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Upper endoscopy (UE) procedures (EGD and ERCP) are an established standard of care in pediatric gastroenterology. The Pediatric Endoscopy Quality Improvement Network (PEnQuIN) recently published its pediatric-specific endoscopy quality guidelines. This study, initiated by the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition, aims to evaluate the adherence of Italian pediatric endoscopy centers (PECs) to these established quality standards. Conducted between April 2019 and March 2021, this nationwide study used a smartphone–based app approach. Data encompassing pediatric endoscopy facilities, patient profiles, endoscopy indications, 17 procedure-related PEnQuIN indicators, and a patient satisfaction questionnaire (Group Health Association of America-9) were systematically collected. A comprehensive analysis of 3582 procedures from 24 centers revealed that 2654 (76%) were UEs. The majority of centers (75%) involved >1 operator, with 9 centers incorporating adult endoscopists, responsible for 5% of UEs. Overall, adherence to quality standards was good; however, areas of improvement include suboptimal reporting of sedation details, adherence to disease-specific guidelines, and patient satisfaction questionnaire completeness (56%). The adverse event rate aligned with literature standards (1%), and patient satisfaction was generally high. A noteworthy observation was a 30% decreased monthly reporting rate and a shift in disease-specific patterns after the COVID-19 outbreak. Pediatric UE practices in Italy adhere well to established quality standards. Emphasizing the adoption of disease-specific guidelines is crucial for optimizing resources, enhancing diagnostic accuracy, and minimizing unnecessary procedures. Prioritizing patient satisfaction is important for immediate enhancements in practice as well as for future research endeavors. [Display omitted] [ABSTRACT FROM AUTHOR]

Meta-analytic comparison of EUS-guided gallbladder drainage (EUS-GBD) versus percutaneous gallbladder drainage (PT-GBD) for acute cholecystitis (AC) brings the risk of spurious results if too few studies are included. Trial sequential analysis (TSA) can overcome this, providing information about its credibility. Comparative studies between EUS-GBD, using lumen-apposing metal stents, and PT-GBD for AC until July 2021 were used for conventional meta-analysis and TSA, which allowed the use of monitoring boundaries and the estimation of the required information size (RIS) needed to prove credibility. Four studies accrued 535 patients. Technical success was in favor of PT-GBD (relative risk [RR],.967; P =.036), but TSA estimated that 1663 participants would be needed to avoid a Type I error (false positive). Clinical success was similar (RR,.965; P =.146), and TSA supported the absence of any demonstrable superiority of one therapy rather than a Type II error (false negative). EUS-GBD reduced overall adverse events (RR,.424; P <.001) and unplanned readmissions (RR,.215; P <.001), and TSA confirmed the avoidance of a Type I error, with early RIS achievement, providing necessary credibility. EUS-GBD had fewer reinterventions (RR,.244; P <.001), but a Type I error was not avoided, needing additional 97 patients to the accrued 535 to prove credibility. PT-GBD can provide superior technical success than EUS-GBD if a very large sample size is accrued, thus limiting the single-patient benefit. Clinical success is probably equivalent. EUS-GBD convincingly decreased overall adverse events and unplanned readmissions, whereas the need for reinterventions requires additional studies. [ABSTRACT FROM AUTHOR]

Self-expandable metal stents (SEMSs) are standardly used for distal malignant biliary obstruction (dMBO). Although data suggest that covered versus uncovered SEMSs increase the time to recurrent biliary obstruction (TRBO), no data are available for fully covered (FC) versus partially covered (PC) designs. PubMed, Scopus, and Cochrane databases were screened up to January 2023 for studies concerning dMBO treated by an FC- or PC-SEMS and describing adverse events (AEs), recurrences, or TRBO for specific design subpopulations. Pooled proportions or means were calculated using a random-effects model. Several subanalyses were preplanned, including a subanalysis restricted to prospective studies and unresectable diseases. Heterogeneity and publication bias were explored. Standardized differences (d-values) were calculated between groups. From 1290 records, 62 studies (3327 using FC-SEMSs and 2322 using PC-SEMSs) were included. FC- versus PC-SEMSs showed negligible differences in the rate of total AEs (12% vs 9.9%) and all specific AEs, including cholecystitis (2.5% vs 2.6%). In a subanalysis restricted to prospective studies and unresectable diseases, the rate of RBO was comparable between FC-SEMSs (27.3% [95% confidence interval {CI}, 23.7-31.2], I 2 = 35.34%) and PC-SEMSs (25.3% [95% CI, 20.2-30.7], I 2 = 85.09%), despite small differences (d-values between.186 and.216) in the rate of ingrowth (.5% vs 2.9%) favoring FC-SEMSs and migration (9.8% vs 4.3%) favoring PC-SEMSs. TRBO was shorter for FC-SEMSs (238 days [95% CI, 191-286], I2 = 63.1%) versus PC-SEMSs (369 days [95% CI, 290-449], I 2 = 71.9%; d-value =.116). Despite considerable heterogeneity and small standardized differences, PC-SEMSs consistently exhibited longer TRBO than FC-SEMSs across analyses, without any other differences in AE rates, potentially proposing PC-SEMSs as the standard comparator and TRBO as the primary outcome for future randomized studies on dMBO. (Clinical trial registration number: CRD42023393965.) [Display omitted] [ABSTRACT FROM AUTHOR]

