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Background and study aims Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a safe and efficacious procedure to treat pancreaticobiliary diseases in Roux-en-Y gastric bypass (RYGB). This multicenter study aimed to determine the long-term outcomes of EDGE focusing on fistula persistence rates and post-procedure weight change.

Background and study aims Peroral endoscopic myotomy (POEM) has become a recognized treatment for achalasia. The technique requires CO2 insufflation. It is estimated that the partial pressure of CO2 (PaCO2) is 2 to 5 mm Hg higher than the end tidal CO2 (etCO2), and etCO2 is used as a surrogate for PaCO2 because PaCO2 requires an arterial line. However, no study has compared invasive and noninvasive CO2 monitoring during POEM.

Background and study aims Endoscopic necrosectomy is limited by the proximity of necrosis to the gastrointestinal tract. Percutaneous endoscopic necrosectomy (PEN) is a minimally invasive endoscopic method of percutaneous debridement. Studies regarding its efficacy and safety are lacking. The purpose of this study was to assess the efficacy and safety of PEN in necrotizing pancreatitis. Methods Pubmed, Ovid, Cochrane, Scopus and Web of Science Database were searched from inception through February 2021. Dual extraction and quality assessment of studies using Cochrane risk of bias tool were performed independently by two authors. The primary outcome was defined as clinical success of PEN. Secondary outcomes included periprocedural morbidity, mortality, and long-term morbidity and mortality. Results Sixteen observational studies including 282 subjects were analyzed. The average reported age of the participants was 50.3 years. Patients with reported gender included 39 % females and 61 % males. The success rate as defined by complete resolution of necrosis and removal of drainage catheters/stents was 82 % (95 % confidence interval 77–87). The mean size of pancreatic necrosis was 14.86 cm (5–54 cm). The periprocedural morbidity rate was 10 %, while there was no reported periprocedural mortality. The long-term morbidity rate was reported as 23 % and mortality at follow-up was 16 %. Conclusions PEN is a novel method of endoscopic management of pancreatic necrosis. Based on our meta-analysis of retrospective studies, it represents a safe treatment modality with high rates of clinical success and low rates of perioperative morbidity and mortality. This study supports the use of PEN when conventional endoscopic therapy is not feasible.

Background and Aims: Liver biopsies are traditionally performed using percutaneous, transjugular, or surgical approaches. Endoscopic ultrasound (EUS)-guided liver biopsy is a new modality to sample liver parenchyma. This technique allows sampling of both liver lobes and obviates the need for sampling error. However, there is paucity of literature demonstrating that EUS-guided liver biopsy provides adequate tissue sample for histologic analysis. This study aimed to review the experience of 2 large tertiary care centers to demonstrate the efficacy and safety of EUS-guided liver biopsy. Methods: All patients undergoing EUS-guided liver biopsy between March 2018 and October 2019 between 2 tertiary care centers were included in this retrospective study. The main outcomes of the study included technical success of EUS-guided liver biopsy, details of the specimen (length of the specimen, number of complete portal tracts), and adverse events of EUS-guided liver biopsy. Results: A total of 229 patients underwent EUS-guided liver biopsy at the 2 tertiary care centers. There was 100% technical success. Of the 229 patients, 226 patients (98.7%) had adequate tissue for histopathological evaluation with a mean total length of 3.20 cm and complete portal tracts of 20.2. Overall, 2.6% of patients had adverse events. Conclusion: Our study illustrates that EUS-guided liver biopsy provides adequate specimen for histologic analysis and is a safe, viable alternative to other methods of liver biopsy.

Background/Aims Peroral endoscopic myotomy (POEM) has been increasingly used for achalasia in Latin America, where Chagas disease is prevalent, and this makes POEM more challenging. The aim of this study was to determine the learning curve for POEM in Latin America. Method: Patients undergoing POEM in Latin America with a single operator were included from a prospective registry over 4 years. Non-linear regression and cumulative sum control chart (CUSUM) analyses were conducted for the learning curve. Results A total of 125 patients were included (52% male; mean age, 59 years), of which 80 had type II achalasia (64%), and 38 had Chagas disease (30%). The average pre-procedure and post-procedure Eckardt scores were 6.79 and 1.87, respectively. Technical success was achieved in 93.5% of patients, and clinical success was achieved in 88.8%. Adverse events occurred in 27 patients (22%) and included bleeding (4 patients), pneumothorax (4 patients), mucosal perforation (13 patients), mediastinitis (2 patients), and leakage (4 patients). The CUSUM chart showed a median procedure time of 97 min (range, 45-196 min), which was achieved at the 61st procedure. Procedure duration progressively decreased, with the last 10 procedures under 50 min approaching a plateau (p-value

