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Background: Stent misdeployment (SMD) is a feared technical challenge of EUS-guided choledochoduodenostomy using a lumen apposing stent (EUS-CDS) that has been poorly characterized. We aim to ascertain the rate of SMD in EUS-CDS for malignant distal biliary obstruction (MDBO) and describe its outcomes while identifying variables associated with its occurrence. In addition, we aim to propose a de novo SMD classification., Method: A post hoc analysis of two RCTs comparing EUS-CDS vs. endoscopic retrograde cholangiopancreatography in MDBO. The main endpoint was the rate of SMD classified as misdeployment of the distal flange (type I), proximal flange (type II), contralateral bile duct wall injury (type III), or double mucosal puncture (type IV). A multivariable analysis was performed to identify variables associated with the odds of SMD and/or technical failure and clinical failure or stent dysfunction., Results: 152 patients were included with a technical success of 93.4%. SMDs occurred in 11 (7.2%) patients (95% CI, 3.1%-11.4%): 8 type I, 1 type II, and 2 type III. Endoscopic salvage was successful in 81.8%. SMDs led to an adverse event (AE) in 4 cases (2 mild and 2 moderate) with an overall AE rate of 2.6% (95% CI, 0.7%-6.6%). On multivariable analysis, an extrahepatic bile duct diameter of ≤ 15 mm was associated with increase odds of SMD and/or technical failure., Conclusion: SMD is relatively common in EUS-CDS and is associated with an extra-hepatic bile duct diameter measuring ≤ 15 mm. The majority of SMDs can be rescued endoscopically with low risk for AE., Competing Interests: Yen-I Chen is a consultant for Boston Scientific, has received research funding from Boston Scientific and is the co-founder of Chess Medical Inc. Anand Sahai is a consultant Boston Scientific and Pentax. Bertrand Napoleon has received honorarium for proctoring endoscopy training from Maunea Kea, Boston Scientific, Olympus, and Taewoong Medical. Rastislav Kunda is a consultant for Boston Scientific, Olympus, M.I.Tech, Omega Medical Imaging, Q3 Medical-AMG International and EndoGastricSolutions. Nauzer Forbes is a consultant and speaker for Boston Scientific and Pentax Medical, a speaker for AstraZeneca, and has received research funding from Pentax Medical. Anthony Yuen Bun Teoh is a consultant for Boston Scientific, Cook, Taewoong, Microtech, and MI Tech Medical Corporations. All other authors have no relevant conflict of interest., (Thieme. All rights reserved.)

Background:  Post-endoscopic retrograde cholangiopancreatography (ERCP) adverse events (AEs) are common, as is unplanned healthcare utilization (UHU). We aimed to assess potential etiologic associations between intra-/post-procedural patient-reported experience measures (PREMs) and post-ERCP AEs and UHU. METHODS : Prospective data from a multicenter collaborative were used. A 0-10 Likert-based PREM assessing intra- and post-procedural symptoms was applied to patients following ERCP, and follow-up was performed at 30 days to identify AEs and UHU for reasons not meeting the definitions of any AE. Multivariable logistic regression was conducted using PREM domains as exposures and AEs and UHU as outcomes, with a priori selected covariates. Odds ratios (ORs) and 95 %CIs for each PREM domain were reported., Results:  From 2018 to 2023, 3434 patients were included. A post-procedural abdominal pain score > 3 was associated with pancreatitis (OR 3.71 [95 %CI 2.37-5.73]), while a score > 6 was associated with perforation (OR 9.54 [95 %CI 1.10-59.37]). Post-procedural pain was also associated with UHU within 30 days when used as a continuous exposure (OR 1.08 per point [95 %CI 1.01-1.16]), and when partitioned at a score > 3 (OR 1.79 [95 %CI 1.13-2.74]) and a score > 6 (OR 1.93 [95 %CI 1.02-3.46]). No other intra- or post-procedural PREMs were associated with any AEs or UHU., Conclusions:  Patient-reported abdominal pain from a Likert-based PREM at the time of discharge from ERCP was associated with pancreatitis, perforation, and UHU within 30 days. Applying PREMs could potentially prevent UHU and/or facilitate earlier management and improved outcomes for patients with post-ERCP AEs., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Introduction: Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding (CSPEB) is common. Contemporary estimates of risk are lacking. We aimed to identify risk factors of and outcomes after CSPEB., Methods: We analyzed multicenter prospective ERCP data between 2018 and 2024 with 30-day follow-up. The primary outcome was CSPEB, defined as hematemesis, melena, or hematochezia resulting in (i) hemoglobin drop ≥ 20 g/L or transfusion and/or (ii) endoscopy to evaluate suspected bleeding and/or (iii) unplanned healthcare visitation and/or prolongation of existing admission. Firth logistic regression was used. P values <0.05 were significant, with odds ratios (ORs) and 95% confidence intervals reported., Results: CSPEB occurred after 129 (1.5%) of 8,517 ERCPs (mean onset 3.2 days), with 110 of 4,849 events (2.3%) occurring after higher risk interventions (sphincterotomy, sphincteroplasty, precut sphincterotomy, and/or needle-knife access). Patients with CSPEB required endoscopy and transfusion in 86.0% and 53.5% of cases, respectively, with 3 cases (2.3%) being fatal. P2Y 12 inhibitors were held for a median of 4 days (interquartile range 4) before higher risk ERCP. After higher risk interventions, P2Y 12 inhibitors (OR 3.33, 1.26-7.74), warfarin (OR 8.54, 3.32-19.81), dabigatran (OR 13.40, 2.06-59.96), rivaroxaban (OR 7.42, 3.43-15.24), and apixaban (OR 4.16, 1.99-8.20) were associated with CSPEB. Significant intraprocedural bleeding after sphincterotomy (OR 2.32, 1.06-4.60), but not after sphincteroplasty, was also associated. Concomitant cardiorespiratory events occurred more frequently within 30 days after CSPEB (OR 12.71, 4.75-32.54)., Discussion: Risks of antiplatelet-related CSPEB may be underestimated by endoscopists based on observations of suboptimal holding before higher risk ERCP. Appropriate periprocedural antithrombotic management is essential and could represent novel quality initiative targets., (Copyright © 2024 by The American College of Gastroenterology.)

