BACKGROUND: The therapeutic hierarchy of current pharmacologic options for eosinophilic esophagitis (EoE) has not been established. We performed a network meta-analysis to evaluate the comparative efficacy of pharmacological therapies for EoE.

METHODS: PubMed, Scopus, Web of Science, and the Cochrane Library were searched from inception to May 25, 2025, for randomised controlled trials (RCTs) ≥12 weeks in duration comparing corticosteroids, biologics, or proton pump inhibitors with placebo or active comparators in participants aged ≥12 years. Key outcomes included changes in dysphagia from baseline and histological remission (≤6 eosinophils/high-power field) at 12, 24, and 48 weeks. Treatments were ranked using the surface under the cumulative ranking curve (SUCRA). Certainty of evidence was assessed using the GRADE framework.

RESULTS: Thirteen RCTs were included. For dysphagia improvement compared with placebo and active comparators, dupilumab 300 mg and cendakimab 360 mg demonstrated moderate-to-high-certainty benefit at 12 and 24 weeks, while budesonide oral suspension (BOS) 2 mg demonstrated moderate-to-high-certainty benefit at 12 weeks; no 24-week data were available for BOS. At 48 weeks, budesonide orodispersible tablets (BOT) 0.5 and 1 mg demonstrated high-certainty benefits for dysphagia improvement compared with placebo and active comparators. SUCRA ranked dupilumab highest for dysphagia improvement at 12 and 24 weeks (92% and 97%), and BOT 1 mg highest at 48 weeks (96%). For histological remission, all agents except etrasimod showed moderate-certainty benefits versus placebo across time points. SUCRA ranked BOS 2 mg highest at 12 weeks (78%), benralizumab 30 mg at 24 weeks (80%), and BOT 1 mg at 48 weeks (79%).

CONCLUSION: All evaluated therapies except etrasimod achieved histologic remission, while only dupilumab, cendakimab, BOS, and BOT were associated with symptomatic improvement in EoE, highlighting dissociations between histologic and symptomatic responses. Most corticosteroid trials were short-term and lacked direct comparisons with biologics. Robust head-to-head trials are needed to define optimal treatment strategies, assess long-term outcomes, and clarify the role of symptom, endoscopic, and histologic endpoints in therapeutic decision-making.

Recent advances in the diagnosis and management of reflux disease were the central focus of the inaugural Gatherings in Esophagology (GiE), which convened experts across gastroenterology, surgery, otolaryngology, pulmonology, and basic research. The sessions highlighted innovations in reflux monitoring-including high-resolution manometry, wireless pH monitoring, and novel salivary biomarkers-while critically evaluating their diagnostic accuracy and clinical utility. Presentations explored the limitations of traditional proton-pump inhibitor therapy, the emergence of potassium-competitive acid blockers as a new class of acid suppressants, and the evolving role of adjunctive treatments such as mucosal protectants, reflux reducers, and neuromodulators for refractory symptoms. The discourse extended to advanced interventional procedures, including transoral incisionless fundoplication, magnetic sphincter augmentation, and the RefluxStop device, with discussion of patient selection, efficacy, and complication management. Discussants emphasized the pathophysiology and management of extraesophageal manifestations of reflux, the interplay between reflux and pulmonary disease, and the diagnostic challenges in pediatric populations. The meeting also addressed the integration of behavioral therapies, the role of the microbiome, and the application of artificial intelligence in reflux diagnostics. Collectively, these insights underscore a shift toward precision medicine in reflux disease, emphasizing individualized diagnostic strategies and tailored therapeutic approaches to improve patient outcomes.