Background and study aims Endoscopic techniques are rapidly emerging for resection of subepithelial tumors (SETs). Submucosal tunneling for endoscopic resection (STER), endoscopic full-thickness resection (EFTR) and laparoscopic endoscopic cooperative surgery (LECS) are current alternatives to open surgery. In this study, we aimed to compare the three endoscopic techniques. Patients and methods Consecutive patients who underwent resection of a submucosal esophageal or gastric lesion at several tertiary care centers were included in a dedicated registry over 3 years. Demographics, size and location of resected lesion, histology of specimen, length of procedure, adverse events (AEs), duration of hospital stay, and follow-up data were collected. Results Ninety-six patients were included (47.7 % male, mean age 62): STER n = 34, EFTR n = 34, LECS n = 280. The lesions included leiomyoma, gastrointestinal stromal tumors (GISTs) and other. The mean lesion size was 28 mm (STD 16, range 20–72 mm). The majority of lesions in the EFTR and laparoscopic-assisted resection group were GISTs. There was no significant difference in clear resection margins, post-procedure complication rates, recurrence rate and total follow-up duration between the groups. However, the LECS group had a procedure time at least 30 minutes longer than STER or EFTR (P

Some have said that it is inappropriate and perhaps impossible to consider wave and Windkessel phenomena simultaneously. For 50 years, arterial hemodynamics has been dominated by the frequency-domain “impedance analysis” in which it was assumed that all variations in aortic pressure and flow were caused only by forward- and backward-going waves. This paper is a review of the results of incorporating the effects of Frank’s Windkessel. We have taken the view that measured aortic pressure is the sum of a Windkessel component and forward-going and backward-going wave components. When the Windkessel component is initially subtracted out, the pattern of propagation and reflection of wave components becomes clear. Furthermore, this analysis obviates the implications of impedance analysis that have not been explained satisfactorily.

Background and study aims Optical coherence tomography (OCT) is a new technology available for evaluation of indeterminate biliary strictures. It allows under-the-surface visualization and preliminary studies have confirmed standardized characteristics associated with malignancy. The aim of this study is to evaluate the first interobserver agreement in identifying previously agreed upon OCT criteria and diagnosing of malignant versus benign disease. Patients and methods Fourteen endoscopists were asked to review an atlas of reference clips and images of eight criteria derived from expert consensus A total of 35 de-identified video clips were then evaluated for presence of the eight criteria and for final diagnosis of malignant versus benign using the atlas as reference Intraclass correlation (ICC) analysis was done to evaluate interrater agreement. Results Clips of 23 malignant lesions and 12 benign lesions were scored. Excellent interobserver agreement was seen with dilated hypo-reflective structures (0.85) and layering effacement (0.89); hyper-glandular mucosa (0.76), intact layering (0.81), and onion-skin layering (0.77); fair agreement was seen with scalloping (0.58), and thickened epithelium (0.4); poor agreement was seen with hyper-reflective surface (0.36). The diagnostic ICC for both neoplastic (0.8) and non-neoplastic (0.8) was excellent interobserver agreement. The overall diagnostic accuracy was 51 %, ranging from 43 % to 60 %. Conclusions Biliary OCT is a promising new modality for evaluation of indeterminate biliary strictures. Interobserver agreement ranged from fair to almost perfect on eight previously identified criteria. Interobserver agreement for malignancy diagnosis was substantial (0.8). Further studies are needed to validate this data.

Background: Endoscopic sleeve gastroplasty (ESG) is an incisionless procedure that reduces the size of the gastric cavity. In prior studies, it has been proven to be a safe and effective treatment for obesity. In this study, we performed a collaborative study to evaluate the effectiveness of ESG among new endobariatric programs. Methods: This was an international, multicenter study reviewing the outcomes of ESG in centers starting ESG programs. Total body weight loss, change of body mass index (BMI), excess body weight loss (EBWL), technical success, duration of hospitalization, and immediate and delayed adverse events and complications at 24 h, 1 week, and 1, 3, and 6 months post-procedure were evaluated. Results: A total of 91 patients (35 males) from six centers were included. The patients’ mean BMI before the procedure was 38.7 kg/m 2 . BMI reduction at 3 months was 7.3 ( p