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the role of endoscopy in the diagnosis and management of pancreatic masses. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses needle selection (fine-needle biopsy [FNB] needle vs FNA needle), needle caliber (22-gauge vs 25-gauge needles), FNB needle type (novel or contemporary [fork-tip and Franseen] vs alternative FNB needle designs), and sample processing (rapid on-site evaluation [ROSE] vs no ROSE). In addition, this guideline addresses stent selection (self-expandable metal stents [SEMS] vs plastic stents), SEMS type (covered [cSEMS] vs uncovered [uSEMS]), and pain management (celiac plexus neurolysis [CPN] vs medical analgesic therapy). In patients with solid pancreatic masses undergoing EUS-guided tissue acquisition (EUS-TA), the ASGE recommends FNB needles over FNA needles. With regard to needle caliber, the ASGE suggests 22-gauge over 25-gauge needles. When an FNB needle is used, the ASGE recommends using either a fork-tip or a Franseen needle over alternative FNB needle designs. After a sample has been obtained, the ASGE suggests against the routine use of ROSE in patients undergoing an initial EUS-TA of a solid pancreatic mass. In patients with distal malignant biliary obstruction undergoing drainage with ERCP, the ASGE suggests using SEMS over plastic stents. In patients with proven malignancy undergoing SEMS placement, the ASGE suggests using cSEMS over uSEMS. If malignancy has not been histopathologically confirmed, the ASGE recommends against the use of uSEMS. Finally, in patients with unresectable pancreatic cancer and abdominal pain, the ASGE suggests the use of CPN as an adjunct for the treatment of abdominal pain. This document outlines the process, analyses, and decision approaches used to reach the final recommendations and represents the official ASGE recommendations on the above topics., Competing Interests: Disclosure The following authors disclosed financial relationships: J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc and Boston Scientific Corporation. S. G. Sheth: Consultant for Janssen Research & Development, LLC. J. M. Chalhoub: Travel compensation from Olympus Corporation of the Americas; food and beverage compensation from Boston Scientific Corporation. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. S. Ngamruengphong: Consultant for Boston Scientific Corporation; food and beverage compensation from Medtronic, Inc, Boston Scientific Corporation, Pentax of America, Inc, and Ambu Inc. G. I. Papachristou: Research support from AbbVie Inc. V. Sahai: Consultant and advisor for AstraZeneca, Autem, Cornerstone, Delcath Systems, GlaxoSmithKline, Helsinn, Histosonics, Ipsen, Incyte, Kinnate, Lynx Group, Servier, and Taiho; research support from Actuate, Agios, Bristol-Myers Squibb, Celgene, Clovis, Cornerstone, Exelixis, Fibrogen, Incyte, Ipsen, Medimmune, NCI, Relay, Repare, Syros, and Beigene; travel compensation from ASCO, Cholangiocarcinoma Foundation, and Lynx Group. W. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and ConMed Corporation; research support from GI Dynamics; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, ConMed Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals. S. K. Amateau: Consultant for Boston Scientific Corporation, Merit Medical, Olympus Corporation of the Americas, MTEndoscopy, US Endoscopy, Heraeus Medical Components, LLC, and Cook Medical LLC; travel compensation from Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Olympus Corporation of the Americas, and Cook Medical LLC; advisory board for Merit Medical. N. Coelho-Prabhu: Consultant for Boston Scientific Corporation and Alexion Pharma; research support from Cook Endoscopy and Fujifilm; food and beverage compensation from Olympus America Inc and Boston Scientific Corporation. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. L. L. Fujii-Lau: Food and beverage compensation from Pfizer Inc and AbbVie Inc. D. R. Kohli: Research grant from Olympus Corporation of the Americas. N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. S. Pawa: Consultant for Boston Scientific Corporation. N. R. Thiruvengadam: Received support from Boston Scientific Corporation. N. C. Thosani: Consultant for Pentax of America, Inc, Boston Scientific Corporation, and Ambu Inc; travel compensation Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Disclosure The following authors disclosed financial relationships: J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies and Boston Scientific Corporation. S. G. Sheth: Consultant for Janssen Research & Development, LLC. J. M. Chalhoub: Travel compensation from Olympus Corporation of the Americas; food and beverage compensation from Boston Scientific Corporation. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. S. Ngamruengphong: Consultant for Boston Scientific Corporation; food and beverage compensation from Medtronic, Inc, Boston Scientific Corporation, Pentax of America, Inc, and Ambu Inc. G. I. Papachristou: Research support from AbbVie Inc. V. Sahai: Consultant and advisor for AstraZeneca, Autem, Cornerstone, Delcath Systems, GlaxoSmithKline, Helsinn, Histosonics, Ipsen, Incyte, Kinnate, Lynx Group, Servier, and Taiho; research support from Actuate, Agios, Bristol-Myers Squibb, Celgene, Clovis, Cornerstone, Exelixis, Fibrogen, Incyte, Ipsen, Medimmune, NCI, Relay, Repare, Syros, and Beigene; travel compensation from ASCO, Cholangiocarcinoma Foundation, and Lynx Group. W. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and ConMed Corporation; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, ConMed Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals; research support from GI Dynamics. S. K. Amateau: Consultant for Boston Scientific Corporation, Merit Medical, MTEndoscopy, US Endoscopy, Heraeus Medical Components, LLC, and Cook Medical LLC; travel compensation from Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Cook Medical LLC, and Olympus Corporation of the Americas; advisory board for Merit Medical. N. Coelho-Prabhu: Consultant for Boston Scientific Corporation and Alexion Pharma; research support from Cook Endoscopy and Fujifilm; food and beverage compensation from Olympus America Inc and Boston Scientific Corporation. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. L. L. Fujii-Lau: Food and beverage compensation from Pfizer Inc. and AbbVie Inc. D. R. Kohli: Research support from Olympus Corporation of the Americas. N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. S. Pawa: Consultant for Boston Scientific Corporation. N. R. Thiruvengadam: Research support from Boston Scientific Corporation. N. C. Thosani: Consultant for Pentax of America, Inc, Ambu Inc, and Boston Scientific Corporation; travel compensation and food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences. All other authors disclosed no financial relationships.

Background:  Computer-aided detection (CADe) has been developed to improve detection during colonoscopy. After initial reports of high efficacy, there has been an increasing recognition of variability in the effectiveness of CADe systems. The aim of this study was to evaluate a CADe system in a varied colonoscopy population., Methods:  A multicenter, randomized trial was conducted at seven hospitals (both university and non-university) in Europe and Canada. Participants referred for diagnostic, non-immunochemical fecal occult blood test (iFOBT) screening, or surveillance colonoscopy were randomized (1:1) to undergo CADe-assisted or conventional colonoscopy by experienced endoscopists. Participants with insufficient bowel preparation were excluded from the analysis. The primary outcome was adenoma detection rate (ADR). Secondary outcomes included adenomas per colonoscopy (APC) and sessile serrated lesions (SSLs) per colonoscopy., Results:  581 participants were enrolled, of whom 497 were included in the final analysis: 250 in the CADe arm and 247 in the conventional colonoscopy arm. The indication was surveillance in 202/497 colonoscopies (40.6 %), diagnostic in 199/497 (40.0 %), and non-iFOBT screening in 96/497 (19.3 %). Overall, ADR (38.4 % vs. 37.7 %; P  = 0.43) and APC (0.66 vs. 0.66; P  = 0.97) were similar between CADe and conventional colonoscopy. SSLs per colonoscopy was increased (0.30 vs. 0.19; P  = 0.049) in the CADe arm vs. the conventional colonoscopy arm., Conclusions:  In this study conducted by experienced endoscopists, CADe did not result in a statistically significant increase in ADR. However, the ADR of our control group substantially surpassed our sample size assumptions, increasing the risk of an underpowered trial., Competing Interests: T. Rath has received speaker fees from Olympus Medical, PENTAX Medical, Mauna Kea Technologies, Medtronic, Takeda, Galapagos, Falk, Janssen, AbbVie, Repha, Medical Tribune, and Lilly. C. Spada has received consultancy fees from Medtronic and AnX Robotics, and speaker fees from Olympus, PENTAX Medical, and Norgine. N. Forbes is a consultant for Boston Scientific Corp. and PENTAX Medical, and has received speaker fees and research funding from PENTAX Medical. G. Vanbiervliet has received consultancy fees from Boston Scientific Corp. and Ambu A/S, and lecture and conference fees from Fujifilm Medical, Norgine, Tillots, and PENTAX Medical. P.J. Belletrutti has received speaker fees from Pendopharm and consultancy fees from Vantage Endoscopy. P. Siersema has received research support from The E-Nose company, Lucid Diagnostics, Micro Tech, Magentiq Eye Ltd., Norgine, and Endo Tools Therapeutics, and consultancy fees from Magentiq Eye Ltd. M. Maas, E. Soons, S. Kashin, P. Cesaro, A. Eickhoff and D. Salvi declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Competing Interests: Disclosure All authors disclosed no financial relationships.

Competing Interests: Disclosure The following authors disclosed financial relationships: N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. S. Pawa: Consultant for Boston Scientific Corporation. N. R. Thiruvengadam: Research support from Boston Scientific Corporation. S. Ngamruengphong: Consultant for Boston Scientific Corporation, Olympus, and Neptune Medical. T. H. Baron: Consultant for Boston Scientific Corporation, Olympus Corporation, Medtronic, Inc, WL Gore & Associates, Inc, Cook Endoscopy, and CONMED Corporation; speaker for Boston Scientific Corporation, Olympus Corporation, Medtronic, Inc, and WL Gore & Associates; travel compensation from CONMED Corporation; food and beverage compensation from Olympus Corporation of the Americas, Ambu, Inc, Boston Scientific Corporation, and Cook Medical LLC. A. Y. B. Teoh: Consultant for Boston Scientific Corporation, Cook Medical LLC, Taewoong and Microtech, MI Tech, and CMR Medical Corporations. W. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and CONMED Corporation; research support from GI Dynamics; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, CONMED Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals. S. K. Amateau: Consultant for Boston Scientific Corporation, Merit Medical, Olympus Corporation of the Americas, MTEndoscopy, US Endoscopy, Heraeus Medical Components, LLC, and Cook Medical LLC; travel compensation from Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Olympus Corporation of the Americas, and Cook Medical LLC; advisory board for Merit Medical. J. M. Chalhoub: Travel compensation from Olympus Corporation of the Americas; food and beverage compensation from Boston Scientific Corporation. N. Coelho-Prabhu: Consultant for Boston Scientific Corporation and Alexion Pharma; research support from Cook Endoscopy and FujiFilm; food and beverage compensation from Olympus America Inc and Boston Scientific Corporation. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. L. L. Fujii-Lau: Food and beverage compensation from Pfizer Inc and AbbVie Inc; consultant for Boston Scientific. D. R. Kohli: Research support from Olympus Corporation of the Americas. J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc and Boston Scientific Corporation. U. Navaneethan: Consultant for ER Squibb & Sons, LLC; travel compensation from ER Squibb & Sons, LLC, Janssen Scientific Affairs, LLC, Takeda Pharmaceuticals USA, Inc, and AbbVie Inc; food and beverage compensation from ER Squibb & Sons, LLC, Janssen Scientific Affairs, LLC, Takeda Pharmaceuticals USA, Inc, AbbVie Inc, Pfizer Inc, Apollo Endosurgery US Inc, Celgene Corporation, and Olympus America Inc; speaker for Janssen Scientific Affairs, LLC, Takeda Pharmaceuticals USA, Inc, AbbVie Inc, and Pfizer Inc. S. G. Sheth: Consulted for Janssen Research & Development, LLC. N. C. Thosani: Consultant for Pentax of America, Inc, Boston Scientific Corporation, and Ambu Inc; travel compensation and food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences. All other authors disclosed no financial relationships.

