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Introduction:  The environmental impact of endoscopy, including small-bowel capsule endoscopy (SBCE), is a topic of growing attention and concern. This study aimed to evaluate the greenhouse gas (GHG) emissions (kgCO 2 ) generated by an SBCE procedure., Methods:  Life cycle assessment methodology (ISO 14040) was used to evaluate three brands of SBCE device and included emissions generated by patient travel, bowel preparation, capsule examination, and video recording. A survey of 87 physicians and 120 patients was conducted to obtain data on travel, activities undertaken during the procedure, and awareness of environmental impacts., Results:  The capsule itself (4 g) accounted for < 6 % of the total product weight. Packaging (43-119 g) accounted for 9 %-97 % of total weight, and included deactivation magnets (5 g [4 %-6 %]) and paper instructions (11-50 g [up to 40 %]). A full SBCE procedure generated approximately 20 kgCO 2 , with 0.04 kgCO 2 (0.2 %) attributable to the capsule itself and 18 kgCO 2 (94.7 %) generated by patient travel. Capsule retrieval using a dedicated device would add 0.98 kgCO 2 to the carbon footprint. Capsule deconstruction revealed materials (e. g. neodymium) that are prohibited from environmental disposal; 76 % of patients were not aware of the illegal nature of capsule disposal via wastewater, and 63 % would have been willing to retrieve it. The carbon impact of data storage and capsule reading was negligible., Conclusion:  The carbon footprint of SBCE is mainly determined by patient travel. The capsule device itself has a relatively low carbon footprint. Given that disposal of capsule components via wastewater is illegal, retrieval of the capsule is necessary but would likely be associated with an increase in device-related emissions., Competing Interests: M. Pioche is a consultant for Olympus and a trainer for Olympus, Pentax, Norgine, Boston, and Cook. X. Dray is co-founder and a shareholder of Augmented Endoscopy; he provides consultancy for Norgine and Provepharma, and lectures and demonstrations for Alfasigma, Bouchara Recordati, Fujifilm, Medtronic, Norgine, and Sandoz. E. Rodriguez de Santiago has had educational and advisory roles for Olympus, educational roles at Apollo Endosurgery and Norgine, and has received conference fees from Norgine and Casen.J.A. Cunha Neves, H. Pohl, M.-Q. Lê, R.Grau, C. Yzet, M. Mochet, J. Jacques, T. Wallenhorst, J. Rivory, N. Siret, A.-L. Peillet, J.-B. Chevaux, F. Mion, U. Chaput, P. Jacob, D. Grinberg, J.-C. Saurin, R. Baddeley, and P.-J. Cottinet declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background and Aims: EUS-guided placement of fiducial markers in patients with esophageal or rectal cancer who have been referred for radiation therapy lacks data regarding its feasibility and safety. The aim of this study was to assess the success rate of EUS-guided fiducial marker placement in these indications., Methods: This prospective multicenter study enrolled patients with rectal or esophageal tumors who were treated between March 2017 and June 2021. The primary endpoint was the success of fiducial marker placement under EUS guidance utilizing the preloaded 22-gauge EchoTip Ultra Fiducial Needle (Cook Medical, Limerick, Ireland), defined by the ability to release fiducials at least at the proximal and distal ends of the tumor. Secondary endpoints were the adverse events, length of procedure, and fiducial markers remaining throughout radiation therapy., Results: A total of 33 patients were included in this study, with a mean age of 64.2 ± 11.3 years; 66.7% were male. Twenty patients had rectal adenocarcinoma, and 13 had esophageal malignancies. The success rate of fiducial marker placement was 93.9%. Markers could only be released at the proximal end of the tumor in 2 cases. The average procedure time (±SD) was 12.5 ± 4.8 minutes. The number of fiducial markers placed for each patient was 3.8 ± .5. No adverse events were reported. At the end of radiotherapy, markers were still visible on imaging in all patients., Conclusions: This prospective multicenter study highlights the safety and high success of the placement of fiducial markers under EUS guidance for rectal and esophageal tumors, with no adverse events and with a short procedure time. Fiducial markers remained in place over time during radiation therapy. (Clinical trial registration number: NCT03057288.)., Competing Interests: Disclosure The following authors disclosed financial relationships: U. Chaput: financial support for Case Report Form editing, monitoring and clinical study insurance from Cook Medical. M. Camus: consultant for Cook Medical. D. Karsenti: consultant for Olympus, Covidien, Norgine, and AlfaSigma; support from FujiFilm for attending meetings. E. Coron: consultant for Creo Medical, FujiFilm, Mayoly Spindler, and Provepharm. S. Koch: consultant for Pentax, Creo Medical, and Olympus. G. Vanbiervlet: paid speaker for Takeda, Tillots, Fujifilm, Pentax, and Norgine. M. Pioche: endoscopy training from Cook Medical, Boston Scientific, Olympus, and Norgine. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Competing Interests: A. Poujol-Robert is a consultant for Biotest. R. Leenhardt is cofounder and shareholder of Augmented Endoscopy, and has given a lecture for Abbvie. M. Camus is a consultant for Cook Medical, Ambu, and Medtronic. X. Dray is a founder and shareholder of Augmented Endoscopy, has acted as a consultant for Boston Scientific and Norgine, and has given lectures for Fujifilm, Medtronic, MSD, and Pentax. U. Chaput is a consultant for Boston Scientific. A.P.S.T. Kotinda, A. Payancé, and R. Leenhardt declare that they have no conflict of interest.

Competing Interests: Romain Leenhardt is cofounder and shareholder of Augmented Endoscopy and has given a lecture for Abbvie. Marine Camus is a consultant for Cook Medical, Ambu and Medtronic. Xavier Dray is a founder of and shareholder of Augmented Endoscopy and has acted as a consultant for Boston Scientific and Norgine and has given lectures for Fujifilm, Medtronic, MSD, and Pentax. Ulriikka Chaput is a consultant for Boston Scientific. The others authors have no discosures.

Background and Objective: LPAC (low phospholipid-associated cholelithiasis) syndrome is a rare genetic form of cholelithiasis. ERCP (endoscopic retrograde cholangiopancreatography) is often used to remove gallstones in the bile duct. No published data is available on the role of ERCP in LPAC syndrome., Patients and Methods: In this retrospective cohort study, we included patients diagnosed with LPAC syndrome in a single tertiary referral center between 2009 and 2021. Our aim was to assess the frequency, indications, modalities, results, and complications of ERCP, as well as predictive factors for ERCP, in LPAC syndrome. Independent factors associated with ERCP occurrence were identified using a multivariable Cox regression analysis., Results: ERCP was required in 31.2 % of the 269 patients included for analysis. Among patients who required ERCPs, 78.6 % had the procedure before diagnosis (i.e., starting UDCA). Most common indications were choledocholithiasis (53.6 %) and acute cholangitis (29.5 %). Post ERCP pancreatitis, perforation and bleeding rates were 7.2 %, 2.6 %, and 1.3 %, respectively. Age and history of cholelithiasis in first-degree relatives were associated with a higher risk of ERCP (Hazard-ratio [HR]=1.30 [95 %confidence-interval [CI] 1.04-1.62] and HR=1.88 [95 %CI 1.15-3.07] respectively). Female gender and UDCA intake ≥ 1 year were associated with a lower risk of ERCP (HR=0.49 [95 %CI 0.29-0.82] and HR=0.44 [95 %CI 0.22-0.90] respectively). Median follow-up was 10.8 years., Conclusion: One-third of patients with LPAC syndrome undergo sphincterotomy. However, most procedures are performed before diagnosis and UDCA is associated with a lower risk of endoscopic procedure. Earlier diagnosis and treatment with UDCA may further reduce the need for ERCP in patients with LPAC syndrome., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