Obesity is a pandemic affecting approximately 700 million adults worldwide, with an additional 2 billion overweight. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic bariatric therapy that involves remodeling of the greater curvature in an effort to reduce gastric capacity and delay gastric emptying. A variety of ESG suture patterns has been reported. This study is the first to use a uniform "U" stitch pattern across all centers to simplify technical aspects of the procedure and limit cost. This also uniquely assessed outcomes in all body mass index (BMI) categories and changes in metabolic rate, lean body mass, and adipose tissue composition. This is a multicenter analysis of prospectively collected data from 7 centers including patients with overweight and obesity who underwent ESG. Primary outcomes included absolute weight loss, percent total body weight loss (%TWL), change in BMI, and percent excess weight loss (%EWL) at 6 and 12 months in overweight and obese classes I, II, and III. Secondary outcomes included adipose tissue, lean body mass reduction, and metabolic rate analyzed by bioimpedance. Additionally, immediate or delayed adverse events (AEs) were analyzed. Clinical success was defined as achieving ≥25% EWL at 1 year with ≤5% serious AE (SAE) rate following the American Society for Gastrointestinal Endoscopy (ASGE)/American Society for Metabolic and Bariatric Surgery (ASMBS) threshold. A total of 193 patients underwent ESG during the study period. All groups had >10% TWL and >25% EWL at 6 months of follow-up. On average, %TWL was 14.25% ± 5.26% and 15.06% ± 5.22% and the %EWL 56.15% ± 22.93% and 59.41% ± 25.69% at 6 months and 1 year of follow-up, respectively. %TWL was 8.91% ±.3%, 13.92% ± 5.76%, 16.22% ± 7.69%, and 19.01% ±.95% and %EWL 56.21% ± 2.0%, 62.03% ± 27.63%, 54.13% ± 23.46%, and 46.78% ± 2.43% for overweight and obesity classes I, II, and III, respectively, at 1 year. Male sex, age <41 years, and higher BMI were predictors of achieving a TWL ≥10% at 1-year follow-up. There was a significant reduction in adipose tissue from baseline. SAEs occurred in 1.03%, including 2 perigastric collections needing surgery. ESG appears to be feasible, safe, and effective in the treatment of patients with overweight and obesity according to ASGE/ASMBS thresholds. [ABSTRACT FROM AUTHOR]

Background and Aims Several studies have compared EUS-guided FNA with fine-needle biopsy (FNB), but none have proven superiority. We performed a multicenter randomized controlled trial to compare the performance of a commonly used 25-gauge FNA needle with a newly designed 20-gauge FNB needle. Methods Consecutive patients with a solid lesion were randomized in this international multicenter study between a 25-gauge FNA (EchoTip Ultra) or a 20-gauge FNB needle (ProCore). The primary endpoint was diagnostic accuracy for malignancy and the Bethesda classification (non-diagnostic, benign, atypical, malignant). Technical success, safety, and sample quality were also assessed. Multivariable and supplementary analyses were performed to adjust for confounders. Results A total of 608 patients were allocated to FNA (n = 306) or FNB (n = 302); 312 pancreatic lesions (51%), 147 lymph nodes (24%), and 149 other lesions (25%). Technical success rate was 100% for the 25-gauge FNA and 99% for the 20-gauge FNB needle (P =.043), with no differences in adverse events. The 20-gauge FNB needle outperformed 25-gauge FNA in terms of histologic yield (77% vs 44%, P <.001), accuracy for malignancy (87% vs 78%, P =.002) and Bethesda classification (82% vs 72%, P =.002). This was robust when corrected for indication, lesion size, number of passes, and presence of an on-site pathologist (odds ratio, 3.53; 95% confidence interval, 1.55-8.56; P =.004), and did not differ among centers (P =.836). Conclusion The 20-gauge FNB needle outperformed the 25-gauge FNA needle in terms of histologic yield and diagnostic accuracy. This benefit was irrespective of the indication and was consistent among participating centers, supporting the general applicability of our findings. (Clinical trial registration number: NCT02167074.) [ABSTRACT FROM AUTHOR]