Background and Aims: Audit and feedback (A&F) for endoscopic retrograde cholangiopancreatography (ERCP) is relatively understudied despite the demonstrated effectiveness of A&F for endoscopic procedures such as colonoscopy. Endoscopist 'report cards' are one A&F tool. We aimed to develop an ERCP report card and assess its appropriateness, acceptability and feasibility through usability testing., Methods: A prototype report card was designed using a combination of published quality indicators and established predictors of adverse events (AE). Exploratory analyses from a prospective multi-center registry were performed to further identify novel and/or understudied parameters for possible inclusion. Semi-structured interviews with ERCP endoscopists were conducted and framework analysis performed. Validated post-interview usability instruments were administered. Feedback was incorporated to create a final report card., Results: The report card included domains of technical parameters, AE rates/prevention, and patient-reported experience measures (PREMs). Qualitative feedback was positive, with respondents agreeing with inclusion of relevant content in most domains. Post-interview instruments revealed adequate appropriateness and acceptability. PREMs were felt by respondents to be poorly actionable and were replaced with appropriateness of indication and fluoroscopy usage parameters in the final report card. Concerns were raised regarding the feasibility of implementation due to reliance on difficult-to-obtain granular intraprocedural data., Conclusions: We designed and tested an ERCP report card that has potential to be an effective A&F intervention for endoscopists in clinical practice. Though feasibility of data capture and implementation are currently limitations, advances in video recording and artificial intelligence technologies could accelerate widespread adoption of such a tool., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Difficult biliary cannulation (DBC) is a known risk factor for developing post-ERCP pancreatitis (PEP). To better understand how DBC increases PEP risk, we examined the interplay between technical aspects of DBC and known PEP risk factors., Methods: This was a secondary analysis of a multicenter, randomized controlled trial comparing rectal indomethacin alone with the combination of rectal indomethacin and prophylactic pancreatic duct (PD) stent placement for PEP prophylaxis in high-risk patients. Participants were categorized into 3 groups: 1) DBC with high pre-procedure risk for PEP, 2) DBC without high pre-procedure risk, and 3) non-DBC at high pre-procedure risk., Results: In all, 1601 (84.1%) participants experienced DBC, which required a mean of 12 (SD 10) cannulation attempts and mean duration of 14.7 minutes (SD 14.9). PEP rate was highest (20.7%) in DBC with high pre-procedure risk, followed by non-DBC with high pre-procedure risk (13.5%) and then DBC without high pre-procedure risk (8.8%). Increasing number of PD-wire passages (aOR:1.97, 95% CI:1.25-3.1) was associated with PEP in DBC, but PD injection, pancreatic sphincterotomy and number of cannulation attempts were not associated with PEP. Combining indomethacin with PD stenting lowered PEP risk (aOR:0.61, 95% CI:0.44-0.84) in DBCs. This protective effect was evident in up to at least 4 PD wire passages., Conclusions: DBC confers higher PEP risk in additive fashion to pre-procedural risk factors. PD wire passages appear to add the greatest PEP risk in DBCs, but combining indomethacin with PD stenting reduces this risk, even with increasing PD wire passages., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the role of endoscopy in the management of chronic pancreatitis (CP). This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses effectiveness of endoscopic therapies for the management of pain in CP, including celiac plexus block, endoscopic management of pancreatic duct (PD) stones and strictures, and adverse events such as benign biliary strictures (BBSs) and pseudocysts. In patients with painful CP and an obstructed PD, the ASGE suggests surgical evaluation in patients without contraindication to surgery before initiation of endoscopic management. In patients who have contraindications to surgery or who prefer a less-invasive approach, the ASGE suggests an endoscopic approach as the initial treatment over surgery, if complete ductal clearance is likely. When a decision is made to proceed with a celiac plexus block, the ASGE suggests an EUS-guided approach over a percutaneous approach. The ASGE suggests indications for when to consider ERCP alone or with pancreatoscopy and extracorporeal shock wave lithotripsy alone or followed by ERCP for treating obstructing PD stones based on size, location, and radiopacity. For the initial management of PD strictures, the ASGE suggests using a single plastic stent of the largest caliber that is feasible. For symptomatic BBSs caused by CP, the ASGE suggests the use of covered metal stents over multiple plastic stents. For symptomatic pseudocysts, the ASGE suggests endoscopic therapy over surgery. This document clearly outlines the process, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics., Competing Interests: Disclosure The following authors disclosed financial relationships: S. G. Sheth: Consultant for Janssen Research & Development, LLC. J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc and Boston Scientific Corporation. J. M. Chalhoub: Travel compensation from Olympus Corporation of the Americas;food and beverage compensation from Boston Scientific Corporation. C. Forsmark: Consultant for Nestle Healthcare Nutrition, Inc. N. C. Thosani: Consultant for Pentax of America, Inc, Boston Scientific Corporation, AbbVie Inc, and Ambu Inc; travel and food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. N. R. Thiruvengadam: Research support from Boston Scientific Corporation. S. Pawa: Consultant for Boston Scientific Corporation. S. Ngamruengphong: Consultant for Boston Scientific Corporation; food and beverage compensation from Medtronic, Inc, Boston Scientific Corporation, Pentax of America, Inc, and Ambu Inc. N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. D. R. Kohli: Research support from Olympus Corporation of the Americas. L. L. Fujii-Lau: Food and beverage compensation from Pfizer Inc. and AbbVie Inc. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. N. Coelho-Prabhu: Consultant for Boston Scientific Corporation and Alexion Pharma; research support from Cook Endoscopy and FujiFilm; food and beverage compensation from Olympus America Inc and Boston Scientific Corporation. S. K. Amateau: Consultant for Boston Scientific Corporation, Merit Medical, Olympus Corporation of the Americas, MTEndoscopy, US Endoscopy, Heraeus Medical Components, LLC, and Cook Medical LLC; travel compensation Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Olympus Corporation of the Americas, and Cook Medical LLC; advisory board for Merit Medical. W. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and ConMed Corporation; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, ConMed Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals; research support from GI Dynamics. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Disclosure The following authors disclosed financial relationships: S. G. Sheth: Consultant for Janssen Research & Development, LLC. J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc and Boston Scientific Corporation. J. M. Chalhoub: Travel compensation from Olympus Corporation of the Americas; food and beverage compensation from Boston Scientific Corporation. C. Forsmark: Consultant for Nestle Healthcare Nutrition, Inc. N. C. Thosani: Consultant for Pentax of America, Inc, Boston Scientific Corporation, and Ambu Inc; travel compensation Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. N. R. Thiruvengadam: Research support from Boston Scientific Corporation. S. Pawa: Consultant for Boston Scientific Corporation. S. Ngamruengphong: Consultant for Boston Scientific Corporation; food and beverage compensation from Medtronic, Inc, Boston Scientific Corporation, Pentax of America, Inc, and Ambu Inc. N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. D. R. Kohli: Research grant from Olympus Corporation of the Americas. L. L. Fujii-Lau: Food and beverage compensation from Pfizer Inc and AbbVie Inc. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. N. Coelho-Prabhu: Consultant for Boston Scientific Corporation and Alexion Pharma; research support from Cook Endoscopy and Fujifilm; food and beverage compensation from Olympus America Inc and Boston Scientific Corporation. S. K. Amateau: Consultant for Boston Scientific Corporation, Merit Medical, Olympus Corporation of the Americas, MTEndoscopy, US Endoscopy, Heraeus Medical Components, LLC, and Cook Medical LLC; travel compensation from Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Olympus Corporation of the Americas, and Cook Medical LLC; advisory board for Merit Medical. W. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and ConMed Corporation; research support from GI Dynamics; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, ConMed Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences. All other authors disclosed no financial relationships.