INTRODUCTION : Residual colorectal neoplasia (RCN) after previous endoscopic mucosal resection is a frequent challenge. Different management techniques are feasible including endoscopic full-thickness resection using the full-thickness resection device (FTRD) system and endoscopic submucosal dissection (ESD). We aimed to compare the efficacy and safety of these two techniques for the treatment of such lesions. METHODS : All consecutive patients with RCN treated either using the FTRD or by ESD were retrospectively included in this multicenter study. The primary outcome was the R0 resection rate, defined as an en bloc resection with histologically tumor-free lateral and deep margins. RESULTS : 275 patients (median age 70 years; 160 men) who underwent 177 ESD and 98 FTRD procedures for RCN were included. R0 resection was achieved in 83.3 % and 77.6 % for ESD and FTRD, respectively ( P  = 0.25). Lesions treated by ESD were however larger than those treated by FTRD ( P  < 0.001). The R0 rates for lesions of 20-30 mm were 83.9 % and 57.1 % in the ESD and FTRD groups, respectively, and for lesions of 30-40 mm were 93.6 % and 33.3 %, respectively. On multivariable analysis, ESD procedures were associated with statistically higher en bloc and R0 resection rates after adjustment for lesion size ( P  = 0.02 and P  < 0.001, respectively). The adverse event rate was higher in the ESD group (16.3 % vs. 5.1 %), mostly owing to intraoperative perforations. CONCLUSION:  ESD is effective in achieving R0 resection for RCN whatever the size and location of the lesions. When residual lesions are smaller than 20 mm, the FTRD is an effective alternative., Competing Interests: C. Yzet has received consultancy and lecture fees from Abbvie, Takeda, Jansen, Amgen, and Galapagos. Y. Le Baleur has provided training sessions for Ovesco Endoscopy AG. J. Jacques has provided ESD training sessions for Olympus, Fuji, Erbe, Pentax, and Lumendi and has received lecture fees from Abbvie, Janssen, and Norgine. M. Barret is on the boards of Norgine and Ambu, and has received research grants from Pentax. M. Shaefer has provided training sessions for Boston Scientific, and has received congress invitations from Olympus, Cook, Cousin Medical, Boston Scientific, Pentax, Abbvie, MSD, Amgen, and Norgine. S. Leblanc has received consulting and lecture fees from Norgine, Olympus, Alfasigma, and Ovesco. J. Rivory has provided training sessions in endoscopy and endoscopic resection for Olympus, and Cook Medical.E. Coron had a speaker's and consultancy agreement with Fujifilm. G. Vanbiervliet has provided consultancy for Boston Scientific, Cook Medical, Fujifilm Inc., and Ambu, and has provided expert lectures/medical training for Boston Scientific, Cook Medical, Mayloy Spindler, Pentax Inc., Fujifilm Inc., and Tillotts. M. Pioche has provided training sessions in endoscopy and endoscopic resection for Olympus, Cook Medical, Boston Scientific, and Pentax Medical, and in endoscopic characterization with Norgine and Provepharm; he received an invitation to UEGW from AlfaSigma; he holds a patent with his institution, Hospices civils de Lyon, for the IPEFIX device.J. Albouys, P. Mandengue, E. Abou Ali, J.-B. Chevaux, V. Lepillez, J. Privat, T. Degand, T. Wallenhorst, U. Chaput, A. Berger, K. Aziz, G. Rahmi, E. Kull, L. Caillo, S. Koch, and F. Subtil declare that they have no conflict of interest., (Thieme. All rights reserved.)

BACKGROUND : The diagnosis of cholangiocarcinoma in patients with a biliary stricture without mass syndrome can be obtained by biliary brushing with a sensitivity of ~50 %. We performed a multicenter randomized crossover trial comparing the aggressive Infinity brush with the standard RX Cytology Brush. The aims were to compare sensitivity for cholangiocarcinoma diagnosis and cellularity obtained. METHODS : Biliary brushing was performed consecutively with each brush, in a randomized order. Cytological material was studied with blinding to the brush type used and order. The primary end point was sensitivity for cholangiocarcinoma diagnosis; the secondary end point was the abundance of cellularity obtained with each brush, with cellularity quantified in order to determine if one brush strongly outperformed the other. RESULTS : 51 patients were included. Final diagnoses were cholangiocarcinoma (n = 43; 84 %), benign (n = 7; 14 %), and indeterminate (n = 1; 2 %). Sensitivity for cholangiocarcinoma was 79 % (34 /43) for the Infinity brush versus 67 % (29/43) for the RX Cytology Brush ( P  = 0.10). Cellularity was rich in 31/51 cases (61 %) with the Infinity brush and in 10/51 cases (20 %) with the RX Cytology Brush ( P  < 0.001). In terms of quantification of cellularity, the Infinity brush strongly outperformed the RX Cytology Brush in 28/51 cases (55 %), while the RX Cytology Brush strongly outperformed the Infinity brush in 4/51 cases (8 %; P  < 0.001). CONCLUSIONS : This randomized crossover trial showed that the Infinity brush is not significantly more effective than the RX Cytology Brush for biliary stenosis without mass syndrome in terms of sensitivity for cholangiocarcinoma diagnosis, but does offer a significantly higher abundance of cellularity., Competing Interests: D. Karsenti has received consulting fees from Olympus. J. Privat has received consulting fees from Boston Scientific. S. Leblanc has received consulting fees from Boston Scientific and Olympus, and is on the advisory board of Alfasigma and Norgine. J. Levy has received consulting fees from Ambu. M. Schaefer has received consulting fees from Boston Scientific, lecture fees from Ferring, Alfasigma and Duomed Endoscopy, and is on the advisory board of Abbvie. G. Vanbiervliet has received consulting fees from Ambu, Boston Scientific, Cook and Fujifilm, and lecture fees from Tillots Inc. Fujifilm, Boston Scientific and Pentax. G. Rahmi has received consulting fees from Medtronic and Fujifilm, and lecture fees from Boston Scientific and Pentax. E. Perez-Cuadrado Robles has received consulting fees from Boston Scientific. T. Wallenhorst has received consulting fees from Fujifilm and Olympus.The remaining authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: Endoscopic retrograde cholangiopancreatography (ERCP) for malignant hilar strictures is challenging. The correlation between Magnetic resonance cholangiopancreatography (MRCP) and per ERCP 2D fluoroscopic images is not obvious. The aim of this study was to evaluate the feasibility and potential usefulness of MRCP-based handmade biliary 3D reconstruction in this setting., Methods: Methods Patients who underwent MRCP followed by ERCP for biliary drainage of a malignant hilar stricture at our institution between 2018 and 2020 were reviewed. A handmade 3D segmentation using 3D slicer© (Kitware, France) was fashioned and reviewed with an expert radiologist. The primary outcome was the feasibility of biliary segmentation., Results: A total of 16 patients were included. The mean age was 70.1 (+/- 8.6) years-old and 68.8% had hilar cholangiocarcinoma. Handmade segmentation was successful in all cases. The agreement between the MRCP interpretation and the 3D reconstruction was 37.5%, as per the Bismuth classification. 3D reconstruction available prior to ERCP could have helped guide for better stent placement in 11 cases (68.8%)., Conclusions: MRCP-based biliary 3D segmentation-reconstruction, in patients with malignant hilar stricture is feasible and seems to provide a better anatomical understanding compared to MRCP and could help improve endoscopic management., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Background and Objectives: Pancreatic cyst fluid level of glucose is a promising marker to identify mucinous from nonmucinous tumors, but the glucose assay has not yet been recommended. The objective of this study is to compare the diagnostic performances of pancreatic cyst fluid level of glucose and carcinoembryonic antigen (CEA)., Methods: In this French multicenter study, data of consecutive patients who underwent fine-needle aspiration of pancreatic cyst with intracyst glucose assay between 2018 and 2022 were retrospectively reviewed. The area under the receiver operating characteristic curve (AUROC) of glucose and corresponding sensitivity (Se), specificity (Sp), accuracy (Acc), positive predictive value (PPV), and negative predictive value (NPV) were calculated and compared with those of CEA. The best threshold of glucose was identified using the Youden index., Results: Of the 121 patients identified, 81 had a definitive diagnosis (46 mucinous, 35 nonmucinous tumors) and were included for analysis. An intracystic glucose level <41.8 mg/dL allowed identification of mucinous tumors with better diagnostic performances (AUROC, 93.6%; 95% confidence interval, 87.2%-100%; Se, 95.3%; Sp, 91.2%; Acc, 93.5%; PPV, 93.2%; NPV, 93.9%) compared with CEA level >192 ng/mL (AUROC, 81.2%; 95% confidence interval, 71.3%-91.1%; Se, 41.7%; Sp, 96.9%; Acc, 67.6%; PPV, 93.8%; NPV, 59.6%) ( P = 0.035). Combining values of glucose and CEA did not offer additional benefit in terms of diagnosis., Conclusion: Our results confirm previously published data and support the use of pancreatic cyst fluid glucose for the identification of mucinous tumors when the definitive diagnosis remains uncertain., Competing Interests: The authors declare that they have no financial conflict of interest with regard to the content of this report., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc on behalf of Scholar Media Publishing.)