The optimal endoscopic resection method of challenging colorectal lesions (ie, adenomatous recurrences, nongranular laterally spreading tumors [LST-NGs], lesions without lifting sign <30 mm) is still under debate. The aim of this study was to directly compare endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) for the resection of challenging colorectal lesions in a randomized trial. A multicenter, prospective, randomized study was performed in 4 Italian referral centers. Consecutive patients referred for endoscopic resection of challenging lesions were randomly assigned to undergo EFTR or ESD. Primary outcomes were complete (R0) resection and en bloc resection of lesions. Technical success, procedure time, procedure speed, area of the resected specimen, adverse event rate, and local recurrence rate at 6 months were also compared. Overall, 90 patients were included in the study, equally representing the 3 challenging lesion types. Age and sex were comparable in the 2 groups. En bloc resection was obtained in 95.5% of the EFTR group and in 93.3% of the ESD group. R0 resection rate was comparable in the 2 groups (EFTR vs ESD, 42 [93.3%] vs 36 [80%]; P =.06). The EFTR group exhibited a significantly shorter total procedure time (25.6 ± 10.6 minutes vs 76.7 ± 26.4 minutes, P ≤.01), as well as overall procedure speed (16.8 ± 11.8 mm2/min vs 11.9 ± 9.2 mm2/min, P =.03). The EFTR group had a significantly smaller mean lesion size (21.6 ± 8.3 mm vs 28.7 ± 7.7 mm, P ≤.01). Adverse events were reported less frequently in patients in the EFTR group (4.44% vs 15.5%, P =.04). EFTR is comparable to ESD in the treatment of challenging colorectal lesions in terms of safety and efficacy. EFTR is considerably faster than ESD in the treatment of nonlifting lesions and adenoma recurrences. (Clinical trial registration number: NCT05502276.) [Display omitted] [ABSTRACT FROM AUTHOR]

Retrospective studies on malignant gastric outlet obstruction (mGOO) highlighted several advantages of EUS-guided gastroenterostomy (EUS-GE) over enteral stenting (ES). However, no prospective evidence is available. The aim of this study was to report on clinical outcomes of EUS-GE in a prospective cohort study, with a subgroup comparison versus ES. All consecutive patients endoscopically treated for mGOO between December 2020 and December 2022 in a tertiary, academic center were enrolled in a prospective registry (Prospective Registry of Therapeutic Endoscopic Ultrasound [PROTECT]; NCT04813055) and followed up every 30 days to register efficacy/safety outcomes. EUS-GE and ES cohorts were matched according to baseline frailty and oncologic disease. A total of 104 patients were treated for mGOO during the study; 70 (58.6% male subjects; median age, 64 [interquartile range, 58-73] years; 75.7% pancreatic cancer, 60.0% metastatic cancer) underwent EUS-GE via the wireless simplified technique. Technical success was 97.1% and clinical success was 97.1% after a median of 1.5 (interquartile range, 1-2) days. Adverse events occurred in 9 (12.9%) patients. After a median follow-up of 105 (49-187) days, symptom recurrence was 7.6%. In the matched comparison versus ES (28 patients per arm), EUS-GE–treated patients experienced higher and faster clinical success (100% vs 75.0%, P =.006), reduced recurrences (3.7% vs 33.3%, P =.02), and a trend toward shorter time to chemotherapy. In this first, prospective, single-center comparison, EUS-GE showed excellent efficacy in treating mGOO, with an acceptable safety profile and long-term patency, and several clinically significant advantages over ES. While awaiting randomized trials, these results might endorse EUS-GE as first-line strategy for mGOO, where adequate expertise is available. [Display omitted] [ABSTRACT FROM AUTHOR]

Gastric outlet and biliary obstruction are common manifestations of GI malignancies and some benign diseases for which standard treatment would be surgical gastroenterostomy and hepaticojejunostomy (ie, "double bypass"). Therapeutic EUS has allowed for the creation of an EUS-guided double bypass. However, same-session double EUS-guided bypass has only been described in small proof-of-concept series and lacks a comparison with surgical double bypass. A retrospective multicenter analysis was performed of all consecutive same-session double EUS-guided bypass procedures performed in 5 academic centers. Surgical comparators were extracted from these centers' databases from the same time interval. Efficacy, safety, hospital stay, nutrition and chemotherapy resumption, long-term patency, and survival were compared. Of 154 identified patients, 53 (34.4%) received treatment with EUS and 101 (65.6%) with surgery. At baseline, patients undergoing EUS exhibited higher American Society of Anesthesiologists scores and a higher median Charlson Comorbidity Index (9.0 [interquartile range {IQR}, 7.0-10.0] vs 7.0 [IQR, 5.0-9.0], P <.001). Technical success (96.2% vs 100%, P =.117) and clinical success rates (90.6% vs 82.2%, P =.234) were similar when comparing EUS and surgery. Overall (11.3% vs 34.7%, P =.002) and severe adverse events (3.8% vs 19.8%, P =.007) occurred more frequently in the surgical group. In the EUS group, median time to oral intake (0 days [IQR, 0-1] vs 6 days [IQR, 3-7], P <.001) and hospital stay (4.0 days [IQR, 3-9] vs 13 days [IQR, 9-22], P <.001) were significantly shorter. Despite being used in a patient population with more comorbidities, same-session double EUS-guided bypass achieved similar technical and clinical success and was associated with fewer overall and severe adverse events when compared with surgical gastroenterostomy and hepaticojejunostomy. [ABSTRACT FROM AUTHOR]