Large animal models, while valuable, are expensive, time-consuming, and limited to discrete interventional or terminal timepoints, while existing benchtop models do not offer an accurate representation of the esophageal environment. Moreover, current pre-clinical models cannot effectively simulate swallowing dysfunction (dysphagia), restricting progress in understanding motility disorders like achalasia and hindering evidence-based dietary recommendations. In response, we present RoboGullet, a biomimetic soft-robotic model with independent localized longitudinal and circumferential muscle actuation, enabling, for the first time, simulation of both normal and diseased esophageal motility. We further enhance realism with a biohybrid variant, RoboGullet + , incorporating porcine esophageal mucosa/submucosa. We demonstrate this platform's versatility through three key applications: assessing stent migration, simulating achalasia I-III within clinical diagnostic criteria, and analyzing bolus swallowing. Our findings reveal that: (1) stent migration increases over fivefold when incorporating longitudinal muscle movement versus isolated circumferential; (2) using a viscous non-Newtonian bolus improves high-resolution manometry diagnostic sensitivity of Achalasia III through increasing the Distal Latency diagnostic metric by 20.83%; and (3) stirring Greek-style yoghurt (common non-Newtonian dietary recommendation) significantly improves bolus transit versus unstirred for Achalasia Types I-II patients. This establishes RoboGullet+ as a powerful translational tool, advancing our understanding of esophageal motility and its therapeutic interventions.

BACKGROUND: Since gastroesophageal reflux disease (GERD) manifests typical and atypical symptoms of varying frequency and severity, the dominant symptom needs identification and quantification.

GOALS: We aimed to compare 5-point Likert scales assessing symptom burden to validated GERD questionnaires and outcomes following GERD management.

STUDY: We retrospectively analyzed pooled data from patients undergoing pH-impedance testing for reflux symptoms from 2 centers. Preprocedure questionnaires assessed symptom severity and frequency on 5-point Likert scales (0=not severe, infrequent; 4=extremely severe, multiple daily episodes); the product for the highest scoring symptom constituted the dominant symptom intensity (DSI). DSI was compared against validated instruments [global symptom severity (GSS), GERD questionnaire (GERDQ) and reflux symptom index (RSI)], and pH-impedance parameters per Lyon Consensus 2.0. DSI change after GERD management was compared against GSS and satisfaction with therapy.

RESULTS: Among 808 patients (mean age: 53.8±1.44 y, 65.2% female). DSI significantly correlated with GSS (R=0.682), GERDQ (R=0.414), RSI (R=0.577), acid exposure time (AET) (R=0.175), total reflux episodes (R=0.194) and mean nocturnal baseline impedance (R=-0.157) (P<0.0001 for each comparison). On ROC analyses, DSI (AUROC=0.60) was noninferior to GSS, GERDQ, and RSI in predicting pathologic AET and total reflux episodes, and conclusive GERD. Percentage DSI improvement after antireflux treatment significantly correlated with GSS change (R=0.632, P<0.0001) and treatment satisfaction (R=0.513, P<0.0001) and was an independent predictor of GSS change (β=0.302, P<0.0001), and satisfaction with therapy (β=0.833, P=0.011) on multivariable regression.

CONCLUSIONS: DSI correlates with validated reflux questionnaires and discriminates abnormal from normal reflux burden. DSI change reflects reflux treatment outcome and satisfaction.

BACKGROUND: Erosive esophagitis (EE) is commonly managed with proton pump inhibitors (PPIs), yet many patients experience incomplete healing or recurrence. Potassium-competitive acid blockers (P-CABs) have emerged as potential alternatives, but high-certainty comparative evidence across agents remains limited. We performed a network meta-analysis to evaluate the relative efficacy and safety of P-CABs versus PPIs and to assess the certainty of the evidence.

METHODS: We systematically searched PubMed, the Cochrane Library, and Web of Science from inception through March 1, 2025, for randomized controlled trials (RCTs) comparing P-CAB, PPI, and/or placebo for the treatment of EE. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool. Key outcomes were 8-week endoscopic healing and 24-week recurrence. Certainty of evidence was evaluated using GRADE. Risk difference (RD) estimates were calculated using random-effects models. The study protocol was registered with PROSPERO (CRD420251116179).