Background: The incidence of major gastrointestinal bleeding (GIB) in patients on low-dose direct-acting oral anticoagulants (DOACs) is relatively unknown. Estimates from randomised controlled trials (RCTs) are lacking., Aims: To assess GIB incidence and predictors from RCT data of patients on aspirin, low-dose rivaroxaban, or both., Methods: This was a secondary analysis of RCT data wherein patients received aspirin 100 mg daily and rivaroxaban 2.5 mg b.d., aspirin alone, or rivaroxaban 5 mg b.d. Patients were followed from 2013 to 2016 at 602 centres. Outcomes included overall, upper, and lower GIB. We employed multivariable logistic regression to yield odds ratios (ORs) and 95% confidence intervals for potential exposures., Results: Among 27,395 patients, the annual incidence of GIB on rivaroxaban 2.5 mg b.d. with aspirin was 801.7 per 100,000 compared with 372.3 in 100,000 for aspirin. Age (OR 4.16, 2.53-6.82 for ≥75 vs. 55-64), peptic ulcer disease (PUD, OR 1.57, 1.01-2.44), liver disease (OR 2.09, 1.01-4.33), hypertension (OR 1.42, 1.04-1.94), and smoking (OR 1.85, 1.26-2.73) were associated with overall GIB. Kidney disease (OR 1.68, 1.12-2.51) was significantly associated with upper GIB, whereas diverticular disease (OR 3.75, 1.88-7.49) was associated with lower GIB. Addition of rivaroxaban to aspirin was associated more with lower GIB (OR 2.82, 1.64-4.84) than upper GIB (OR 1.86, 1.18-2.92)., Conclusions: We established incidences and identified risk factors for GIB in users of low-dose DOACs. Novel risk factors included current or former smoking and diverticulosis. Future studies should aim to validate these risk factors., (© 2024 The Author(s). Alimentary Pharmacology & Therapeutics published by John Wiley & Sons Ltd.)

Introduction: Prophylactic pancreatic stent placement (PSP) is effective for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk cases, but the optimal technical approach to this intervention remains uncertain., Methods: In this secondary analysis of 787 clinical trial patients who underwent successful stent placement, we studied the impact of (i) whether pancreatic wire access was achieved for the sole purpose of PSP or naturally during the conduct of the case, (ii) the amount of effort expended on PSP, (iii) stent length, (iv) stent diameter, and (v) guidewire caliber. We used logistic regression models to examine the adjusted association between each technical factor and post-ERCP pancreatitis (PEP)., Results: Ninety-one of the 787 patients experienced PEP. There was no clear association between PEP and whether pancreatic wire access was achieved for the sole purpose of PSP (vs occurring naturally; odds ratio [OR] 0.82, 95% confidence interval [CI] 0.37-1.84), whether substantial effort expended on stent placement (vs nonsubstantial effort; OR 1.58, 95% CI 0.73-3.45), stent length (>5 vs ≤5 cm; OR 1.01, 95% CI 0.63-1.61), stent diameter (≥5 vs <5 Fr; OR 1.13, 95% CI 0.65-1.96), or guidewire caliber (0.035 vs 0.025 in; 0.83, 95% CI 0.49-1.41)., Discussion: The 5 modifiable technical factors studied in this secondary analysis of large-scale randomized trial data did not appear to have a strong impact on the benefit of prophylactic PSP in preventing PEP after high-risk ERCP. Within the limitations of post hoc subgroup analysis, these findings may have important implications in procedural decision making and suggest that the benefit of PSP is robust to variations in technical approach., (Copyright © 2024 by The American College of Gastroenterology.)

Background & Aims: Significant variability exists in colonoscopy quality indicators, including adenoma detection rate (ADR). We synthesized evidence from randomized trials in a network meta-analysis on interventions to improve colonoscopy quality., Methods: We included trials from database inceptions to September 25, 2023, of patients undergoing screening-related colonoscopy and presented efficacies of interventions within domains (periprocedural parameters, endoscopist-directed interventions, intraprocedural techniques, endoscopic technologies, distal attachment devices, and additive substances) compared to standard colonoscopy. The primary outcome was ADR. We used a Bayesian random-effects model using Markov-chain Monte Carlo simulation, with 10,000 burn-ins and 100,000 iterations. We calculated odds ratios with 95% credible intervals and present surface under the cumulative ranking (SUCRA) curves., Results: We included 124 trials evaluating 37 interventions for the primary outcome. Nine interventions resulted in statistically significant improvements in ADR compared to standard colonoscopy (9-minute withdrawal time, dual observation, water exchange, i-SCAN [Pentax Ltd], linked color imaging, computer-aided detection, Endocuff [Olympus Corp], Endocuff Vision [Olympus Corp], and oral methylene blue). Dual observation (SUCRA, 0.84) and water exchange (SUCRA, 0.78) ranked highest among intraprocedural techniques; i-SCAN (SUCRA, 0.95), linked color imaging (SUCRA, 0.85), and computer-aided detection (SUCRA, 0.78) among endoscopic technologies; WingCap (A&A Medical Supply LLC) (SUCRA, 0.87) and Endocuff (SUCRA, 0.85) among distal attachment devices and oral methylene blue (SUCRA, 0.94) among additive substances. No interventions improved detection of advanced adenomas, and only narrow-band imaging improved detection of serrated lesions (odds ratio, 2.94; 95% credible interval, 1.46-6.25)., Conclusions: Several interventions are effective in improving adenoma detection and overall colonoscopy quality, many of which are cost-free. These results can inform endoscopists, unit managers, and endoscopy societies on relative efficacies., (Copyright © 2024 AGA Institute. Published by Elsevier Inc. All rights reserved.)