Background: PRSS1 and PRSS2 constitute the only functional copies of a tandemly-arranged five-trypsinogen-gene cluster (i.e., PRSS1, PRSS3P1, PRSS3P2, TRY7 and PRSS2) on chromosome 7q35. Variants in PRSS1 and PRSS2, including missense and copy number variants (CNVs), have been reported to predispose to or protect against chronic pancreatitis (CP). We wondered whether a common trypsinogen pseudogene deletion CNV (that removes two of the three trypsinogen pseudogenes, PRSS3P2 and TRY7) might be associated with CP causation/predisposition., Methods: We analyzed the common PRSS3P2 and TRY7 deletion CNV in a total of 1536 CP patients and 3506 controls from France, Germany, India and Japan by means of quantitative fluorescent multiplex polymerase chain reaction., Results: We demonstrated that the deletion CNV variant was associated with a protective effect against CP in the French, German and Japanese cohorts whilst a trend toward the same association was noted in the Indian cohort. Meta-analysis under a dominant model yielded a pooled odds ratio (OR) of 0.68 (95% confidence interval (CI) 0.52-0.89; p = 0.005) whereas an allele-based meta-analysis yielded a pooled OR of 0.84 (95% CI 0.77-0.92; p = 0.0001). This protective effect is explicable by reference to the recent finding that the still functional PRSS3P2/TRY7 pseudogene enhancers upregulate pancreatic PRSS2 expression., Conclusions: The common PRSS3P2 and TRY7 deletion CNV was associated with a reduced risk for CP. This finding provides additional support for the emerging view that dysregulated PRSS2 expression represents a discrete mechanism underlying CP predisposition or protection., Competing Interests: Declaration of competing interest The authors are unaware of any conflict of interest., (Copyright © 2022 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background: Endoscopic internal drainage (EID) with double-pigtail stents or low negative-pressure endoscopic vacuum therapy (EVT) are treatment options for leakage after upper gastrointestinal oncologic surgery. We aimed to compare the effectiveness of these techniques., Methods: Between 2016 and 2019, patients treated with EID in five centers in France and with EVT in Göttingen, Germany were included and retrospectively analyzed using univariate analysis. Pigtail stents were changed every 4 weeks; EVT was repeated every 3-4 days until leak closure., Results: 35 EID and 27 EVT patients were included, with a median (interquartile range [IQR]) leak size of 0.75 cm (0.5-1.5). Overall treatment success was 100 % (95 % confidence interval [CI] 90 %-100 %) for EID vs. 85.2 % (95 %CI 66.3 %-95.8 %) for EVT ( P  = 0.03). The median (IQR) number of endoscopic procedures was 2 (2-3) vs. 3 (2-6.5; P  = 0.003) and the median (IQR) treatment duration was 42 days (28-60) vs. 17 days (7.5-28; P  < 0.001), for EID vs. EVT, respectively., Conclusion: EID and EVT provide high closure rates for upper gastrointestinal anastomotic leaks. EVT provides a shorter treatment duration, at the cost of a higher number of procedures., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background and Study Aims: In the recent years, topical hemostatic powders have been used for the management of upper gastrointestinal bleeding. The aim of this study was to report on the use of an hemostatic powder (Hemospray®), outside regular hours, by on-call endoscopists during urgent endoscopic procedures., Material and Methods: In this retrospective multicenter cohort study, consecutive patients having undergone an urgent endoscopy with the use of Hemospray® from November 2015 to December 2018 in the Paris and suburbs area were included. We collected clinical, biological and endoscopic variables. The outcomes such as the recurrence, repeat endoscopy and hemostatic treatment need, complications and survival were also collected., Results: A total of 152 patients (mean 65 years old, 70.4% male) were included. Amongst the 31 endoscopists, 11 were "more experienced", and performed 48% of the endoscopies. The most common causes of bleeding were peptic ulcer (47.7%), malignancy (22.2%) and esophagitis (12.4%). Most bleedings originated from the upper GI tract (95.0%). Hemospray® was used as a salvage therapy in 60.8% of cases. Other hemostatic techniques were used in 52.9% of cases. Immediate bleeding cessation was noted in 79.0% of cases, recurrence in 39.9% of cases, and 26.4% of patients benefited from a repeat endoscopic hemostasis. 34 (23.0%) patients required a non-endoscopic treatment. At day 30, the survival rate was 71.6%. One complication was reported (perforation)., Conclusions: Hemostatic powder application by on-call endoscopists outside regular hours is technically feasible, but comes with a high risk of rebleeding in severely ill patients., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: Most anastomotic leaks after surgical resection for esophageal or esophagogastric junction malignancies are treated endoscopically with esophageal stents. Internal drainage by double pigtail stents has been used for the endoscopic management of leaks following bariatric surgery, and recently introduced for anastomotic leaks after resections for malignancies. Our aim was to assess the overall efficacy of the endoscopic treatment for anastomotic leaks after esophageal or gastric resection for malignancies., Methods: We conducted a multicenter retrospective study in four digestive endoscopy tertiary referral centers in France. We included consecutive patients managed endoscopically for anastomotic leak following esophagectomy or gastrectomy for malignancies between January 2016 and December 2018. The primary outcome was the efficacy of the endoscopic management on leak closure., Results: Sixty-eight patients were included, among which 46 men and 22 women, with a mean ± SD age of 61 ± 11 years. Forty-four percent had an Ivor Lewis procedure, 16% a tri-incisional esophagectomy, and 40% a total gastrectomy. The median time between surgery and the diagnosis of leak was 9 (6-13) days. Endoscopic treatment was successful in 90% of the patients. The efficacy of internal drainage and esophageal stents was 95% and 77%, respectively ( p  = 0.06). The mortality rate was 3%. The only predictive factor of successful endoscopic treatment was the initial use of internal drainage ( p  = 0.002)., Conclusion: Endoscopic management of early postoperative leak is successful in 90% of patients, preventing highly morbid surgical revisions. Internal endoscopic drainage should be considered as the first-line endoscopic treatment of anastomotic fistulas whenever technically feasible., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest., (© The Author(s), 2021.)

