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Background and Aims The role of per-oral pancreatoscopy (POP) in the evaluation of occult pancreatic duct (PD) lesions remains limited to case series. The aim of this study was to evaluate the ability of POP to differentiate malignant from benign diseases of the PD. Methods Patients who underwent POP between 2000 and 2013 for the evaluation of indeterminate PD strictures, dilatations, or with suspected or known main duct intraductal papillary mucinous neoplasm were identified. Main outcome measurements were visual impression accuracy, POP tissue sampling, efficacy, and safety of POP. Results During the study period, 79 patients who underwent POP for the evaluation of pancreatic stricture or dilatation were identified. Technical success was achieved in 78 (97%). In the PD neoplasia group (n = 33), the final diagnosis was based on index confirmatory POP-guided tissue sampling in 29 (88%). For the detection of PD neoplasia, POP visual impression had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 87%, 86%, 83%, 91%, and 87%, respectively. When combined with POP-guided tissue sampling, the values were 91%, 95%, 94%, 93%, and 94%, respectively. Of 102 POPs performed, adverse events were noted in 12 (12%) cases. Conclusions This study demonstrates a high technical success rate, visual impression accuracy, and tissue sampling capability of POP. Examinations were performed by endoscopists with expertise in pancreatoscopy interpretation, and the results may not be generalizable.

Background and Aims The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. Methods This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated. Results A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred. Conclusions Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.

Factors associated with successful endoscopic therapy with temporary stents for esophageal leaks, fistulae, and perforations (L/F/P) are not well known.To evaluate the safety, efficacy, and outcomes of esophageal stenting in these patients and identify factors associated with successful closure.Retrospective.Academic tertiary referral center.All patients with attempted stent placement for esophageal L/F/P between January 2003 and May 2012.Esophageal stent placement and removal.Factors predictive of therapeutic success defined as complete closure after index stent removal (primary closure) or after further endoscopic stenting (secondary closure).Sixty-seven patients with 132 attempted stents for esophageal L/F/P were considered; 13 patients were excluded. Among the remaining 54 patients, 117 stents were placed for leaks (29 patients; 64 stents), fistulae (15 patients; 36 stents), and perforations (10 patients; 17 stents). Procedural technical success was achieved in all patients (100%). Primary closure was successful in 40 patients (74%) and secondary closure in an additional 5 (83% overall). On short-term (3 months) follow-up, 27 patients (50%) were asymptomatic, whereas 22 (41%) had technical adverse events, including stent migration in 15 patients (28%). Factors associated with successful primary closure include a shorter time between diagnosis of esophageal L/F/P and initial stent insertion (9.03 vs 22.54 days; P = .003), and a smaller luminal opening size (P = .002).Retrospective, single-center study.Temporary stents are safe and effective in treating esophageal L/F/P. Defect opening size and time from diagnosis to stent placement appear to be candidate predictors for successful closure.

Problems of compliance, quality, and safety of colon preparation regimens have prompted continued investigation with alternative forms of cleansing.To evaluate the efficacy of tegaserod as an adjunct to a polyethylene glycol electrolyte solution (PEG-E), given as a whole dose or split dose, in colonoscopy preparation.Randomized, placebo-controlled, double-blind trial.A single university-based hospital.Patients who were undergoing elective colonoscopy.A 4-arm randomization scheme that compared tegaserod with a placebo, each with whole-dose or split-dose PEG-E preparation.Efficacy of colon cleansing was the primary outcome. Secondary outcomes included adherence, tolerability, adverse effects, and patient perceptions of their preparation quality.A total of 382 patients completed the trial. Patients who received the split-dose preparation had significantly better colon cleansing than those who received the whole-dose preparation (88.9% vs 42.6%, P.001). The addition of tegaserod did not significantly improve the overall colonoscopy preparation quality compared with a placebo. However, there were fewer poor preparations in the whole-dose PEG-E group (12.4% vs 1.1%, P = .002, Bonferroni correction removes significance) and more excellent preparations in the split-dose group (53.3% vs 38.3%, P = .035, Bonferroni correction removes significance) in favor of tegaserod. Interobserver and intraobserver variability analysis showed substantial agreement among endoscopists. Adherence was significantly lower in the whole-dose group versus the split-dose PEG-E group (68.8% vs 91%, P.001), independent of the use of tegaserod. Adverse effects were not different between study groups.A 4-arm randomization and the single-center nature of the study.Tegaserod has a marginal effect on the quality of colonoscopy preparation when used as an adjuvant to PEG-E. The split-dose PEG-E was superior to the whole-dose PEG-E and resulted in better colon cleansing, adherence, and tolerance.