Background/Aims Endoscopic ultrasonography (EUS)-guided drainage is the preferred approach for infected or symptomatic pancreatic fluid collections (PFCs). Here, we developed an algorithm for the management of pancreatitis complicated by PFCs and report on its effcacy and safety. Methods Between September 2011 and October 2017, patients were prospectively managed according to the algorithm. PFCs were classified as poorly organized fluid collections (POFCs), pancreatic pseudocysts (PPs), or walled-off pancreatic necrosis (WOPN). Clinical success was defined as a decrease in PFC size by ≥50% of the maximal diameter or to ≤2 cm. Results A total of 108 patients (62% male; mean age, 53 years) were included: 13 had POFCs, 43 had PPs, and 52 had WOPN. Seventytwo patients (66%) required a pancreatic duct (PD) stent, whereas 65 (60%) received enteral feeding. A total of 103 (95%) patients achieved clinical success. Eight patients experienced complications including bleeding (n=6) and surgical intervention (n=2). Patients with enteral feeding were 3.4 times more likely to achieve resolution within 60 days (p=0.0421), whereas those with PD stenting was five times more likely to achieve resolution within 90 days (p=0.0069). Conclusions A high PFC resolution rate can be achieved when a dedicated algorithm encompassing EUS-guided drainage, PD stenting, and early enteral feeding is adopted.

Background and study aims The SARS-CoV-2 pandemic heavily impacted the New York metro area causing most institutions to either reduce case volume or fully close remaining open units incorporated specific guidelines for procedures lockdown potentially leading to a greater turn-over time. We analyzed the quantitative and financial impact of this lost time on our tertiary care center’s endoscopy unit. Patients and methods This single-center, retrospective study included demographics, procedure details and turn-over times (TOT) from all endoscopic procedures between December 1, 2019 to June 30, 2020. Cases were categorized as pre-COVID-19 group from December 1, 2019 to March 15, 2020 and during COVID-19 (lockdown) group from March 16, 2020 to June 30, 2020. The financial impact was assessed using national averages for reimbursement of outpatient endoscopic procedures provided by Center for Medicare and Medicaid Services. Results A total of 3622 procedures were performed during the study period: 2297 in the pre-COVID-19 period, 1325 in the COVID-19 period, representing a 42.32 % decrease. In the COVID-19 lockdown group, there was a significant increase in TOT in both the general endoscopy cases (18.11 minutes, P = 0.000) and advanced endoscopy cases (17.7 minutes, P = 0.000). The 42.3 % decrease in volume equated to at least $1.6 million USD in lost revenue during the lockdown. Conclusions COVID-19 pandemic led to an increase in TOT with overall reduced procedure volume and a negative effect on revenue. Providing continued endoscopic management during a pandemic avoids delays in reopening the endoscopy unit and hampers the post-pandemic surge of delayed cases and its financial impact.

Background Although evidence suggests frequent gastrointestinal (GI) involvement during coronavirus disease 2019 (COVID-19), endoscopic findings are scarcely reported.Aims We aimed at registering endoscopic abnormalities and potentially associated risk factors among patients with COVID-19.Methods All consecutive patients with COVID-19 undergoing endoscopy in 16 institutions from high-prevalence regions were enrolled. Mann-Whitney U, χ2 or Fisher’s exact test were used to compare patients with major abnormalities to those with negative procedures, and multivariate logistic regression to identify independent predictors.Results Between February and May 2020, during the first pandemic outbreak with severely restricted endoscopy activity, 114 endoscopies on 106 patients with COVID-19 were performed in 16 institutions (men=70.8%, median age=68 (58–74); 33% admitted in intensive care unit; 44.4% reporting GI symptoms). 66.7% endoscopies were urgent, mainly for overt GI bleeding. 52 (45.6%) patients had major abnormalities, whereas 13 bled from previous conditions. The most prevalent upper GI abnormalities were ulcers (25.3%), erosive/ulcerative gastro-duodenopathy (16.1%) and petechial/haemorrhagic gastropathy (9.2%). Among lower GI endoscopies, 33.3% showed an ischaemic-like colitis.Receiver operating curve analysis identified D-dimers >1850 ng/mL as predicting major abnormalities. Only D-dimers >1850 ng/mL (OR=12.12 (1.69–86.87)) and presence of GI symptoms (OR=6.17 (1.13–33.67)) were independently associated with major abnormalities at multivariate analysis.Conclusion In this highly selected cohort of hospitalised patients with COVID-19 requiring endoscopy, almost half showed acute mucosal injuries and more than one-third of lower GI endoscopies had features of ischaemic colitis. Among the hospitalisation-related and patient-related variables evaluated in this study, D-dimers above 1850 ng/mL was the most useful at predicting major mucosal abnormalities at endoscopy.Trial registration number ClinicalTrial.gov (ID: NCT04318366).