Competing Interests: Marine Camus is a consultant for Boston Scientific and Cook Medical. Ulriikka Chaput is a consultant for Boston Scientific. The remaining authors declare that they have no conflict of interest.

Background and Aims: EUS-guided biliary drainage is indicated in cases of impossibility or failure of classic biliary drainage by ERCP. Recently we reported good efficiency of EUS-guided choledochoduodenostomy (EUS-CDS) using the electrocautery-enhanced lumen-apposing metal stent (ECE-LAMS) in a retrospective multicenter study. Use of the recommended technique (direct puncture with the ECE-LAMS with use of a pure cut current and a 6-mm stent) was the only predictive factor of clinical success. We re-evaluated this procedure after 1 year in the same centers., Methods: This was a French retrospective multicenter study of a prospective database including all cases of EUS-guided CDS with ECE-LAMS in the 7 centers that participated in the first study., Results: Seventy consecutive patients were included in this study between September 1, 2017, and September 22, 2018. Failure of primary ERCP was due to duodenal stenosis in 44% of cases and to tumoral infiltration of the papilla in 22% of cases. The mean duration of the procedure was 5 ± 3 minutes. The recommended technique was used in 98.5% of cases. The technical and clinical success rates were both 97.1% (69/70). Short-term adverse events (periprocedural and intrahospital) occurred in 1.6%., Conclusions: EUS-CDS with the ECE-LAMS is efficacious and safe in distal malignant obstruction of the common bile duct in cases of ERCP failure with impressive results once expertise is acquired and the recommended technique (direct fistulotomy, pure cut current, and 6-mm stent) is followed., (Copyright © 2020 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Objectives: The results of only a few endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic solid pseudopapillary neoplasm (SPN) have been published, and the safety of the procedure has never been investigated. Our study compared the recurrence rate in patients with and without preoperative EUS-FNA., Methods: This European multicenter registry-based study was conducted in 22 digestive units, and retrospectively included all patients who underwent complete resection of a pancreatic SPN from 2000 to 2018. Patients with and without initial EUS-FNA were compared, and postsurgery recurrence and the associated risk factors were evaluated., Results: A complete resection of a pancreatic SPN was performed in 149 patients (133 women, 89%), with a mean age of 34 (standard deviation, 14) years. There were no significant differences between the with (78 patients) and without (71 patients) EUS-FNA groups, except for age and tumor size and location.Preoperative EUS-FNA allowed pancreatic SPN diagnosis in 63/78 cases (81%). After a mean follow-up of 43 (standard deviation, 36) months, recurrence was noted in 4 patients (2.7%). Preoperative EUS-FNA was not correlated with recurrence, but an older age (P = 0.005) was significant., Conclusions: Preoperative EUS-FNA does not affect pancreatic SPN recurrence. In this series, old age was significantly correlated with recurrence.

Competing Interests: Drs. Camus and Chaput are consultants for Boston Scientific.

Competing Interests: None

Background: The aim of this study was to identify predictive criteria of improvement after endoscopic treatment (ET) for severe strictures of extrahepatic bile ducts in patients with primary sclerosing cholangitis (PSC)., Methods: PSC patients who had at least one ET for severe stricture were included. Features of magnetic resonance cholangiography (MRC), performed before ET, were evaluated according to a standard model of interpretation, and a radiologic qualitative score of probability of improvement after ET was built. Score 3 (likely) was given in case of severe common bile duct (CBD) stricture with marked dilatation without severe strictures of upstream ducts, Score 1 (unlikely) was given in case of severe multiple strictures of secondary ducts without biliary dilatation and Score 2 (undeterminate) was given to an intermediate pattern. The response to ET was assessed at 2 months (T2-response) from the last ET and at 12 months (T12-response) from inclusion., Results: Thirty-one patients were included. All had severe stricture (reduction ≥ 75% of the diameter) of CBD and 50% had severe stricture of right and/or left hepatic duct (LHD) at MRC before ET. According to the qualitative score, 16 patients had Score 3, 7 had Score 1 and 9 had Score 2. T12-response was obtained in 50% of patients. In univariate analysis, short LHD strictures, bilirubin, transaminases, pruritus and Score 3 were associated with T12-response. Increased bilirubin and transaminases were independent predictive factors of T12-response (HR 24, 95% CI: 3.4-170.4, P = 0.001 and 23.8, 95% CI: 3.4-169.4, P = 0.002, respectively)., Conclusion: MRC, together with biochemical features, may contribute to identify the PSC patients who are likely to be improved after ET for severe strictures of extrahepatic bile ducts., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Background: Infected pancreatic necrosis, which occurs in about 40% of patients admitted for acute necrotizing pancreatitis, requires combined antibiotic therapy and local drainage. Since 2010, drainage by open surgical necrosectomy has been increasingly replaced by less invasive methods such as percutaneous radiological drainage, endoscopic necrosectomy, and laparoscopic surgery, which proved effective in small randomized controlled trials in highly selected patients. Few studies have evaluated minimally invasive drainage methods used under the conditions of everyday hospital practice. The aim of this study was to determine whether, compared with conventional open surgery, minimally invasive drainage was associated with improved outcomes of critically ill patients with infection complicating acute necrotizing pancreatitis., Methods: A single-center observational study was conducted in patients admitted to the intensive care unit for severe acute necrotizing pancreatitis to compare the characteristics, drainage techniques, and outcomes of the 62 patients managed between September 2006 and December 2010, chiefly with conventional open surgery, and of the 81 patients managed between January 2011 and August 2015 after the introduction of a minimally invasive drainage protocol., Results: Surgical necrosectomy was more common in the early period (74% versus 41%; P <0.001), and use of minimally invasive drainage increased between the early and late periods (19% and 52%, respectively; P <0.001). The numbers of ventilator-free days and catecholamine-free days by day 30 were higher during the later period. The proportions of patients discharged from intensive care within the first 30 days and from the hospital within the first 90 days were higher during the second period. Hospital mortality was not significantly different between the early and late periods (19% and 22%, respectively)., Conclusion: In our study, the implementation of a minimally invasive drainage protocol in patients with infected pancreatic necrosis was associated with shorter times spent with organ dysfunction, in the intensive care unit, and in the hospital. Mortality was not significantly different. These results should be interpreted bearing in mind the limitations inherent in the before-after study design.