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for the role of therapeutic EUS in the management of biliary tract disorders. This guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses the following: 1: The role of EUS-guided biliary drainage (EUS-BD) versus percutaneous transhepatic biliary drainage (PTBD) in resolving biliary obstruction in patients after failed ERCP. 2: The role of EUS-guided hepaticogastrostomy versus EUS-guided choledochoduodenostomy in resolving distal malignant biliary obstruction after failed ERCP. 3: The role of EUS-directed transgastric ERCP (EDGE) versus laparoscopic-assisted ERCP and enteroscopy-assisted ERCP (E-ERCP) in resolving biliary obstruction in patients with Roux-en-Y gastric bypass (RYGB) anatomy. 4: The role of EUS-BD versus E-ERCP and PTBD in resolving biliary obstruction in patients with surgically altered anatomy other than RYGB. 5: The role of EUS-guided gallbladder drainage (EUS-GBD) versus percutaneous gallbladder drainage and endoscopic transpapillary transcystic gallbladder drainage in resolving acute cholecystitis in patients who are not candidates for cholecystectomy., Competing Interests: Disclosure The following authors disclosed financial relationships: S. Pawa: Consultant for Boston Scientific Corporation. N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. N. R. Thiruvengadam: Research support from Boston Scientific Corporation. S. Ngamruengphong: Consultant for Boston Scientific Corporation, Olympus, and Neptune Medical. T. H. Baron: Consultant for Boston Scientific Corporation, Olympus Corporation, Medtronic, Inc, WL Gore & Associates, Inc, Cook Endoscopy, and CONMED Corporation; speaker for Boston Scientific Corporation, Olympus Corporation, Medtronic, Inc, and WL Gore & Associates; travel compensation from CONMED Corporation; food and beverage compensation from Olympus Corporation of the Americas, Ambu, Inc, Boston Scientific Corporation, and Cook Medical LLC. A. Y. B. Teoh: Consultant for Boston Scientific Corporation, Cook Medical LLC, Taewoong and Microtech, MI Tech, and CMR Medical Corporations. W. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and CONMED Corporation; research support from GI Dynamics; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, CONMED Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals. S. K. Amateau: Consultant for Boston Scientific Corporation, Merit Medical, Olympus Corporation of the Americas, MTEndoscopy, US Endoscopy, Heraeus Medical Components, LLC, and Cook Medical LLC; travel compensation from Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Olympus Corporation of the Americas, and Cook Medical LLC; advisory board for Merit Medical. J. M. Chalhoub: Travel compensation from Olympus Corporation of the Americas; food and beverage compensation from Boston Scientific Corporation. N. Coelho-Prabhu: Consultant for Boston Scientific Corporation and Alexion Pharma; research support from Cook Endoscopy and FujiFilm; food and beverage compensation from Olympus America Inc and Boston Scientific Corporation. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. L. L. Fujii-Lau: Food and beverage compensation from Pfizer Inc and AbbVie Inc; consultant for Boston Scientific. D. R. Kohli: Research support from Olympus Corporation of the Americas. J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc and Boston Scientific Corporation. U. Navaneethan: Consultant for ER Squibb & Sons, LLC; travel compensation from ER Squibb & Sons, LLC, Janssen Scientific Affairs, LLC, Takeda Pharmaceuticals USA, Inc, and AbbVie Inc; food and beverage compensation from ER Squibb & Sons, LLC, Janssen Scientific Affairs, LLC, Takeda Pharmaceuticals USA, Inc, AbbVie Inc, Pfizer Inc, Apollo Endosurgery US Inc, Celgene Corporation, and Olympus America Inc; speaker for Janssen Scientific Affairs, LLC, Takeda Pharmaceuticals USA, Inc, AbbVie Inc, and Pfizer Inc. S. G. Sheth: Consulted for Janssen Research & Development, LLC. N. C. Thosani: Consultant for Pentax of America, Inc, Boston Scientific Corporation, and Ambu Inc; travel compensation and food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background Aims: Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding (CSPEB) is common. Contemporary estimates of risk are lacking. We aimed to identify risk factors for and outcomes following CSPEB., Methods: We analyzed multi-center prospective ERCP data between 2018-2023 with 30-day follow-up. The primary outcome was CSPEB, defined as hematemesis, melena, or hematochezia resulting in: hemoglobin drop ≥20 g/L or transfusion and/or endoscopy to evaluate suspected bleeding, and/or unplanned healthcare visitation and/or prolongation of existing admission. Firth logistic regression was employed. P-values <0.05 were significant, with odds ratios (ORs) and 95% confidence intervals reported., Results: CSPEB occurred following 129 (1.5%) of 8,517 ERCPs (mean onset 3.2 days), with 110 of 4,849 events (2.3%) occurring following higher-risk interventions (sphincterotomy, sphincteroplasty, pre-cut sphincterotomy, and/or needle-knife access). CSPEB patients required endoscopy and transfusion in 86.0% and 53.5% of cases, respectively, with three cases (2.3%) being fatal. P2Y12 inhibitors were held for a median of 4 days (IQR 4) prior to higher-risk ERCP. Following higher-risk interventions, P2Y12 inhibitors (OR 3.33, 1.26-7.74), warfarin (OR 8.54, 3.32-19.81), dabigatran (OR 13.40, 2.06-59.96), rivaroxaban (OR 7.42, 3.43-15.24) and apixaban (OR 4.16, 1.99-8.20) were associated with CSPEB. Significant intraprocedural bleeding post sphincterotomy (OR 2.32, 1.06-4.60), but not post sphincteroplasty, was also associated. Concomitant cardiorespiratory events occurred more frequently within 30 days following CSPEB (OR 12.71, 4.75-32.54)., Conclusions: Risks of antiplatelet-related CSPEB may be underestimated by endoscopists based on observations of suboptimal holding before higher-risk ERCP. Appropriate periprocedural antithrombotic management is essential and could represent novel quality initiative targets., (Copyright © 2024 by The American College of Gastroenterology.)

Background & Aims: Acute enteric infections are well known to result in long-term gastrointestinal (GI) disorders. Although COVID-19 is principally a respiratory illness, it demonstrates significant GI tropism, possibly predisposing to prolonged gut manifestations. We aimed to examine the long-term GI impact of hospitalization with COVID-19., Methods: Nested within a large-scale observational cohort study of patients hospitalized with COVID-19 across North America, we performed a follow-up survey of 530 survivors 12-18 months later to assess for persistent GI symptoms and their severity, and for the development of disorders of gut-brain interaction (DGBIs). Eligible patients were identified at the study site level and surveyed electronically. The survey instrument included the Rome IV Diagnostic Questionnaire for DGBI, a rating scale of 24 COVID-related symptoms, the Gastrointestinal Symptoms Rating Scale, and the Impact of Events-Revised trauma symptom questionnaire (a measure of posttraumatic stress associated with the illness experience). A regression analysis was performed to explore the factors associated with GI symptom severity at follow-up., Results: Of the 530 invited patients, 116 responded (52.6% females; mean age, 55.2 years), and 73 of those (60.3%) met criteria for 1 or more Rome IV DGBI at follow-up, higher than the prevalence in the US general population (P < .0001). Among patients who experienced COVID-related GI symptoms during the index hospitalization (abdominal pain, nausea, vomiting, or diarrhea), 42.1% retained at least 1 of these symptoms at follow-up; in comparison, 89.8% of respondents retained any (GI or non-GI) COVID-related symptom. The number of moderate or severe GI symptoms experienced during the initial COVID-19 illness by self-report correlated with the development of DGBI and severity of GI symptoms at follow-up. Posttraumatic stress disorder (Impact of Events-Revised score ≥33) related to the COVID-19 illness experience was identified in 41.4% of respondents and those individuals had higher DGBI prevalence and GI symptom severity. Regression analysis revealed that higher psychological trauma score (Impact of Events-Revised) was the strongest predictor of GI symptom severity at follow-up., Conclusions: In this follow-up survey of patients 12-18 months after hospitalization with COVID-19, there was a high prevalence of DGBIs and persistent GI symptoms. Prolonged GI manifestations were associated with the severity of GI symptoms during hospitalization and with the degree of psychological trauma related to the illness experience., (Copyright © 2024 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background and Aims: The incidence, risk factors, and outcomes of post-ERCP cholecystitis are poorly described. We aimed to describe cases of post-ERCP cholecystitis from a prospective multicenter registry with protocolized 30-day follow-up., Methods: Patient- and procedure-related data from 7 centers were obtained. The primary outcome was post-ERCP cholecystitis, defined according to a Delphi-based criteria and causal attribution system. Risk factors and outcomes were described for all cases., Results: Seventeen cases of post-ERCP cholecystitis were identified among 4428 patients with gallbladders undergoing ERCP between 2018 and 2023 (incidence, 0.38%; 95% confidence interval, 0.20-0.57). In ERCPs with covered metal stenting, 7 of 467 resulted in cholecystitis (incidence, 1.50%; 95% confidence interval, 0.40-2.60). Patients had symptoms at a median of 5 days (interquartile range, 5) after ERCP. Management strategies included cholecystectomy, percutaneous cholecystostomy, and endoscopic stent removal/exchange., Conclusions: Estimates of post-ERCP cholecystitis incidence can inform discussions around procedural risk., Competing Interests: Disclosure The following authors disclosed financial relationships: Y.-I Chen: Consultant and speaker for Boston Scientific. N. Forbes: Consultant and speaker for Boston Scientific and Pentax Medical. All other authors disclosed no financial relationships. Funding for this study was provided by the NB Hershfield Chair in Therapeutic Endoscopy, University of Calgary and Pentax Medical Canada., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Stent dysfunction is common after ERCP with self-expandable metal stent (SEMS) insertion for malignant distal biliary obstruction (MDBO). Chronic aspirin (acetylsalicylic acid; ASA) exposure has been previously shown to potentially decrease this risk. We aim to further ascertain the protective effect of ASA and to identify other predictors of stent dysfunction., Methods: This multicenter retrospective cohort study was conducted at 9 sites in Canada and 1 in the United States. Patients with MDBO who underwent ERCP with SEMS placement between January 2014 and December 2019 were included and divided into 2 cohorts: ASA exposed (ASA-E) and ASA unexposed (ASA-U). Propensity-score matching (PSM) was performed to limit selection bias. Matched variables were age, sex, tumor stage, and type of metal stent. The primary outcome was the hazard rate of stent dysfunction. A multivariable Cox proportional hazards model was used to identify independent predictors of stent dysfunction., Results: Of 1396 patients assessed, after PSM 496 patients were analyzed (248 ASA-E and 248 ASA-U). ERCP with SEMS placement was associated with a high clinical success of 82.2% in ASA-E and 81.2% in ASA-U cohorts (P = .80). One hundred eighty-four patients had stent dysfunction with a mean stent patency time of 229.9 ± 306.2 days and 245.4 ± 241.4 days in ASA-E and ASA-U groups, respectively (P = .52). On multivariable analysis, ASA exposure did not protect against stent dysfunction (hazard ratio [HR], 1.25; 95% confidence interval [CI], .96-1.63). An etiology of pancreatic cancer (HR, 1.36; 95% CI, 1.15-1.61) predicted stent dysfunction, whereas cancer therapy was protective (HR, .73; 95% CI, .55-.96). Chronic ASA use was not associated with an increased risk for adverse events including bleeding, post-ERCP pancreatitis, and perforation., Conclusions: In this large, multicenter study using PSM, chronic exposure to ASA did not protect against stent dysfunction in MDBO. Instead, the analysis revealed that the etiology of pancreatic cancer was an independent predictor of stent dysfunction and cancer therapy was protective., Competing Interests: Disclosure The following author received research support for this study from the Fonds de Recherche du Québec–Santé: Y.-I Chen. In addition, the following authors disclosed financial relationships: N. Forbes: Consultant for Pentax Medical, Boston Scientific, and AstraZeneca; speaker for Pentax Medical. D. Pleskow: Consultant for Boston Scientific, Olympus, Fuji, Medtronic, Nine Point, and Allurion. Y.-I Chen: Consultant for Boston Scientific; shareholder of Chess Medical Inc. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) can lead to significant morbidity and mortality. We aimed to develop an accurate post-ERCP pancreatitis risk prediction model using easily obtainable variables., Methods: Using prospective multi-center ERCP data, we performed logistic regression using stepwise selection on several patient-, procedure-, and endoscopist-related factors that were determined a priori. The final model was based on a combination of the Bayesian information criterion and Akaike's information criterion performance, balancing the inclusion of clinically relevant variables and model parsimony. All available data were used for model development, with subsequent internal validation performed on bootstrapped data using 10-fold cross-validation., Results: Data from 3021 ERCPs were used to inform models. There were 151 cases of post-ERCP pancreatitis (5.0% incidence). Variables included in the final model included female sex, pancreatic duct cannulation, native papilla status, pre-cut sphincterotomy, increasing cannulation time, presence of biliary stricture, patient age, and placement of a pancreatic duct stent. The final model was discriminating, with a receiver operating characteristic curve statistic of 0.79, and well-calibrated, with a predicted risk-to-observed risk ratio of 1.003., Conclusions: We successfully developed and internally validated a promising post-ERCP pancreatitis clinical prediction model using easily obtainable variables that are known at baseline or observed during the ERCP procedure. The model achieved an area under the curve of 0.79. External validation is planned as additional data becomes available., Competing Interests: Nauzer Forbes has been a consultant for Boston Scientific, has been on the speaker's bureau for Pentax Medical and Boston Scientific, and has received research funding from Pentax Medical. The rest of the authors declare no conflict of interest., (© 2024 The Authors. DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Background: Cold snare polypectomy (CSP) is safer than and equally efficacious as hot snare polypectomy (HSP) for the removal of small (<10mm) colorectal polyps. The maximum polyp size that can be effectively managed by piecemeal CSP (p-CSP) without an excessive burden of recurrence is unknown., Methods: Resection error risks (RERs), defined as the estimated likelihood of incomplete removal of adenomatous tissue for a single snare resection pass, for CSP and HSP were calculated, based on an incomplete resection rate. Polyp area, snare size, estimated number of resections, and optimal resection defect area were modeled. Overall risk of incomplete resection (RIR) was defined as RIR=1 - (1 - p) n , where p is the RER and n the number of resections., Results: A 40-mm polyp has a four times greater area than a 20-mm polyp (314.16mm 2 vs. 1256.64mm 2 ), and requires three times more resections (11 vs. 33, respectively, assuming 8-mm piecemeal resection pieces for p-CSP). RIRs for a 40-mm polyp by HSP and p-CSP were 15.1%-23% and 40.74%-60.60% respectively., Conclusion: RER is more important with p-CSP than with HSP. The number of resections, n, and consequently RIR increases with increasing polyp size. Given the overwhelming safety of CSP, specific techniques to minimize the RER should be studied and developed., Competing Interests: Michael Bourke: Research Support: Olympus Medical, Cook Medical, Boston Scientific. Nauzer Forbes: Speaker and consultant for Boston Scientific and Pentax Medical; research support from Pentax Medical. There are no other potential conflicts of interest to report., (Thieme. All rights reserved.)