Superior mesenteric artery syndrome (SMAS) causes compression and partial or complete obstruction of the duodenum, resulting in abdominal pain, nausea, vomiting, and weight loss. If conservative therapy fails, the patient is typically referred for enteral feeding or laparoscopic gastrojejunostomy. The last few years have seen increasing use of endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) for gastric obstruction indications. EUS-GJ involves the creation of a gastric bypass via an echoendoscope in cases in which the small intestine can be punctured under ultrasonographic visualization, resulting in an incision-free, efficient, and safe procedure. In this case report, we present the first case of SMAS treated using a reverse EUS-GJ, and describe the steps and advantages of the procedure in this particular case.

Background: The purpose of this article is to examine the systemic circulation and left ventricular (LV) performance by alternative, nonconventional approaches: systemic vascular conductance (GSV) and the head-capacity relation (ie, the relation between LV pressure and cardiac output), respectively; in so doing, we aspired to present a novel and improved interpretation of integrated cardiovascular function. Methods: In 16 open-chest, anaesthetized pigs, we measured LV pressure (PLV), central aortic pressure (PAo), and central venous pressure (PCV) and aortic flow (QAo). We calculated heart rate (HR), stroke volume, cardiac index (CI = cardiac output/body weight), mean PLV (P¯LV), and the average arteriovenous pressure difference (ΔP=P¯Ao−P¯CV); GSV = CI/(P¯Ao−P¯CV). We studied the effects of changing loading conditions with the administration of phenylephrine (ΔP¯Ao ≥ +25 mm Hg), isoproterenol (ΔHR ∼+25%), sodium nitroprusside (ΔP¯Ao ≥ −25 mm Hg), and proximal aortic constriction (to maximize developed PLV and minimize QAo). Results: Sodium nitroprusside and isoproterenol increased GSV compared with phenylephrine and constriction. A maximum head-capacity curve was derived from pooled data using nonlinear regression on the maximum P¯LV values in QAo bins 12.5 mL/min/kg wide. The head-capacity relation and the plots of conductance were combined using CI as a common axis, which illustrated that CI is the output of the heart and the input of the circulation. Conclusions: Thus, at a given CI, GSV determines the driving pressure and, thereby, PAo. We also demonstrated how decreases in GSV compensate for arterial hypotension by restoring the arteriovenous pressure difference and arterial pressure. Résumé: Contexte: Le présent article examine l’efficacité de la circulation générale et la fonction ventriculaire gauche à l’aide de paramètres de rechange non conventionnels, soit la conductance vasculaire systémique (GVS) pour l’une et la relation pression-volume (c.-à-d. la relation entre la pression ventriculaire gauche et le débit cardiaque) pour l’autre, dans le but de présenter une interprétation nouvelle et améliorée de la fonction cardiovasculaire intégrée. Méthodologie: Chez 16 porcs anesthésiés, nous avons mesuré à thorax ouvert la pression ventriculaire gauche (PVG), la pression aortique centrale (PAC), la pression veineuse centrale (PVC) et le flux aortique (QA). Nous avons établi la fréquence cardiaque (FC), le volume d’éjection systolique, l’index cardiaque (IC; rapport entre le débit cardiaque et le poids corporel), la PVG moyenne (P¯VG) et la différence de pression artérioveineuse moyenne (ΔP=P¯AC−P¯VC); GVS = IC/(P¯AC−P¯VC). Nous avons aussi étudié les effets d’une modification des conditions de charge cardiaque provoquée par l’administration de phényléphrine (ΔP¯AC ≥ + 25 mmHg), d’isoprotérénol (ΔFC d’environ + 25 %) ou de nitroprussiate de sodium (ΔP¯AC ≥ − 25 mmHg) et par la constriction de l’aorte proximale (pour maximiser la PVG développée et réduire le plus possible le QA). Résultats: Le nitroprussiate de sodium et l’isoprotérénol ont augmenté la GVS comparativement à la phényléphrine et à la constriction. Une courbe de la relation pression-volume maximale a été dérivée à partir des données groupées, au moyen d’une régression non linéaire sur les valeurs maximales de la P¯VG réparties dans des classes de QA de 12,5 ml/min/kg d’amplitude. La courbe de la relation pression-volume et le tracé de la conductance ont été superposés en utilisant l’IC comme axe commun, ce qui a permis de constater que l’IC correspond au débit cardiaque et au volume entrant dans la circulation. Conclusions: Pour un IC donné, la GVS détermine la pression motrice et donc, la PAC. Nous avons aussi démontré comment une diminution de la GVS compense l’hypotension artérielle en rétablissant la différence de pression artérioveineuse et la pression artérielle.