Background and Study Aims: Colon capsule endoscopy (CCE) does not possess an objective and reliable scoring system to assess the quality of visualization of the colon mucosa. The aim of this study was to establish a colonic computed assessment of cleansing (CAC) score able to discriminate "adequately cleansed" from "inadequately cleansed" CCE still frames., Patients and Methods: Twelve normal and complete CCEs, using the Pillcam Colon 2 system (Medtronic, Minnesota, United States), were prospectively selected amongst a database. A CAC score, defined as the ratio of color intensities red over green (R/G ratio), and red over brown (R/(R + G) ratio) was calculated for each extracted colonic frame. After sorting and random selection, two sets of still frames representative of the range of these ratios were obtained. These images were analyzed twice in random order by two experienced CCE readers who were blinded to the CAC scores. A receiver operating characteristic (ROC) curve was forged for both types of ratios and a threshold established, yielding the highest diagnostic performance in terms of adequate cleansing assessment., Results: Four-hundred-and-eight frames were extracted. Regarding the R/G ratio, a threshold value of 1.55 was calculated, with a sensitivity of 86.5 % and a specificity of 77.7 %. Regarding the R/(R + G) ratio, a threshold value of 0.58 was calculated with a sensitivity of 95.5 % and a specificity of 62.9 %., Conclusion:  The two proposed CAC scores based on the ratio of color intensities come with high sensitivities for discriminating between "adequately cleansed" and "inadequately cleansed" CCE still frames, but they lack specificity. Further refinement, with implementation of additional image parameters, is warranted.

Background and Study Aims:  An objective and reliable scoring system is needed to assess quality of visualization in small bowel (SB) capsule endoscopy (CE), for both clinical practice and research purposes. The aim of this study was to establish and to validate a SB-computed assessment of cleansing (SB-CAC) score., Patients and Methods:  Thirty-three SB-CE were selected. A CAC score, defined as the ratio of the red over green pixels (R/G ratio), was calculated for each frame. Intervals were then determined, ranging from the lowest to the highest ratio among the extracted frames. Twelve frames were randomly selected in each of these intervals. Two hundred eighty-eight frames were shuffled and analyzed twice in random order by two experienced CE readers who were blinded to the CAC scores. Once an "adequately cleansed" or "inadequately cleansed" qualification was allotted to every still frame, a receiver operating characteristic (ROC) curve was created. In case of discrepancy between the two readers, the still frames were excluded. A second dataset of 288 different SB still frames was generated and read twice in random order by two other experienced SB-CE readers, using the same methodology., Results:  A SB-CAC score threshold of 1.6 best achieved discrimination of adequately from inadequately cleansed frames, with a sensitivity of 92.7 % (95 %CI [89.7 - 95.8]) and a specificity of 92.9 % (95 %CI [89.9 - 95.9]). This threshold was validated using the second dataset, yielding the following performances: sensitivity 91.3 % (95 %CI [87.9 - 94.6]), specificity 94.7 % (95 %CI [92.1 - 97.3])., Conclusion:  An SB-CAC score of 1.6 has the highest sensitivity and specificity to discriminate "adequately cleansed" from "inadequately cleansed" SB-CE still frames. This constitutes an objective, reproducible, reliable, and automated cleansing score for SB-CE.

Background and Study Aims: Bubbles can impair visualization of the small bowel (SB) mucosa during capsule endoscopy (CE). We aimed to develop and validate a computed algorithm that would allow evaluation of the abundance of bubbles in SB-CE still frames., Patients and Methods: Two sets of 200 SB-CE normal still frames were created. Two experienced SB-CE readers analyzed both sets of images twice, in a random order. Each still frame was categorized as presenting with < 10 % or ≥ 10 % of bubbles. Reproducibility (κ), sensitivity (Se), specificity (Sp), receiver operating characteristic curve, and calculation time were measured for different algorithms (Grey-level of co-occurrence matrix [GLCM], fractal dimension, Hough transform, and speeded-up robust features [SURF]) using the experts' analysis as reference. Algorithms with highest reproducibility, Se and Sp were then selected for a validation step on the second set of frames. Criteria for validation were κ = 1, Se ≥ 90 %, Sp ≥ 85 %, and a calculation time < 1 second., Results: Both SURF and GLCM algorithms had high operating points (Se and Sp over 90 %) and a perfect reproducibility (κ = 1). The validation step showed the GLCM detector strategy had the best diagnostic performances, with a Se of 95.79 %, a Sp of 95.19 %, and a calculation time of 0.037 seconds per frame., Conclusion: A computed algorithm based on a GLCM detector strategy had high diagnostic performance allowing assessment of the abundance of bubbles in SB-CE still frames. This algorithm could be of interest for clinical use (quality reporting) and for research purposes (objective comparison tool of different preparations).

