was changed, and a complete circumferential incision was performed followed by a submucosal dissection assisted by the saline-immersion technique and double clip-line traction method. Importantly, during ESD a dense network of marked dilated esophageal varices (up to 7 mm in diameter) were encountered in the third space, significantly prolonging the procedural time. However, varices were all preventively identified and treated. Finally, the lesion was resected en bloc, and no adverse events occurred. The patient was discharged home 3 days later asymptomatic, and histopathological evaluation revealed a curative intramucosal adenocarcinoma (pT1a, m2, L0, V0, Bd1, R0, G1) resection. At 3-month endoscopic follow-up, no significant stricture or residual/recurrence neoplastic lesion were observed. ESD of Barrett's esophagus adenocarcinoma located at esophageal varices may be considered a viable option even without previous variceal treatment.

Background/Objectives: Gastric cancer often presents at advanced stages with complications such as iron-deficiency anemia (IDA) due to chronic bleeding, representing a significant global health burden. Palliative management of bleeding tumors in frail patients remains challenging. This study evaluates the feasibility, safety, and efficacy of endoscopic calcium-electroporation (Ca-EP), a novel non-thermal ablation technique, for controlling bleeding in end-stage gastric cancer. Methods: Retrospective case series including consecutive patients with end-stage, bleeding gastric cancer and IDA requiring transfusions. Ca-EP was performed using the EndoVE system, which delivers bipolar electrical pulses (250 kHz) to induce reversible electroporation, enabling calcium influx and tumor cell apoptosis. Primary endpoints were clinical success (hemoglobin stabilization/reduced transfusions) and safety. Secondary endpoints included tumor regression, procedural time, and hospital stay. Results: Five patients (median age 81 years) were included. Clinical success was achieved in 80% (4/5) of patients, with reduced transfusion needs and stable hemoglobin levels. One patient required adjunctive hemostatic radiotherapy. No major or minor adverse events were reported, and all patients were discharged within 24 h. Procedural median time was 38 min (range: 22–65). Endoscopic follow-up in three patients showed mild tumor regression or stability. Three patients required repeat Ca-EP sessions due to recurrent bleeding. Conclusions: Endoscopic Ca-EP is a safe, minimally invasive palliative option for bleeding gastric cancer, offering sustained hemostasis and potential antitumor effects without systemic toxicity. Its feasibility in frail patients underscores its clinical relevance, though larger prospective studies are needed to optimize parameters and validate long-term outcomes.

Acute cholecystitis in patients unfit for surgery presents a significant therapeutic challenge, often requiring alternatives to traditional cholecystectomy. In recent years, endoscopic ultrasound (EUS)-guided gallbladder drainage using Lumen-Apposing Metal Stents (LAMSs) has emerged as a promising minimally invasive approach. This umbrella review synthesizes evidence from existing systematic reviews and meta-analyses evaluating the efficacy and safety of EUS-guided gallbladder drainage with LAMSs in high-surgical-risk patients. The pooled data demonstrate that this approach provides effective symptomatic relief, with high technical and clinical success rates and a low incidence of adverse events. The use of EUS allows real-time visualization and precise access to the gallbladder, contributing to the safety and efficacy of the procedure. These results reinforce the expanding role of endoscopic techniques in managing complex biliary conditions, suggesting that the use of diagnostic EUS in combination with LAMS placement can lead to a significant reduction in the need for surgical intervention among frail patients.