FINDINGS: Thirty-nine RCTs were included; all evaluated once-daily dosing. At 8 weeks, zastaprazan 20 mg, vonoprazan 20 mg, and esomeprazole 40 mg demonstrated moderate-certainty superiority over rabeprazole 20 mg and omeprazole 20 mg with RDs ranging from 0.05 to 0.11, while only vonoprazan 20 mg demonstrated moderate-certainty benefit versus lansoprazole 30 mg (RD: 0.04). In Los Angeles (LA) grade C/D EE, vonoprazan 20 mg, esomeprazole 40 mg, and rabeprazole-ER 50 mg demonstrated moderate-to-high-certainty benefit over lansoprazole 30 mg and omeprazole 20 mg with RDs ranging from 0.05 to 0.15. Vonoprazan 20 mg and rabeprazole-ER 50 mg demonstrated moderate-certainty benefit compared with pantoprazole 40 mg (RDs: 0.12 and 0.09, respectively).At 24 weeks, vonoprazan 10 mg and 20 mg showed moderate-to-high-certainty benefit versus lansoprazole 15 mg (RDs: -0.11 and -0.13, respectively), while in direct comparisons, esomeprazole 20 mg outperformed lansoprazole 15 mg and pantoprazole 20 mg, with approximately 40-50% relative reductions in recurrence. In LA grade C/D EE, vonoprazan 10 mg and 20 mg demonstrated moderate-to-high-certainty superiority over lansoprazole 15 mg and pantoprazole 20 mg with RDs ranging from -0.12 to -0.20. Esomeprazole 20 mg showed a high-certainty benefit compared with pantoprazole 20 mg (RD: -0.16). At 8 and 24 weeks, safety profiles were generally comparable between P-CABs and PPIs.

INTERPRETATION: Among once-daily regimens, vonoprazan 20 mg, zastaprazan 20 mg, and esomeprazole 40 mg were most effective for healing EE, while vonoprazan 10 mg and 20 mg and esomeprazole 20 mg were most effective in preventing recurrence. Benefits were most pronounced in LA grade C/D EE and are supported by moderate to high-certainty evidence. Comparative trials evaluating newer P-CABs against optimized PPI strategies, including twice-daily dosing, are needed to evaluate efficacy and long-term safety, particularly with respect to hypergastrinemia and infection risk.

FUNDING: None was received for the study.

BACKGROUND AND AIMS: Peroral endoscopic myotomy (POEM) is a complex, technically demanding endoscopic procedure that requires focused, structured training. While increasingly adopted in both gastroenterology and surgical practice, there has been no consensus-based guidance to establish adequate training standards in POEM. Using a validated consensus methodology, we aimed to define minimum standards for POEM training programs to ensure competence in technical, cognitive, and integrative skills necessary for safe and effective practice.

METHODS: A multidisciplinary expert panel was convened by the American Society for Gastrointestinal Endoscopy. The Research and Development (RAND)/University of California, Los Angeles appropriateness method (RAM) was used to evaluate candidate statements across 5 domains: pretraining activities, structure of training programs, POEM-specific cognitive training, POEM-specific technical training, and assessment of competence. Experts participated in 2 rounds of voting, rating each statement on a 9-point scale from highly inappropriate (1) to highly appropriate (9). For each statement, the median score and mean absolute deviation from the median were calculated. A statement was considered appropriate if it received a median score ≥7 and met the criteria for appropriateness based on the BIOMED, Interpercentile Range Adjusted for Symmetry, and P value methods.

RESULTS: Of the 40 proposed statements, 34 met the criteria as appropriate. Key recommendations included that trainees should undergo POEM training within programs performing at least 40 procedures annually, be mentored by at least 1 trainer with ≥100 prior POEMs, and complete a minimum of 15 POEMs before undergoing milestone assessments with a validated assessment tool. Cognitive requirements included mastery of mediastinal anatomy, GERD management, electrosurgical tools, and interpretation of motility and imaging studies. Simulation model training and exposure to esophageal POEM, gastric POEM, and Zenker POEM were also recommended.

CONCLUSIONS: This consensus effort provides evidence-based minimum standards for POEM training, applicable to both GI and surgical trainees. These recommendations are intended to guide the structure of training programs, ensure safe dissemination of POEM, and support the evolution of competency-based education in third-space endoscopy.