Background: Targeted temperature management (TTM) between 32 and 36°C is recommended after out-of-hospital cardiac arrest (OHCA). We aimed to assess the feasibility and safety of the "Esophageal Cooling Device" (ECD) in performing TTM., Patients and Methods: This single-centre, prospective, interventional study included 17 comatose OHCA patients. Main exclusion criteria were: delay between OHCA and return of spontaneous circulation (ROSC)>60min, delay between sustained ROSC and inclusion >360min, known oesophageal disease. A TTM between 32 and 34°C was performed using the ECD (Advanced Cooling Therapy, USA) connected to a heat exchanger console (Meditherm III ® , Gaymar, France), without cold fluids' use. Primary endpoint was feasibility of inducing, maintaining TTM, and rewarming using the ECD alone. Secondary endpoints were adverse events, focusing on potential digestive damages. Results were expressed as median (interquartiles 25-75)., Results: Cooling rate to reach the Target Temperature (33°C-TT) was 0.26°C/h [0.19-0.36]. All patients reached the 32-34°C range with a time spent within the range of 26h [21-28] (3 patients did not reach 33°C). Temperature deviation outside the TT during TTM-maintenance was 0.10°C [0.03-0.20]. Time with deviation >1°C was 0h. Rewarming rate was 0.20°C/h [0.18-0.22]. Among the 16 gastrointestinal endoscopy procedures performed, 10 (62.5%) were normal. Minor oeso-gastric injuries (37.5% and 19%, respectively) were similar to usual orogastric tube injuries. One patient experienced severe oesophagitis mimicking peptic lesions, not cooling-related. No patient among the 9 alive at 3-month follow-up had gastrointestinal complains., Conclusion: ECD seems an interesting, safe, accurate, semi-invasive cooling method in OHCA patients treated with 33°C-TTM, particularly during the maintenance phase., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Background and study aims: The hemostatic powder TC-325 (Hemospray; Cook Medical, Winston-Salem, North Carolina, USA) has shown promising results in the treatment of upper gastrointestinal bleeding (UGIB) in expert centers in pilot studies. The aim of this study was to evaluate the feasibility and efficacy of TC-325 in a large prospective registry of use in routine practice. Patients and methods: The data of all patients treated with TC-325 were prospectively collected through a national registry. Outcomes were the immediate feasibility and efficacy of TC-325 application, as well as the rates of rebleeding at Day 8 and Day 30. Multivariate analysis was performed to determine predictive factors of rebleeding. Results: A total of 202 patients were enrolled and 64 endoscopists participated from 20 centers. TC-325 was used as salvage therapy in 108 patients (53.5 %). The etiology of bleeding was an ulcer in 75 patients (37.1 %), tumor in 61 (30.2 %), postendoscopic therapy in 35 (17.3 %), or other in 31 (15.3 %). Application of the hemostatic powder was found to be very easy or easy in 31.7 % and 55.4 %, respectively. The immediate efficacy rate was 96.5 %. Recurrence of UGIB was noted at Day 8 and Day 30 in 26.7 % and 33.5 %, respectively. Predictive factors of recurrence at Day 8 were melena at initial presentation and use of TC-325 as salvage therapy. Conclusion: These multicenter data confirmed the high rate of immediate hemostasis, excellent feasibility, and good safety profile of TC-325, which could become the treatment of choice in bleeding tumors or postendoscopic bleeding but not in bleeding ulcers where randomized studies are needed., Trial Registration: ClinicalTrials.gov (NCT02595853)., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Endoscopic treatment of benign biliary strictures (BBS) can be challenging., Objective: To evaluate the efficacy of fully covered self-expandable metal stents (FCSEMS) in BBS., Methods: Ninety-two consecutive patients with BBS (chronic pancreatitis (n = 42), anastomotic after liver transplantation (n = 36), and post biliary surgical procedure (n = 14)) were included. FCSEMS were placed across strictures for 6 months before endoscopic extraction. Early success rate was defined as the absence of biliary stricture or as a minimal residual anomaly on post-stent removal endoscopic retrograde cholangiopancreatography (ERCP). Secondary outcomes were the final success and stricture recurrence rates as well as procedure-related morbidity., Results: Stenting was successful in all patients. Stenting associated complications were minor and occurred in 22 (23.9%) patients. Migration occurred in 23 (25%) patients. Stent extraction was successful in all but two patients with proximal stent migration. ERCP after the 6 months stenting showed an early success in 84.9% patients (chronic pancreatitis patients: 94.7%, liver transplant: 87.9%, post-surgical: 61.5%) (p = 0.01). Final success was observed in 57/73 (78.1%) patients with a median follow-up of 12 ± 3.56 months. Recurrence of biliary stricture occurred in 16/73 (21.9%) patients., Conclusions: FCSEMS placement is efficient for patients with BBS, in particular for chronic pancreatitis patients. Stent extraction after 6 months indwelling, although generally feasible, may fail in a few cases.

Background: The diagnosis of acute diverticulitis is mainly based on clinical, biological and computed tomography (CT)-scan findings. Elective colonoscopy is recommended after medical treatment, to rule out another diagnosis and to detect associated conditions; however, the relevance of this recommendation has been questioned., Patients and Methods: Between January 2005 and December 2011, we retrospectively identified in three referral centers the consecutive patients whom underwent a colonoscopy after the medical treatment of a CT scan-proven acute diverticulitis episode. We excluded from the analysis patients with haematochezia or recent change in bowel habits. Sex and age-matched asymptomatic patients undergoing a screening colonoscopy were chosen as a control group. We collected and compared the results of colonoscopy and histological findings in both groups., Results: We matched 404 patients whom underwent a colonoscopy after an episode of acute diverticulitis with 404 control patients. Their mean age was 60.9 years, with 59% being women. Colorectal adenoma, advanced adenoma and cancer detection rates in acute diverticulitis patients were 12.1%, 2.7% and 0.25%, respectively; versus 14.6% (p = 0.35), 6.7% (p = 0.01) and 0.25% respectively, in control patients., Conclusions: Diagnosis rates for adenomas and for colorectal cancer during a colonoscopy scheduled after acute diverticulitis were similar than those of control patients undergoing a screening colonoscopy, while the detection rate of advanced adenomas was lower. We suggest that colonoscopy should be indicated only in selected patients, i.e. those presenting with reasonable doubt on initial CT-scan, those with alarm symptoms, and those with identified risk factors for colorectal cancer.

Purpose: To compare the capabilities of apparent diffusion coefficient (ADC) and normalized ADC using the pancreatic parenchyma as reference organ in the characterization of focal pancreatic lesions., Patients and Methods: Thirty-six patients with focal pancreatic lesions (malignant, n=18; benign tumors, n=10; focal pancreatitis, n=8) underwent diffusion-weighted MR imaging (DWI) at 1.5-Tesla using 3 b values (b=0, 400, 800 s/mm(2)). Lesion ADC and normalized lesion ADC (defined as the ratio of lesion ADC to apparently normal adjacent pancreas) were compared between lesion types using nonparametric tests., Results: Significant differences in ADC values were found between malignant (1.150 × 10(-3)mm(2)/s) and benign tumors (2.493 × 10(-3)mm(2)/s) (P=0.004) and between benign tumors and mass-forming pancreatitis (1.160 × 10(-3)mm(2)/s) (P=0.0005) but not between malignant tumors and mass-forming pancreatitis (P=0.1092). Using normalized ADC, significant differences were found between malignant tumors (0.933 × 10(-3)mm(2)/s), benign tumors (1.807 × 10(-3)mm(2)/s) and mass-forming pancreatitis (0.839 × 10(-3)mm(2)/s) (P<0.0001)., Conclusion: Our preliminary results suggest that normalizing ADC of focal pancreatic lesions with ADC of apparently normal adjacent pancreatic parenchyma provides higher degrees of characterization of focal pancreatic lesions than the conventional ADC does., (Copyright © 2013 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

Endoscopy has an ever-increasing role in the treatment of complications in digestive surgery. Endoscopic treatment is essentially used for (i) fistula or intra-abdominal collection secondary to anastomotic dehiscence and (ii) anastomotic stricture, especially esophagogastric, but also sometimes after colorectal surgery. First intention treatment of fistula following esophagogastric surgery is the insertion of an extractable self-expandable metallic stent (partially or entirely covered); this is supported by a low level of scientific evidence, but clinical experience has been satisfactory. Other techniques for treatment of anastomotic leak have also been reported anecdotally (clip placement, sealing with glue). There are few data available in the literature on endoscopic management (stents essentially) of postoperative colonic fistula. Whatever the approach chosen to treat a postoperative digestive tract fistula, management is medico-surgical and cannot be limited to simple closure of the digestive tube wall defect. Drainage of any collections by endoscopic, radiologic or surgical approach, systemic treatment of infection and nutritional support are essential adjuvant treatment modalities. Treatment of postoperative esophageal or colonic strictures is essentially endoscopic and is based on initial dilatation (endoscopic with hydrostatic balloon or bougie), and placement of extractable metallic stents (partially or entirely covered) in case of refractory outcome., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background: Some esophageal strictures resist endoscopic treatments. There is a need for new treatments, such as specifically designed stents., Objective: Our study sought to compare the results achieved with a standard, fully covered metallic stent (FCMS) and those achieved using a stent designed specifically for benign strictures (BS-FCMS)., Patients and Methods: The study used a prospective, multicenter, controlled design, with patients recruited from tertiary referral centers. Patients with refractory esophageal strictures were included. Standard FCMS were used in group 1 (N = 24), and BS-FCMS were used in group 2 (N = 17). Patients were followed for 24 months after stent removal. The main outcomes measured were stricture resolution rate, 24 months' recurrence rate and stent-related morbidity., Results: Early stent migrations occurred in one (4.1%) patient from group 1 and five (29.4%) from group 2 (p < 0.05). During esophageal stenting, complications occurred in six patients (25%) in group 1 and six patients (35.3%) in group 2 (p = 0.47), respectively. Fifty percent of complications were attributed to migration. There was no procedure-related morbidity associated with the extraction of the stent. The stricture resolution rate was, respectively, 95.2% in group 1 and 87.5% in group 2 (the difference between the two groups is not significant). During follow-up, stricture recurrence occurred in 15/19 patients (group 1, 79%) and 7/8 patients (group 2, 87.5%; p = 1.0). The median time to recurrence of esophageal stricture was 1.7 months (group 1, 0.6-12 months) and 1 month (group 2, 0.1-6 months). Study limitations include its nonrandomized design., Conclusion: The stricture resolution rate was high at the end of the stenting period for both types of stents without any statistical difference between the two groups, but the long-term results were disappointing, with stricture recurring frequently and rapidly in both groups.