Background and Objectives: Flexible endoscopic septal division (FESD) and third-space techniques represent first-line treatments for symptomatic Zenker’s diverticulum (ZD). While technical and clinical success rates are well established, data regarding adverse events (AEs) and their clinical management remain fragmented in recent literature. This systematic review aimed to evaluate the incidence, typology, and therapeutic strategies for AEs associated with flexible endoscopic ZD treatments. Materials and Methods: A systematic search of PubMed/MEDLINE, Embase, and Scopus was conducted up to July 2026 according to PRISMA guidelines. Studies reporting adult patients undergoing flexible endoscopic interventions for ZD reporting data on complication rates and management were included. Methodological quality was evaluated using the MINORS index. Results: Sixty studies were evaluated, comprising 53 cohort series (64 cohorts, 3172 patients, 3266 procedures: 2119 FESD and 1147 third-space procedures) for pooled quantitative incidence estimation, and 7 single-case reports retained for qualitative complication mapping. Bleeding occurred in 4.2% of cases (5.9% in FESD vs. 1.1% in third-space techniques), with most events occurring intraoperatively and resolving entirely through endoscopic hemostasis. Perforation occurred in 3.2% of procedures (3.9% in FESD vs. 1.8% in third-space series), while mucosal leaks were reported in 0.6% (0.2% in FESD vs. 1.5% in third-space). Severe infectious sequelae, such as abscesses (0.2%) and acute mediastinitis (0.1%), were rare. Conservative measures and endoscopic salvage modalities successfully treated transmural defects, with surgical conversion required in only three perforation cases (<0.1%). Isolated subcutaneous emphysema or pneumomediastinum occurred in 1.3% of cases and resolved uneventfully under conservative observation. Direct procedure-related mortality was 0.03% (1/3266). Conclusions: Flexible endoscopic management of ZD demonstrates a high safety profile with minimal procedural mortality. Complication management has shifted from surgical rescue to conservative protocols and versatile endoscopic salvage. Standardized AE grading and ongoing randomized trials are required to refine procedural selection.

Background/Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy (SAA) presents significant technical challenges due to altered bowel reconstructions. Endoscopic peroral cholangioscopy (POC) offers a less invasive alternative to percutaneous or transmural techniques, but robust evidence validating its performance in SAA is lacking. This systematic review and meta-analysis (SRMA) aims to evaluate the feasibility and safety of endoscopic POC as a primary strategy in SAA. Methods: A systematic search was performed on PubMed and Embase up to December 2025 for studies reporting cholangioscopic outcomes in SAA patients utilizing an endoscopic approach. The primary outcome was the cholangioscopic access rate (AR). Secondary outcomes included endoscopic success rate (SR), technical SR, and adverse events. Pooled rates were calculated using Generalized Linear Mixed Models (GLMM). Results: Eight studies comprising 469 patients were included. The pooled endoscopic SR was 86.7% (95% CI, 74.4–93.6%) but showed high heterogeneity (I² = 79.9%), largely driven by the variation in anatomical reconstructions. Subgroup analysis revealed higher endoscopic SR in short-limb anatomies (86.5%) compared to long-limb configurations (76.2%). Conversely, once biliary cannulation was achieved, the procedure was highly reliable: the pooled cholangioscopic AR was 95.9% (95% CI, 78.7–99.3%), with no significant difference across anatomical subgroups. The pooled adverse event rate was 3.1% (95% CI, 1.3–6.8%), predominantly characterized by mild complications. Conclusions: Endoscopic POC is a feasible and safe technique for managing biliary disease in SAA. The procedure’s overall success appears to be strictly dependent on the ability to navigate the altered anatomy (endoscopic phase), whereas the cholangioscopic phase itself proves highly effective and reproducible once biliary access is secured.

Background/Objectives: Sedation is a fundamental component of gastrointestinal endoscopy, improving patient comfort, procedural quality, and overall satisfaction. However, traditional drug-centered sedation models are increasingly challenged by rising procedural volumes, aging populations, and limited anesthesiology resources. The aim of this narrative review is to provide an integrated overview of evolving pharmacological agents, monitoring strategies, organizational models, and future directions toward personalized, technology-supported sedation pathways. Methods: A structured literature search was conducted across PubMed/MEDLINE, Scopus, and Web of Science for studies published between January 2010 and December 2025. Relevant guidelines, randomized controlled trials, meta-analyses, and large observational studies were included. Evidence was synthesized qualitatively, emphasizing clinical applicability and real-world relevance. Results: Propofol remains the most widely used sedative agent due to its rapid onset and recovery profile, although its narrow therapeutic window and lack of antagonist limit its safety in high-risk patients. Emerging agents such as remimazolam and ciprofol demonstrate comparable efficacy with improved respiratory and hemodynamic safety profiles, particularly in elderly populations. Adjunctive strategies, including procedure-specific approaches such as spinal anesthesia, may further optimize sedation. Advanced monitoring tools, such as capnography, bispectral index, and high-flow nasal cannula, show potential in enhancing safety, especially in selected high-risk groups. Structured training programs and standardized discharge criteria are essential for ensuring quality and safety. Conclusions: Sedation in gastrointestinal endoscopy is transitioning from a standardized, drug-centered approach to a personalized, risk-adapted, and technology-supported model. Integration of novel pharmacological agents, advanced monitoring, and structured training will be key to improving patient safety, procedural efficiency, and healthcare sustainability.