Background Gastric mucosa–associated lymphoid tissue (MALT) lymphoma is associated with Helicobacter pylori infection, and regression of the tumor has been described after its eradication. Objective To determine the value of EUS, in addition to other clinical/endoscopic features, in predicting the response of low-grade MALT lymphoma to H pylori eradication. Design A retrospective, single-center study. Setting and Patients Twenty-two patients with primary gastric MALT lymphoma were identified through a retrospective review of charts of patients seen at the American University of Beirut Medical Center. Only 19 patients with histopathologically confirmed gastric MALT lymphoma and H pylori infection who had EUS staging were included in the study. Main Outcome Measurements Regression of the gastric MALT lymphoma as determined by follow-up endoscopy and mucosal biopsies. Results Patients with disease restricted to the gastric mucosa had a significantly higher rate of complete remission after H pylori eradication compared with patients who had disease infiltrating into the gastric submucosa (77.8% vs 12.5%, P value .007). There was no statistical difference in terms of the mean follow-up time to achieve such response ( P value .212). Age, sex, location of the tumor within the stomach, and endoscopic appearance did not correlate with the probability of complete remission of the MALT lymphoma. Limitations The limitations include a retrospective design and a relatively small sample population. Conclusion EUS determination of the invasion depth of gastric MALT lymphoma helps predict a complete response to H pylori eradication.

Background and Aims There are limited data on learning curves and competence in ERCP. By using a standardized data collection tool, we aimed to prospectively define learning curves and measure competence among advanced endoscopy trainees (AETs) by using cumulative sum (CUSUM) analysis. Methods AETs were evaluated by attending endoscopists starting with the 26th hands-on ERCP examination and then every ERCP examination during the 12-month training period. A standardized ERCP competency assessment tool (using a 4-point scoring system) was used to grade the examination. CUSUM analysis was applied to produce learning curves for individual technical and cognitive components of ERCP performance (success defined as a score of 1, acceptable and unacceptable failures [p1] of 10% and 20%, respectively). Sensitivity analyses varying p1 and by using a less-stringent definition of success were performed. Results Five AETs were included with a total of 1049 graded ERCPs (mean ± SD, 209.8 ± 91.6/AET). The majority of cases were performed for a biliary indication (80%). The overall and native papilla allowed cannulation times were 3.1 ± 3.6 and 5.7 ± 4, respectively. Overall learning curves demonstrated substantial variability for individual technical and cognitive endpoints. Although nearly all AETs achieved competence in overall cannulation, none achieved competence for cannulation in cases with a native papilla. Sensitivity analyses increased the proportion of AETs who achieved competence. Conclusion This study demonstrates that there is substantial variability in ERCP learning curves among AETs. A specific case volume does not ensure competence, especially for native papilla cannulation.

1. Zargar SA, Kochhar R, Mehta S, et al. The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. Gastrointest Endosc 1991;37:165-9. 2. Zargar SA, Kochhar R, Nagi B, et al. Ingestion of strong corrosive alkalis: spectrum of injury to upper gastrointestinal tract and natural history. Am J Gastroenterol 1992;87:337-41. 3. Agarwal S, Sikora SS, Kumar A, et al. Surgical management of corrosive strictures of stomach. Indian J Gastroenterol 2004;23: 178-80. 4. Mamede RC, De Mello Filho FV. Treatment of caustic ingestion: an analysis of 239 cases. Dis Esophagus 2002;15:210-3. 5. Anderson KD, Rouse TM, Randolph JG. A controlled trial of corticosteroids in children with corrosive injury of the esophagus. N Engl J Med 1990;323:637-40.