Background & Aims: Capsule enteroscopy (CE) is the best noninvasive tool to explore the entire small bowel of patients with obscure gastrointestinal bleeding (OGIB); it has a diagnostic yield of 40%-80%. However, little is known about the factors associated with a diagnosis of OGIB by CE., Methods: We analyzed data from 911 consecutive patients who underwent CE for OGIB from January 2004 to January 2010. Results from upper and lower gastrointestinal endoscopy examinations were negative in all patients. CE findings were recorded. Features of patients that were associated with diagnosis of OGIB by CE were identified by using logistic regression., Results: Based on CE, 509 patients (56%) had a confirmed lesion responsible for the OGIB: 203 had disease of the small bowel (22%), 88 had ulcerations (10%), 70 had tumors (8%), 24 had varices (2%), 6 had diverticula (0.5%), and 118 had what appeared to be bleeding lesions of the esophagus or stomach (10.6%) or colon (2%). Factors independently associated with a diagnosis of OGIB by CE were age >60 years (odds ratio [OR], 1.2), male sex, history of overt bleeding (OR, 3.8), and current hospitalization (OR, 1.4). Women were less likely to be diagnosed with OGIB by CE (OR, 0.7)., Conclusions: A history of overt bleeding is the factor most strongly associated with a diagnosis of OGIB by CE. Male sex, age >60 years, and inpatient status were also independent predictors of positive diagnosis by CE., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Although the efficacy of gastric electrical stimulation has been reported in short-term studies, there is a lack of data on the long-term improvement of nausea and vomiting by gastric electrical stimulation in patients with delayed or normal gastric emptying., Methods: Thirty-one patients were implanted at our centre for medically refractory severe and chronic nausea and/or vomiting. Patients were evaluated at baseline, 6 months then 5 years after implantation (mean follow-up 80±4 months) using a symptomatic and quality of life scores., Key Results: Amongst the 31 patients, 4 were lost to follow-up, 6 explanted due to lack of improvement, and 1 patient died. Out of the 20 patients evaluated over 5 years, the quality of life score showed 27% improvement (p<0.01), including nausea (62%; p<0.01), vomiting (111%; p=0.03), satiety (158%; p<0.01), bloating (67%; p<0.01) and epigastric pain (43%; p=0.03). Over 5 years, 15/20 patients reported a 50% improvement with a global satisfaction rated at 64±6%. Therefore, 15/27 patients (56%) were improved by gastric electrical stimulation over 5 years in intention to treat. Improvement of nausea 6 months after implantation was predictive of 5-year success of gastric electrical stimulation (p=0.04). Finally, patients with delayed gastric emptying or with normal gastric emptying rate before surgery were similarly improved over 5 years (60% versus 50% respectively)., Conclusion: Gastric electrical stimulation is safe and effective in the long term in patients with medically refractory nausea and vomiting, with an efficacy over 50% beyond 5 years in intention to treat. Gastric emptying measured before implantation did not influence the response rate over 5 years., (Copyright © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: The management of colorectal polyps <10mm in diameter is controversial. Our aim was to evaluate the rate and risk factors for advanced adenomas and high grade neoplasia amongst small (6-9 mm) and diminutive (1-5mm) colorectal polyps., Methods: Endoscopic and pathological reports of colonoscopies performed in our centre were collected prospectively. Advanced adenoma was defined by presence of a villous component and/or high grade dysplasia; high grade neoplasia by presence of high grade dysplasia and/or intramucosal carcinoma., Results: 1468 patients were included (53.1% male, mean age 59.5±14 years); 414 polyps <10mm were detected, 9.9% advanced adenomas and 1.7% high grade neoplasia. Amongst small polyps, 25 (35.2%) were advanced adenomas, mainly due to villous features, and 3 (4.2%) were high grade neoplasia. Polyp size was associated with advanced adenomas (odds ratio=8.47)., Conclusion: The rate of advanced adenomas amongst small polyps was 35%, mainly due to the presence of villous features. Polyp size was identified as a risk factor of advanced adenoma amongst polyps <10mm. Given these results, we believe that polypectomy should be warranted for patients presenting with small polyps at computed tomography colonography., (Copyright © 2011 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Video capsule endoscopy is the first-intention examination in patients with obscure GI bleeding. The new MiroCam capsule, when using electric-field propagation for transmission, has been poorly evaluated in a clinical setting, in contrast with the PillCam SB2 capsule., Objective: To evaluate the diagnostic concordance (κ value) between PillCam SB2 and MiroCam capsule examinations performed in the same patients., Design and Setting: Prospective, randomized study in 7 endoscopy units., Patients and Intervention: Eighty-three consecutive patients, ingesting the 2 capsules at a 1-hour interval., Results: Seventy-three patients were analyzed (10 technical issues). There were 31 concordant negative cases (42.4%) and 30 concordant positive cases (41.1%). The study showed satisfactory diagnostic concordance between the 2 systems (κ = 0.66). In 12 patients (16.4%), the final diagnosis was different: 9 patients had positive findings on MiroCam examination but no image detected with PillCam SB2, 2 had positive findings on PillCam examination only, and 1 patient had 2 different diagnoses. A positive diagnosis was obtained in 46.6% and 56.2% of patients with PillCam SB2 and MiroCam capsule, respectively, so that the procedures identified 78.6% and 95.2% of positive cases, respectively (P = .02). Small-bowel transit time and capsule reading time were significantly longer in MiroCam procedures., Limitations: Technical failures possibly related to capsule interference., Conclusion: This study shows at least comparable efficiency of the MiroCam compared with the PillCam SB2 capsule system for the diagnosis of obscure GI bleeding., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Apart from acute infections, microorganisms may also induce or perpetuate chronic inflammatory diseases and reversible or irreversible proliferation of various cells in the gastrointestinal tract (the extreme being adenocarcinoma and lymphoma). Helicobacter pylori is not only involved in the pathogenesis of lymphoma and gastric adenocarcinoma. The steps and mechanisms of the carcinogenic process involve host predisposition, environmental factors, and strain virulence. The steps of lymphoma genesis include chronic inflammation, acquisition of mucosa-associated lymphoid tissue in the stomach, proliferation of the B lymphocytes in an inflammatory context, acquisition of genetic anomalies and dysregulation of the NF-κB pathway. The role of Campylobacter jejuni in immunoproliferative small bowel disease has also been shown and eradication of this bacterium can cure the lymphoma at its early stage. The evidence for the role of some bacteria in colon cancer development is discussed. Opportunistic pathogens are detected in the stools or mucosa of a proportion of subjects with Crohn's disease. They include Mycobacterium avium paratuberculosis, adherent invasive Escherichia coli, and Clostridium difficile. A dysbiosis has been repeatedly observed in patients with inflammatory bowel disease. Instability of the dominant microbiota and decreased biodiversity (especially in the firmicutes phylum) are major characteristics. The decrease of Faecalibacterium prausnitzii seems to have a prognostic value to predict relapse of Crohn's disease after surgery. Finally, important perspectives are opened by new tools such as metagenomics and metabolomics of the gastrointestinal ecosystems. Major tracks concern irritable bowel syndrome, colon cancer and obesity., (Copyright © 2011 S. Karger AG, Basel.)