Background and study aims The Bethesda ERCP Skill Assessment Tool (BESAT) is a video-based assessment tool of technical endoscopic retrograde cholangiopancreatography (ERCP) skill with previously established validity evidence. We aimed to assess the discriminative validity of the BESAT in differentiating ERCP skill levels. Methods Twelve experienced ERCP practitioners from tertiary academic centers were asked to blindly rate 43 ERCP videos using the BESAT. ERCP videos consisted of native biliary cannulation and sphincterotomy and were recorded from 10 unique endoscopists of various ERCP experience (from advanced endoscopy fellow to > 10 years of ERCP experience). Inter-rater reliability, discriminative validity, and internal structure validity were subsequently assessed. Results The BESAT was found to reliably differentiate between endoscopists of varying levels of ERCP experience with experienced ERCPists scoring higher than novice ERCPists in 11 of 13 (85%) instrument items. Inter-rater reliability for BESAT items ranged from good to excellent (intraclass correlation range: 0.86 to 0.93). Internal structure validity was assessed with item-total correlations ranging from 0.53 to 0.83. Conclusions Study findings demonstrate that the BESAT, a video-based ERCP skill assessment tool, has high inter-rater reliability and has discriminative validity in differentiating novice from expert ERCP skill. Further investigations are needed to determine the role of video-based assessment in improving trainee learning curves and patient outcomes., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background and study aims Patients with primary sclerosing cholangitis (PSC) have a 9% to 20% lifetime incidence of cholangiocarcinoma (CCA). Per-oral cholangioscopy (POCS) added to endoscopic retrograde cholangiography (ERC) could potentially improve detection of CCA occurrence. We prospectively assessed POCS identification of 12-month CCA incidence in PSC patients undergoing ERC. Patients and methods Consecutive patients with PSC, an indication for ERC, and no prior liver transplantation were enrolled. During the index procedure, POCS preceded planned therapeutic maneuvers. The primary endpoint was ability for POCS visualization with POCS-guided biopsy to identify CCA during 12-month follow-up. Secondary endpoints included ability of ERC/cytology to identify CCA, repeat ERC, liver transplantation, and serious adverse events (SAEs). Results Of 42 patients enrolled, 36 with successful cholangioscope advancement were analyzed. Patients had a mean age 43.5±15.6 years and 61% were male. Three patients diagnosed with CCA had POCS visualization impressions of benign/suspicious/suspicious, and respective POCS-guided biopsy findings of suspicious/positive/suspicious for malignancy at the index procedure. The three CCA cases had ERC visualization impressions of benign/benign/suspicious, and respective cytology findings of atypical/atypical/suspicious for malignancy. No additional patients were diagnosed with CCA during median 11.5-month follow-up. Twenty-three repeat ERCs (5 including POCS) were performed in 14 patients. Five patients had liver transplantation, one after CCA diagnosis and four after benign cytology at the index procedure. Three patients (7.1%) had post-ERC pancreatitis. No SAEs were POCS-related. Conclusions In PSC patients, POCS visualization/biopsy and ERC/cytology each identified three cases of CCA. Some patients had a repeat procedure and none experienced POCS-related SAEs., Competing Interests: Conflict of Interest Rachid Mounir Mohamed: none. Sooraj Tejaswi: none. Lars Aabakken: Olympus – training, once-a-year advisory, clinical trial participation; Ambu – advisory board; Boston Scientific – clinical trial participation. Cyriel Ponsioen: research grants from Gilead and Perspectum, speaker’s fee from Tillotts, and advisory board fees from Shire. Christopher L. Bowlus: grants or contracts and consulting fees from Cymabay, GSK, Eli Lilly; grants or contracts from Gilead, BMS, Intercept, Hanmi, TARGET, Pliant, Genfit, Novartis, Takeda, Arena Pharmaceuticals, Callidtas; consulting fees from BiomX, Trevi Therapeutics, Shire, Mirum. Douglas Adler: research funding from Boston Scientific. Nauzer Forbes: Boston Scientific – consultant and speaker’s bureau; Pentax Medical– research funding, consultant and speaker’s bureau; AstraZeneca – consultant. Vemund Paulsen: lecture fee from Boston Scientific. Rogier Voermans: research grants from Boston Scientific and Prion Medical, speaker’s fees from Viatris, Zambon and Boston Scientific. Shiro Urayama: consultant for Olympus. Joyce A. Peetermans: full-time employee of Boston Scientific. Matthew J. Rousseau: full-time employee of Boston Scientific. Bertus Eksteen: Pliant - scientific board; consulting for Jansen, Pfizer, Abbvie., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: The combination of rectally administered indomethacin and placement of a prophylactic pancreatic stent is recommended to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients. Preliminary evidence suggests that the use of indomethacin might eliminate or substantially reduce the need for stent placement, a technically complex, costly, and potentially harmful intervention., Methods: In this randomised, non-inferiority trial conducted at 20 referral centres in the USA and Canada, patients (aged ≥18 years) at high risk for post-ERCP pancreatitis were randomly assigned (1:1) to receive rectal indomethacin alone or the combination of indomethacin plus a prophylactic pancreatic stent. Patients, treating clinicians, and outcomes assessors were masked to study group assignment. The primary outcome was post-ERCP pancreatitis. To declare non-inferiority, the upper bound of the two-sided 95% CI for the difference in post-ERCP pancreatitis (indomethacin alone minus indomethacin plus stent) would have to be less than 5% (non-inferiority margin) in both the intention-to-treat and per-protocol populations. This trial is registered with ClinicalTrials.gov (NCT02476279), and is complete., Findings: Between Sept 17, 2015, and Jan 25, 2023, a total of 1950 patients were randomly assigned. Post-ERCP pancreatitis occurred in 145 (14·9%) of 975 patients in the indomethacin alone group and in 110 (11·3%) of 975 in the indomethacin plus stent group (risk difference 3·6%; 95% CI 0·6-6·6; p=0·18 for non-inferiority). A post-hoc intention-to-treat analysis of the risk difference between groups showed that indomethacin alone was inferior to the combination of indomethacin plus prophylactic stent (p=0·011). The relative benefit of stent placement was generally consistent across study subgroups but appeared more prominent among patients at highest risk for pancreatitis. Safety outcomes (serious adverse events, intensive care unit admission, and hospital length of stay) did not differ between groups., Interpretation: For preventing post-ERCP pancreatitis in high-risk patients, a strategy of indomethacin alone was not as effective as a strategy of indomethacin plus prophylactic pancreatic stent placement. These results support prophylactic pancreatic stent placement in addition to rectal indomethacin administration in high-risk patients, in accordance with clinical practice guidelines., Funding: US National Institutes of Health., Competing Interests: Declaration of interests The following authors have received honoraria, consulting fees, or research support from companies that manufacture prophylactic pancreatic stents or indomethacin within the last 2 years: SAE (consulting fees from Olympus, honoraria from Boston Scientific), NF (consulting fees and payment or honoraria for lectures or receipt of equipment or materials from Boston Scientific and Pentax), FFW (consulting fees from Cook/Boston Scientific), SV (consulting fees from Boston Scientific/Olympus), JYB (consulting fees from Boston Scientific/Olympus), MK (consulting fees from Boston Scientific), RK (consulting fees from Boston Scientific), Y-IC (consulting fees, honoraria, research grants, and travel payments from Boston Scientific), AB (financial interest in Olympus), ARo (payment or honoraria for lectures or presentations and travel from Boston Scientific), and study group members SGK (honoraria and grant support from Taewoong Medical) and SG (consulting fees and honoraria from Boston Scientific). All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background and Aims: Given the underlying properties of cannabinoids, we aimed to assess associations between cannabinoid use and sedation requirements for esophagogastroduodenoscopy (EGD) and colonoscopy. Methods: A prospective cohort study was conducted at three endoscopy units. Adult outpatients undergoing EGD or colonoscopy with endoscopist-directed conscious sedation (EDCS) were given questionnaires on cannabinoid use and relevant parameters. Outcomes included intraprocedural midazolam, fentanyl, and diphenhydramine use, procedural tolerability, and adverse events. Multivariable logistic regression was performed to yield adjusted odds ratios (AORs) of outcomes. Results: A total of 419 patients were included. Baseline cannabinoid use was associated with high midazolam use, defined as ≥5 mg, during EGD (AOR 2.89, 95% confidence interval, CI: 1.19-7.50), but not during colonoscopy (AOR 0.89, 95% CI 0.41-1.91). Baseline cannabinoid use was associated with the administration of any diphenhydramine during EGD (AOR 3.04, 95% CI: 1.29-7.30) with a similar nonsignificant trend for colonoscopy (AOR 2.36, 95% CI: 0.81-7.04). Baseline cannabinoid use was associated with increased odds of requiring high total sedation, defined as any of midazolam ≥5 mg, fentanyl ≥100 mcg, or any diphenhydramine during EGD (AOR 3.72, 95% CI: 1.35-11.68). Cannabinoid use was not independently associated with fentanyl use, intraprocedural awareness, discomfort, or adverse events. Conclusions: Baseline cannabinoid use was associated with higher sedation use during endoscopy with EDCS, particularly with midazolam and diphenhydramine. Given increasingly widespread cannabinoid use, endoscopists should be equipped with optimal sedation strategies for this population. As part of the informed consent process, cannabis users should be counseled that they may require higher sedation doses to achieve the same effect.