449 Variation in Learning Curves and Competence for Endoscopic Retrograde Cholangiopancreatography Among Advanced Endoscopy Trainees (AETs) Using Cumlative Sum Analysis (CUSUM)Implication for American Scoiety for Gastrointestinal Endoscopy Society for Gastrointestinal Endoscopy Recommendations for Training Sachin Wani*, Andrew Y. Wang, Christopher J. Dimaio, V. Raman Muthusamy, Rajesh N. Keswani, Brian C. Brauer, Jeffrey J. Easler, Roy D. Yen, Ihab El Hajj, Norio Fukami, Kourosh F. Ghassemi, Susana Gonzalez, Lindsay Hosford, Thomas G. Hollander, Vladimir M. Kushnir, Jawad Ahmad, Faris Murad, Anoop Prabhu, Rabindra R. Watson, Daniel S. Strand, Stuart K. Amateau, Raj J. Shah, Steven A. Edmundowicz, Daniel Mullady University of Colorado, Centennial, CO; University of Virginia Health System, Charlottesville, VA; Icahn School of Medicine at Mount Sinai, New York, NY; Feinberg School of Medicine Northwestern University, Chicago, IL; Washington University School of Medicine, St. Louis, MO; University of California, Los Angeles, Los Angeles, CA Background: There are limited data on learning curves and competence in ERCP and the guidelines set forth by the ASGE are largely based on expert opinions and biliary cannulation rates (180 total procedures). These guidelines have not been validated, do not account for different rates of learning, and other relevant quality indicators in ERCP.AimTo prospectively define learning curves and measure competency among AETs at multiple training centers using a standardized data collection tool. Methods: AETs were supervised and graded at 5 training programs and introduced to all aspects of ERCP at the onset of training. Starting with 25 hands-on exam, each AET was graded on every ERCP exam during the 1-yr training period. A standardized ERCP competency assessment tool was used. Case number, indication and grade of difficulty were recorded. Technical and cognitive aspects assessed are shown in Table. A 4-point scoring system was used: 1-no assistance, 2-achieves with minimal verbal cues, 3-multiple verbal cues or hands on assistance, 4-unable to complete. CUSUM analysis was applied to produce learning curves for individual components of ERCP performance (success defined as score of 1). Acceptable and unacceptable failure rates of 10% (p0) and 20% (p1) respectively were used. Sensitivity analyses varying p1 between 0.2-0.35 and assessing competence using a less stringent definition of success (score of 1 or 2) were performed. Results: Five AETs were included with a total of 1047 graded ERCPs [mean 209.8 (SD 91.6)/AET]. Distribution of cases based on indication was: biliary 833 (80%), pancreatic (13%) and biliary and pancreatic 73 (7%). With regards to ASGE degree of difficult grade, the majority were biliary grade 1 (nZ591, 56.4%). There were overall 379 (38.9%) procedures in cases with a native papilla and sphincterotomy was performed in 474 (56.9%) cases. Overall mean time allowed for cannulation for AETs was 3.1 minutes (SD 3.6). Overall learning curves demonstrated substantial variability (Table). Nearly all AETs achieved competence in basic techniques, stent removal, overall cannulation, wire placement, balloon sweeps and cognitive aspects. However, none achieved competence in native papilla cannulation and sphincterotomy. Similarly, only 1-2 AETs achieved competence in stone clearance, dilation and insertion (Figure). Sensitivity analyses described above increased the proportion of AETs that achieved competency (Table). Conclusions: Results from this multicenter prospective study demonstrate substantial variability in achieving competency and there is a consistent need for more supervision especially for biliary cannulation and sphincterotomy than currently recommended in ASGE guidelines. Large multicenter study focusing on an assessment tool to accurately define trainee progression providing structured and objective feedback is currently underway. Table: Advanced endoscopy trainees achieving competence based on case number and sensitivity analyses* AB150 GASTROINTESTI Number of AETs achieving competence NAL ENDOSCOPY Procedure number at which competency was achieved Volume 81, Maximum number of AETs achieving competence based on sensitivity analyses* Basic technique Intubation 5 19, 21, 21, 21, 55 5 Achieving short position 5 19, 19, 26, 35

D A 70-year-old man was admitted with acute dysphagia to solids and liquids. He had a history of gastroesophageal reflux disease, Barrett’s esophagus, and large hiatal hernia, and he had previously undergone three antireflux surgical procedures, including a Nissen fundoplication, and then two repeated operations, the first through a left thoracoabdominal approach and the second through a right thoracotomy. His most recent endoscopy, performed for surveillance of Barrett’s esophagus 2 months before admission, showed long segment Barrett’s esophagus, a hiatal hernia with patent hiatal narrowing (A) and large gastric wrap folds around the cardia on retroflexed view (B). Upon admission, an esophagogram revealed distal esophageal obstruction. Upper endoscopy showed a mildly dilated esophagus and intussusception of gastric folds within t