Background and study aims The rate of gastroesophageal reflux disease (GERD) after per oral endoscopic myotomy (POEM) is concerning. Endoscopic anti-reflux methods, such as Trans Oral Incisionless Fundoplication (TIF), are crucial for the long-term success of POEM, especially if they can be performed in the same session. Methods We completed a proof-of-concept canine pilot study (n = 6) to assess safety and feasibility of POEM and TIF in a single session (POEM-TIF). Subsequently, POEM-TIF was also performed in patients with achalasia (n = 5). Herein, we report on the safety, technical and clinical success of the first-in-human cases with symptom follow-up at 1, 3 and 6 months and pH testing at 6 months. Results POEM was completed successfully in six canines (3 anterior and 3 posterior myotomies), followed by TIF in the same session. Necropsy and extensive testing demonstrated no evidence of mucosal injury and no leaks. The reconstructed valve was 220 to 240 degrees, 3 to 4 cm in length, and resulted in concomitant esophageal lengthening (2–5 cm). Using similar principles, the first-in-human cases were performed without intraprocedural or delayed adverse events. pH testing at 6 months showed that four of five patients had no evidence of GERD (DeMeester > 14.72), and in one case, there was evidence of esophagitis. Conclusions Single session POEM-TIF appears to be safe and feasible. Early clinical human data suggests that it may be able to reduce post POEM GERD, however the additional secondary benefits such as lengthening and straightening of the esophagus, may prove to be equally important for the long-term success of POEM.

Background and study aims Both Heller myotomy (HM) and per-oral endoscopic myotomy (POEM) are efficacious therapies for achalasia. The efficacy and safety of POEM vs HM in Latin America and specifically in patients with Chagas disease is unknown. Patients and methods Consecutive patients undergoing either HM or POEM for achalasia were included from nine Latin American centers in a prospective registry over 5 years. Technical success was defined as undergoing a successful myotomy. Clinical success was defined as achieving an Eckardt score

Background and study aims First-generation optical coherence tomography (OCT) has been shown to increase diagnostic sensitivity for malignant biliary and pancreatic-duct strictures. A newer OCT imaging system, NVision Volumetric Laser Endomicroscopy (VLE), allows for in vivo cross-sectional imaging of the ductal wall at the microstructure level during endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to identify and evaluate characteristics on OCT that are predictive of benign and malignant strictures. Patients and methods Consecutive patients from six centers who underwent OCT between September 2016 and September 2017 were included in a dedicated registry. OCT images were analyzed, and nine recurring characteristics were further assessed. Final diagnosis was based on histology and/or surgical pathology. Results 86 patients were included (49 % male, mean age 64.7). OCT was performed in the bile duct in 79 patients and the pancreatic duct in seven. Nine OCT characteristics were identified: dilated hypo-reflective structures (n = 7), onion-skin layering (n = 8), intact layering (n = 17), layering effacement (n = 25), scalloping (n = 20), thickened epithelium (n = 42), hyper-glandular mucosa (n = 13), prominent blood vessels (n = 6), and a hyper-reflective surface (n = 20). Presence of hyper-glandular mucosa, hyper-reflective surface and scalloping significantly increased the odds of malignancy diagnosis by 6 times more (P = 0.0203; 95 % CI 1.3 to 26.5), 4.7 times more (P = 0.0255; 95 % CI 1.2 to 18.0) and 7.9 times more (P = 0.0035; 95 % CI 1.97 to 31.8) respectively. Conclusion By providing in-vivo cross-sectional imaging of the pancreatic and biliary duct wall, OCT technology may improve sensitivity in diagnosing malignant strictures and provide standardizable criteria predictive of malignancy.