Background and study aims Cold-snare polypectomy (CSP) is considered the standard of care for resection of colorectal polyps ≤10 mm. Data on the efficacy of CSP performed with thin-wire snares compared0 with thick-wire snares are conflicting. We performed a meta-analysis comparing complete resection (CR) and adverse event rates of CSP using thin-wire and thick-wire snares. Patients and methods Comparative studies of adult patients with ≧1 colorectal polyp(s) ≦10 mm who underwent CSP with thin-wire or thick-wire snares were included. We collected data on study, patient, polyp, and snare characteristics. The primary outcome was CR rate. Secondary outcomes were polyp retrieval rate, intraprocedural bleeding, delayed post-polypectomy bleeding, deep mural injury or perforation, patient discomfort, total sedation, and procedure time. We used random-effects models to calculate risk ratios for outcomes. We performed risk of bias assessments, rated the certainty of evidence, and assessed publication bias for all studies. Results We included four randomized controlled trials (RCTs) and two observational studies including 1316 patients with 1679 polyps (826 thin-wire CSPs and 853 thick-wire CSPs). There was no significant difference between thin-wire CSP (92.1%) and thick-wire CSP (87.7%) for RCTs (risk ratio [RR] 1.05, 95% confidence interval [CI] 0.94-1.16) or observational studies (78.1% versus 79.6%, RR 1.03, 95% CI 0.99-1.08). There were no significant differences in polyp retrieval rate or intraprocedural bleeding. There were no cases of delayed bleeding or perforation. Conclusions We found no differences in CR rates for CSP between thin-wire and thick-wire snares. CSP, regardless of snare type, is safe and effective for resection of small colorectal polyps., Competing Interests: Conflict of Interest MJB has received research support from Olympus, Cook Medical, and Boston Scientific. SCG has received research support and personal fees from AbbVie and Ferring Pharmaceuticals, personal fees from Takeda, education grants from Janssen, and has equity in Volo Healthcare. NF has received personal fees from Boston Scientific, Pentax Medical, and AstraZeneca and research support from Pentax Medical. All remaining authors have no relevant conflicts to declare., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background and Study Aim: Magnifying endoscopy enables the diagnosis of advanced neoplasia throughout the gastrointestinal tract. The unified magnifying endoscopic classification (UMEC) framework unifies optical diagnosis criteria in the esophagus, stomach, and colon, dividing lesions into three categories: non-neoplastic, intramucosal neoplasia, and deep submucosal invasive cancer. This study aims to ascertain the performance of North American endoscopists when using the UMEC., Methods: In this retrospective cohort study, five North American endoscopists without prior training in magnifying endoscopy independently diagnosed images of gastrointestinal tract lesions using UMEC. All endoscopists were blinded to endoscopic findings and histopathological diagnosis. Using histopathology as the gold standard, the endoscopists' diagnostic performances using UMEC were evaluated., Results: A total of 299 lesions (77 esophagus, 92 stomach, and 130 colon) were assessed. For esophageal squamous cell carcinoma, the sensitivity, specificity, and accuracy ranged from 65.2% (95%CI: 50.9-77.9) to 87.0% (95%CI: 75.3-94.6), 77.4% (95%CI: 60.9-89.6) to 96.8% (95%CI: 86.8-99.8), and 75.3% to 87.0%, respectively. For gastric adenocarcinoma, the sensitivity, specificity, and accuracy ranged from 94.9% (95%CI: 85.0-99.1) to 100%, 52.9% (95%CI: 39.4-66.2) to 92.2% (95%CI: 82.7-97.5), and 73.3% to 93.3%. For colorectal adenocarcinoma, the sensitivity, specificity, and accuracy ranged from 76.2% (95%CI: 62.0-87.3) to 83.3% (95%CI: 70.3-92.5), 89.7% (95%CI: 82.1-94.9) to 97.7% (95%CI: 93.1-99.6), and 86.8% to 90.7%. Intraclass correlation coefficients indicated good to excellent reliability., Conclusion: UMEC is a simple classification that may be used to introduce endoscopists to magnifying narrow-band imaging and optical diagnosis, yielding satisfactory diagnostic accuracy., Competing Interests: H. I. has received personal fees from Olympus Corporation and Top Corporation. He has also received educational grants from Olympus Corp., and Takeda Pharmaceutical Co. S. C. G. has received research grants and personal fees from AbbVie and Ferring Pharmaceuticals, personal fees from Takeda, education grants from Janssen, and has equity in Volo Healthcare. All other authors have no relevant disclosures., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology.)