Background: Management of anastomotic biliary strictures after liver transplantation deserves optimization., Objective: To evaluate placement and removal of partially covered self-expandable metal stents (PCSEMSs) in this setting., Design: Prospective, multicenter, uncontrolled study., Setting: Three French academic hospitals with liver transplantation units and tertiary referral endoscopy centers., Patients: Twenty-two patients (18 men, 4 women, aged 49.7 ± 12 years) with anastomotic biliary stricture. Seventeen (77.3%) presented stricture recurrence after plastic stenting., Interventions: PCSEMSs were placed across the stricture for 2 months and then removed. Patients were followed by clinical examination and liver function tests 1, 3, 6, 9, and 12 months after PCSEMS removal., Main Outcome Measurement: The ability to remove PCSEMS., Results: PCSEMS placement was successful in all patients, after sphincterotomy in 21 patients. Stent-related complications included minor pancreatitis (3 patients), transient pain (1 patient), and cholangitis (1 patient). Stent removal was achieved in all patients but 2 whose stents had migrated distally. Partial stent dislocation was noted in 5 patients (upward in 4, downward in 1). Complications associated with stent removal were minor, including self-contained hemorrhage (1 patient) and fever (1 patient). The stricture persisted at the end of treatment in 3 patients (13.6%), all of whom had stent migration or dislocation. Recurrence of anastomotic stricture after initial success occurred in 9 of 19 patients (47.4%) within 3.5 ± 2.1 months. Sustained stricture resolution was observed in 10 of 19 patients (52.6%), 45.6% from an intent-to-treat perspective., Limitations: Uncontrolled study with limited follow-up., Conclusions: Temporary placement and removal of PCSEMSs in anastomotic biliary strictures after liver transplantation is feasible, although sometimes demanding. Stent migration may impair final outcome., (Copyright © 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Objectives: In 2004, the French health authorities published guidelines on the indications for colonoscopy. However, no study has evaluated the awareness of healthcare practitioners of these guidelines. The aim of this study was to determine the level of awareness of the ANAES guidelines among French gastroenterologists., Patients and Methods: A questionnaire comprising 20 multiple choice questions (MCQ) was presented to a group of 79 gastroenterologists between February and June in 2008. The questions covered screening tests for colon cancer (one question), endoscopic mucosal resection (two questions) and the ANAES guidelines (17 questions). According to the number of colonoscopies performed per year (less than 100, 100-500, more than 500), the answers to these questions were analyzed separately., Results: Among the practitioners carrying out less than 100, 100-500 and more than 500 colonoscopies per year, the guidelines for colon cancer screening were known by 33, 50 and 56%, respectively, the quality criteria for endoscopic mucosal resection by 0, 0 and 3.7%, respectively, and the ANAES guideline indications for colonoscopy by 34.3, 51.2 and 48.9%, respectively (P<0.001). The ANAES guidelines were significantly better known by practitioners who were performing more than 100 colonoscopies per year, while the indications for control colonoscopy were less often correctly anticipated. No differences were found concerning postponed indications., Conclusion: The ANAES guidelines consists of the following elements: (1) awareness of the ANAES guidelines is poor, with control colonoscopy being correctly anticipated in just over a third of the gastroenterologists; (2) performing more than 100 colonoscopies per year improves knowledge of the ANAES guidelines; and (3) the ANAES guidelines need to be simplified and should be covered by continuing medical education., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Conventional optical colonoscopy is the reference examination for exploration of the colon. Its morbidity and its poor acceptability have led to the development of alternative techniques. Considerable work has gone into colon imaging, in particular computed tomography (colo-TC). According to the meta-analysis by Mulhall et al, its sensitivity is 85% and its specificity 97% for the detection of polyps>9 mm. A colo-TC is the alternative examination with the best recognized performance. Among the examinations described below, it is the only examination that can be proposed in the case of the failure of or contraindication to optical colonoscopy. Because of the irradiating nature of this technique, magnetic resonance imaging would be preferable if feasible. This technique has appeared more recently, and work on the topic is less abundant. Capsule endoscopy (the Pill-cam) for the small intestine has been adapted to study of the colon. Results of colon capsule endoscopy studies are promising. A European multicenter study of 320 patients found a sensitivity of 64%, specificity of 84%, positive predictive value (PPV) of 60% and negative predictive value (NPV) of 86% for the detection of polyps>6mm. No severe complication was observed. Finally, improvements have been sought for standard colonoscopy: the Aer-O-Scope, Invendoscope, CathCam colonoscopy - all of these alternative colonoscopies are only in their infancy. The characteristics of these methods for exploring the colon vary substantially between techniques, and their respective roles and indications remain to be defined., ((c) 2009 Elsevier Masson SAS. All rights reserved.)

Background: Gastric electrical stimulation (GES) represents a new therapy in patients with intractable vomiting and nausea. We aimed to determine preoperative factors associated with positive response during GES. Thirty-three consecutive patients received implants for medically refractory nausea or vomiting or both., Study Design: Symptoms, Quality of Life (QOL), and gastric emptying (GE) were monitored before and 6 months after implantation. Compared with baseline, dyspeptic symptoms including nausea and vomiting, and QOL all improved at 6 months, yielding a significant weight gain while the GE rate remained unchanged. Twenty-four patients reported improvement; nine remained unimproved at 6 months., Results: In multivariate analysis, baseline QOL and appetite alterations were predictive of improvement; previous history of gastric surgery was associated with failure. Surprisingly, patients with initial delayed GE (21 of 33) displayed similar improvement compared with patients with normal GE. Likewise, basal GE was not found to be predictive of positive outcomes, QOL, or symptoms improvement., Conclusions: Patients with severe symptoms and altered QOL at inclusion particularly benefit from GES; delay in GE is not predictive of positive outcomes. This suggests that indication for GES should be based on clinical settings rather than initial GE, and then possibly extended to patients with normal GE.