Introduction Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an efficacious and safe option for patients who cannot undergo cholecystectomy. It is a technically challenging procedure, requiring skills in EUS, and ERCP. The aim of this study was to define the learning curve for EUS-GBD. Patients and methods Consecutive patients undergoing EUS-GBD by a single operator were included from a prospective registry over 5 years. Demographics, procedure information, post-procedure follow-up data, and information on adverse events were collected. Non-linear regression and CUSUM analyses were conducted for the learning curve. Clinical success was defined as resolution of cholecystitis post-procedure. Results Forty-eight patients were included (58 % male, mean age 76 years). Twenty patients (42 %) had malignant cholecystitis. Most patients had lumen-apposing metal stents (LAMS) (15 mm, n = 29, 60 %; 10 mm, n = 8, 7 %). The remaining patients had FCSEMS (n = 9, 19 %) or plastic stents alone (n = 2, 4 %). Clinical success was achieved in 36 (86 %) of patients. Of the remaining 12, 7 were lost to follow-up and 5 had persistent cholecystitis. 9 patients (19 %) had adverse events including bleeding (n = 4), liver abscesses (n = 2), and hypotension. Two patients passed away post-procedure. Median procedure time was 41 minutes (range 16 – 121 min), with the 41-minute time occurring during the 19th procedure. Procedure durations further reduced, with the last 10 procedures being 20 minutes or under (nonlinear regression p value P

Objective Significant haemodynamic changes occur at delivery impacting organ blood flow distribution. We aimed to characterise Doppler indices patterns over time in three different organs (brain, gut and kidney) and test them as measures of vascular resistance.Design Observational cohort study. Serial Doppler interrogations of the anterior cerebral, superior mesenteric and renal arteries within 2 hours, 2–6, and 24 hours of life, in combination with central haemodynamic data.Patients Healthy, near-term (>36 weeks of gestation) neonates.Outcome measures Pulsatility (PI) and Resistance Indices (RI) patterns and organ-specific conductances, detailed echocardiographic haemodynamic measures.Results Twenty-one babies were studied. Doppler morphology and adaptation patterns were distinctly different between the organs (brain, gut and kidney) supporting autonomous vascular regulatory effects. The PI differentiated especially between kidney and other organ flow consistently over time. PI and RI for all three organs decreased. The variance in organ conductance did not explain the variance in 1/PI, indicating that PI is not a measure of resistance. Superior mesenteric artery had the highest velocity with 72 cm/s. Non-invasively acquired pilot serial values in a normal population are given. Patent ductus arteriosus flow remained open at discharge for 36%.Conclusions Haemodynamic transitioning patterns assessed by serial Dopplers in healthy near-term neonates differ in brain, gut and kidney: Doppler waveform morphology differs, and PI differentiates renal Doppler morphology, compared with the other organs. While PI and RI decline for all organs, they do not measure resistance. Brain artery velocity increases, mesenteric perfusion is variable and renal Vmax decreases.

Background/Aims Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone Rouxen-Y gastric bypass (RYGB) is challenging. Standard ERCP and enteroscopy-assisted ERCP are associated with limited success rates. Laparoscopy- or laparotomy-assisted ERCP yields improved efficacy rates, but with higher complication rates and costs. We present the first multicenter experience regarding the efficacy and safety of endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) or EUS. Methods All patients who underwent EDGE at two academic centers were included. Clinical success was defined as successful ERCP and/or EUS through the use of lumen-apposing metal stents (LAMS). Adverse events related to EDGE were separated from ERCP- or EUS-related complications and were defined as bleeding, stent migration, perforation, and infection. Results Sixteen patients were included in the study. Technical success was 100%. Clinical success was 90% (n=10); five patients were awaiting maturation of the fistula tract prior to ERCP or EUS, and one patient had an aborted ERCP due to perforation. One perforation occurred, which was managed endoscopically. Three patients experienced stent dislodgement; all stents were successfully repositioned or bridged with a second stent. Ten patients (62.5%) had their LAMS removed. The average weight change from LAMS insertion to removal was negative 2.85 kg. Conclusions EDGE is an effective, minimally invasive, single-team solution to the difficulties associated with ERCP in patients with RYGB.