Background & Aims: Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent (EUS-CDS) is a promising modality for management of malignant distal biliary obstruction (MDBO) with potential for better stent patency. We compared its outcomes with endoscopic retrograde cholangiopancreatography with metal stenting (ERCP-M)., Methods: In this multicenter randomized controlled trial, we recruited patients with MDBO secondary to borderline resectable, locally advanced, or unresectable peri-ampullary cancers across 10 Canadian institutions and 1 French institution. This was a superiority trial with a noninferiority assessment of technical success. Patients were randomized to EUS-CDS or ERCP-M. The primary end point was the rate of stent dysfunction at 1 year, considering competing risks of death, clinical failure, and surgical resection. Analyses were performed according to intention-to-treat principles., Results: From February 2019 to February 2022, 144 patients were recruited; 73 were randomized to EUS-CDS and 71 were randomized to ERCP-M. The mean (SD) procedure time was 14.0 (11.4) minutes for EUS-CDS and 23.1 (15.6) minutes for ERCP-M (P < .01); 40% of the former was performed without fluoroscopy. Technical success was achieved in 90.4% (95% CI, 81.5% to 95.3%) of EUS-CDS and 83.1% (95% CI, 72.7% to 90.1%) of ERCP-M with a risk difference of 7.3% (95% CI, -4.0% to 18.8%) indicating noninferiority. Stent dysfunction occurred in 9.6% vs 9.9% of EUS-CDS and ERCP-M cases, respectively (P = .96). No differences in adverse events, pancreaticoduodenectomy and oncologic outcomes, or quality of life were noted., Conclusions: Although not superior in stent function, EUS-CDS is an efficient and safe alternative to ERCP-M in patients with MDBO. These findings provide evidence for greater adoption of EUS-CDS in clinical practice as a complementary and exchangeable first-line modality to ERCP in patients with MDBO., Clinicaltrials: gov, Number: NCT03870386., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Resection options for early gastric cancer (EGC) include endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and surgery. In patients with metachronous EGC following previous resection, the optimal resection technique is not well elucidated. We conducted a systematic review and meta-analysis of studies comparing ESD to EMR, or ESD to surgery, in patients with metachronous EGC., Methods: We conducted an electronic search of studies reporting on outcomes and AEs following ESD versus either EMR or surgery for patients with metachronous EGC. Pooled odds ratios (OR) of included studies were obtained using DerSimonian and Laird random effects models. Funnel plots were produced and visually inspected for evidence of publication bias. The quality of the evidence was assessed using GRADE., Results: A total of 9367 abstracts were screened and 10 observational studies were included. The odds of complete resection were higher amongst patients undergoing ESD compared to EMR (OR 5.88, 95% confidence intervals, CI, 1.79-19.35), whereas the odds of complete resection were no different between ESD and surgery (OR 0.57, 95% CI 0.04-8.24). There were no differences in the odds of local recurrence with ESD versus surgery (OR 5.01, 95% CI 0.86-29.13). Post-procedural bleeding did not differ significantly between ESD and EMR (OR 0.70, 95% CI 0.16-3.00). There was no evidence of publication bias., Discussion: For metachronous EGC, ESD or surgery is preferred over EMR depending on local expertise and patient preferences, largely due to a higher risk of incomplete resection with EMR., Review Registration: PROSPERO CRD42021270445., (© 2023. The Society for Surgery of the Alimentary Tract.)

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for the diagnosis of malignancy in patients with biliary strictures of undetermined etiology. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses the role of fluoroscopic-guided biopsy sampling, brush cytology, cholangioscopy, and EUS in the diagnosis of malignancy in patients with biliary strictures. In the endoscopic workup of these patients, we suggest the use of fluoroscopic-guided biopsy sampling in addition to brush cytology over brush cytology alone, especially for hilar strictures. We suggest the use of cholangioscopic and EUS-guided biopsy sampling especially for patients who undergo nondiagnostic sampling, cholangioscopic biopsy sampling for nondistal strictures and EUS-guided biopsy sampling distal strictures or those with suspected spread to surrounding lymph nodes and other structures., (Copyright © 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach to strategies to prevent endoscopy-related injury (ERI) in GI endoscopists. It is accompanied by the article subtitled "Methodology and Review of Evidence," which provides a detailed account of the methodology used for the evidence review. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline estimates the rates, sites, and predictors of ERI. Additionally, it addresses the role of ergonomics training, microbreaks and macrobreaks, monitor and table positions, antifatigue mats, and use of ancillary devices in decreasing the risk of ERI. We recommend formal ergonomics education and neutral posture during the performance of endoscopy, achieved through adjustable monitor and optimal procedure table position, to reduce the risk of ERI. We suggest taking microbreaks and scheduled macrobreaks and using antifatigue mats during procedures to prevent ERI. We suggest the use of ancillary devices in those with risk factors predisposing them to ERI., (Copyright © 2023. Published by Elsevier Inc.)

Video 1Clinical case of dual-balloon through-the-scope exchangeable enteroclysis catheter-assisted EUS-guided gastroenterostomy., (© 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

This document from the American Society for Gastrointestinal Endoscopy (ASGE) provides a full description of the methodology used in the review of the evidence used to inform the final guidance outlined in the accompanying Summary and Recommendations document regarding the role of endoscopic submucosal dissection (ESD) in the management of early esophageal and gastric cancers. This guideline used the Grading of Recommendations, Assessment, Development and Evaluation framework and specifically addresses the role of ESD versus EMR and/or surgery, where applicable, for the management of early esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), and gastric adenocarcinoma (GAC) and their corresponding precursor lesions. For ESCC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >15 mm, whereas in patients with similar lesions ≤15 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for such patients with ESCC, whenever possible. For EAC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >20 mm, whereas in patients with similar lesions measuring ≤20 mm, the ASGE suggests either ESD or EMR. For GAC, the ASGE suggests ESD over EMR for patients with early-stage, well or moderately differentiated, nonulcerated intestinal type cancer measuring 20 to 30 mm, whereas for patients with similar lesions <20 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for patients with such lesions measuring ≤30 mm, whereas for lesions that are poorly differentiated, regardless of size, the ASGE suggests surgical evaluation over endosic approaches., (Copyright © 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based summary and recommendations regarding the role of endoscopic submucosal dissection (ESD) in the management of early esophageal and gastric cancers. It is accompanied by the document subtitled "Methodology and Review of Evidence," which provides a detailed account of the methodology used for the evidence review. This guideline was developed using the Grading of Recommendations, Assessment, Development and Evaluation framework and specifically addresses the role of ESD versus EMR and/or surgery, where applicable, for the management of early esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), and gastric adenocarcinoma (GAC) and their corresponding precursor lesions. For ESCC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >15 mm, whereas in patients with similar lesions ≤15 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for such patients with ESCC, whenever possible. For EAC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >20 mm, whereas in patients with similar lesions measuring ≤20 mm, the ASGE suggests either ESD or EMR. For GAC, the ASGE suggests ESD over EMR for patients with early-stage, well- or moderately differentiated, nonulcerated intestinal type cancer measuring 20 to 30 mm, whereas for patients with similar lesions <20 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for patients with such lesions measuring ≤30 mm, whereas for lesions that are poorly differentiated, regardless of size, we suggest surgical evaluation over endoscopic approaches., (Copyright © 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)