Introduction Increased esophageal acid exposure is seen in a large percentage of patients with achalasia who undergo peroral endoscopic myotomy (POEM). Endoscopic transoral fundoplication (TIF) is a novel endoscopic technique for the management of patients with chronic gastroesophageal reflux (GERD). We present the first case series evaluating the role of TIF post-POEM. Methods Consecutive patients 18 years or older from our academic institution who underwent a POEM procedure and subsequently underwent TIF for symptomatic reflux or regurgitation between December 2014 and June 2017 were included. The primary outcome was discontinuation of proton-pump inhibitor (PPI) use and healing of esophagitis (when initially present) on post-procedure esophagogastroduodenoscopy (EGD). Technical success was defined as successful completion of the endoscopic fundoplication. Adverse events (AEs) were recorded for all patients. Results Five patients were included (60 % male, average age 55 ± 14 years). Technical success was achieved in 100 % of patients. Discontinuation of PPI use was achieved in 5/5 patients (100 %). Three patients had esophagitis pre-procedure and all were noted to have resolution of inflammation on post-procedure EGD. No adverse events were noted. Mean follow-up time was 27 months (range 5 – 34 months). Conclusion TIF post-POEM appears feasible, safe, and efficacious in improving symptoms and esophagitis, decreasing long-term risks of acid exposure, and decreasing risks of long-term PPI use in patients post-POEM in this small cohort of patients. Larger studies are needed to confirm these initial findings.

Background Symptomatic pancreatic fluid collections (PFCs) are managed by surgical, percutaneous, or endoscopic drainage. Due to morbidity associated with surgical drainage, percutaneous and/or endoscopic options have increasingly been used as initial management. Aims We conducted a systematic review and meta-analysis comparing the efficacy and safety of endoscopic versus percutaneous drainage for management of PFCs. Methods We searched several databases from inception through 31 August 2017 to identify comparative studies using endoscopic or percutaneous drainage for PFCs. Our primary outcome was clinical success. Secondary outcomes were technical success, adverse events (AE), rates of recurrence, requirement for subsequent procedures, and length of stay in hospital. Pooled risk ratios (RR) and mean difference (MD) were calculated for categorical and continuous outcomes, respectively. Results Seven studies with 490 patients were included in the final analysis. Pooled RR for clinical success was 0.40 (0.26, 0.61), I 2 = 42 % in favor of endoscopic management. On sensitivity analysis, after excluding one study on patients with walled-off necrosis (WON), the clinical success was 0.43 (0.28, 0.66) with no heterogeneity. Pooled RR for technical success was 1.50 (0.52, 4.37) with no heterogeneity. Pooled RR for AE and rate of recurrence were 0.77 (0.46, 1.28) and 0.60 (0.29, 1.24), respectively. Pooled MD for length of stay in hospital and rate of re-intervention were – 8.97 (– 12.88, – 5.07) and – 0.66 (– 0.93, – 0.38), respectively, in favor of endoscopic drainage. Conclusions Endoscopic drainage should be the preferred therapeutic modality for PFCs compared to percutaneous drainage as it is associated with significantly better clinical success, a lower re-intervention rate, and a shorter hospital length of stay. This study was presented as an abstract at Digestive Disease Week 2017 in Chicago, USA.

Background: Surgical gastrojejunostomy and enteral self-expanding metal stents are efficacious for the management of gastric outlet obstruction but limited by high complication rates and short-term efficacy. Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is a novel alternative option. Patients and methods: Patients who underwent EUS-GJ between March 2014 and September 2015 as part of a prospective multicenter registry at four academic centers in two countries were included. Technical success was defined as successful placement of a gastrojejunal lumen-apposing metal stent. Clinical success was defined as the ability of the patient to tolerate an oral diet. Post-procedural adverse events were recorded. Results: The study included 26 patients, of whom 11 (42 %) were male. Technical success was achieved in 24 patients (92 %). Clinical success was achieved in 22 patients (85 %). Of the 4 patients in whom clinical success was not achieved, 2 had persistent nausea and vomiting despite a patent EUS-GJ and required enteral feeding for nutrition, 1 died before the initiation of an oral diet, and 1 underwent surgery for suspected perforation. Adverse events, including peritonitis, bleeding, and surgery, occurred in 3 patients (11.5 %). Conclusion: EUS-GJ is an emerging procedure that has efficacy and safety comparable with those of current therapies and should hold a place as a new minimally invasive option for patients with gastric outlet obstruction. Clinical trial identification number: NCT01522573

Using the reservoir-wave approach, previously we characterized pulmonary vasculature mechanics with multiple interventions in a canine model. In the present study, we measured high-fidelity pulmonary arterial (PA) pressure, Doppler flow velocity, and pulmonary capillary wedge pressure in 11 patients referred for evaluation of exertional dyspnea. The analysis was performed using the reservoir-wave approach; wave intensity analysis was subsequently utilized to characterize the PA wave pattern. Our objective was to identify specific abnormalities associated with pulmonary hypertension. Seven patients with varying PA pressures had reduced pulmonary vascular conductance (i.e., the amount of flow that the lungs can accept per pressure gradient), suggesting that these patients might benefit from pulmonary vasodilator therapy, some even in the absence of markedly elevated PA pressures. Right ventricular (RV) performance was assessed by examining the work done by the wave component of systolic PA pressure. Wave work, the non-recoverable energy expended by the RV to eject blood, varied directly with mean PA pressure. Wave pressure was partitioned into two components: forward-travelling and reflected backward-travelling waves. Among patients with lower PA pressures, we found pressure-decreasing backward waves that aided the RV during ejection, as previously reported in normal experimental animals. Among patients with higher PA pressures, we detected pressure-increasing backward waves that impede RV ejection. We conclude that it is important to measure pulmonary vascular conductance to properly assess the pulmonary vasculature. The reservoir-wave approach and wave intensity analysis may prove to be valuable tools to evaluate RV performance and may facilitate development of therapeutic strategies.

Diastolic filling of the left ventricle (LV) occurs in two phases, early and late filling. Early filling, manifest as the “E-wave”, is thought to be substantially due to diastolic suction (DS), a phenomenon where the LV aspirates blood and fills itself, independent of atrial activity. Late filling, resulting in the mitral flow “A-wave” is a result of left atrial contraction. Adequate filling of the LV is necessary to maintain normal heart function at rest and under stress. DS is thought to be an important mechanism in the efficiency of filling. To study DS, we have invasively measured pressure and used cardiac MRI to evaluate cavitary volume and flow in an animal model to quantify different measures of DS under varied experimental conditions. The amount of filling due to DS (VDS), determined by the change in volume between mitral valve opening and LV pressure minimum of the pressure-volume loop (Katz 1930), is related to the measured end systolic volume (ESV). As ESV decreases the VDS increases. The smaller the ESV, the larger the recoil energy of the LV as it relaxes towards resting volume. This contributes increased energy for the suction of blood into the ventricle in early filling. Wave intensity analysis (the separation of forward and backwards waves and wave type) and intraventricular pressure gradients will also be considered in order to determine which best describes DS and whether they can be used together to better understand changes in filling dynamics under varied loading conditions.

A hydraulic teaching model of the human systemic circulation is proposed, based on the principles of the reservoir-wave approach. Reservoir characteristics are portrayed by the arterial tall-and-narrow and venous short-and-wide columns, the relative compliances of which are signified by their diameters. Wave characteristics are represented by proximal arterial and venous resistances; rapid left ventricular ejection and rapid right atrial filling cause flow-dependent pressure drops across the respective resistances. (The value of the proximal arterial resistance is numerically equal to the characteristic impedance.) The pressure drop across the proximal arterial resistance, excess pressure, is understood to be fundamentally wave-related and has been shown to be a measure of the efficiency of cardiac-vascular coupling. Excess pressure also predicts an incremental risk of cardiovascular morbidity and largely accounts for the hysteresis evidenced by an open aortic pressure-volume loop.

Abstract Background As myocardial oxygenation may serve as a marker for ischemia and microvascular dysfunction, it could be clinically useful to have a non-invasive measure of changes in myocardial oxygenation. However, the impact of induced blood flow changes on oxygenation is not well understood. We used oxygenation-sensitive CMR to assess the relations between myocardial oxygenation and coronary sinus blood oxygen saturation (SvO2) and coronary blood flow in a dog model in which hyperemia was induced by intracoronary administration of vasodilators. Results During administration of acetylcholine and adenosine, CMR signal intensity correlated linearly with simultaneously measured SvO2 (r2 = 0.74, P < 0.001). Both SvO2 and CMR signal intensity were exponentially related to coronary blood flow, with SvO2 approaching 87%. Conclusions Myocardial oxygenation as assessed with oxygenation-sensitive CMR imaging is linearly related to SvO2 and is exponentially related to vasodilator-induced increases of blood flow. Oxygenation-sensitive CMR may be useful to assess ischemia and microvascular function in patients. Its clinical utility should be evaluated.