Background and Aims Pancreatic ductal adenocarcinoma (PDAC) is typically diagnosed at a late stage. Little is known about the incidental finding of early-stage PDAC. The aim of the current study was to determine the etiology of small solid pancreatic lesions (≤15 mm) to optimize clinical management. Methods Inclusion criterion for the retrospective study analysis was the incidental finding of primarily undetermined small solid pancreatic lesions ≤15 mm in 394 asymptomatic patients. Final diagnoses were based on histology or cytology obtained by imaging-guided biopsy (and at least 12-month follow-up) and/or surgery. Contrast-enhanced US or contrast-enhanced EUS was performed in 219 patients. Results The final diagnoses of 394 patients were as follows: 146 PDACs, 156 neuroendocrine tumors, 28 metastases into the pancreas from other primary sites, and 64 various other etiologies. Contrast-enhanced US allowed differential diagnosis of PDAC and non-PDAC in 189 of 219 patients (86%). Conclusions Approximately 40% of patients with small solid pancreatic lesions had very early stage PDAC. Approximately 60% of small solid pancreatic lesions ≤15 mm are not PDAC and, therefore, do not require radical surgery. Without preoperative diagnosis, an unacceptably large proportion of patients would be exposed to radical surgery with significant morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background and Aims Self-expandable metal stent (SEMS) positioning is the recommended method for palliation of dysphagia from esophageal cancer, although it is not adverse event–free. The present study was aimed at identifying predictors for adverse events and at proposing a statistical model to predict them. Methods We performed a retrospective analysis of a prospectively collected database. All patients who underwent SEMS placement for stricture due to esophageal cancer between 2002 and 2011 in a tertiary-care center were identified. Multivariable regression analysis in the presence of competing risk events was used to identify factors associated with SEMS-related adverse events and to build a prediction model. Results A total of 267 patients were included. According to the competing risk regression analysis, only 2 variables were significantly associated with the risk of SEMS-related adverse events: prior chemoradiotherapy (CRT), yielding a hazard ratio (HR) of 1.687 (95% confidence interval [CI], 1.076-2.644), and the SEMS length (HR 0.884; 95% CI, 0.798-0.980) for every 10-mm length increase. Based on the estimated probability curves, after 4 months from SEMS placement, the probability of an adverse event in patients who did receive prior CRT was 50.9% compared with 34.4% in those who did not receive prior therapy, which was reduced to 9.2% and 15.1%, respectively, if a 180 mm-length stent was used. The ability of the predictive model to differentiate between patients who did and did not experience the adverse event was moderate (c-index: 0.617). Conclusion The rate of SEMS-related adverse events was higher in patients with previous CRT and lower in patients receiving longer stents. Both factors were used to build an accurate predictive model. [ABSTRACT FROM AUTHOR]

Background and Aims Because a traditional rendezvous (RV) technique implies stretching of the papilla, possibly leading to post-ERCP pancreatitis, an alternative duodenal RV technique was evaluated. The aim was to assess the effectiveness, safety, and amount of time spent performing duodenal RV versus traditional RV cannulation in orthotopic liver transplantation patients with a T-tube. Methods We retrospectively reviewed data from a prospective ERCP database held by our university hospital. Twenty patients with a T-tube who had undergone ERCP for biliary adverse events after orthotopic liver transplantation were included. The successful cannulation rate, the amount of time spent performing cannulation, the post-ERCP pancreatitis rate, and hyperamylasemia 24 hours after the procedure were recorded. Results Successful cannulation was achieved by the duodenal RV technique in 9 of 10 patients (90%), taking 146 seconds (interquartile range 63-341 seconds) with a short learning curve effect. An unsuccessful duodenal RV procedure occurred because of the angulation of the hydrophilic tip of the guidewire while crossing the papilla, thus preventing cannulation. Successful cannulation was achieved by the traditional RV technique in all cases (N = 11), including the failed duodenal RV technique, taking 374 seconds (interquartile range 320-410 seconds) ( P < .05 vs duodenal RV). However, no post-ERCP pancreatitis occurred after using the duodenal RV technique compared with 2 episodes of mild pancreatitis after using the traditional RV technique. Twenty-four hours after the procedure, the median amylasemia level was 84 IU/L (interquartile range 49-105 IU/L) and 265 IU/L (interquartile range 73-2945 IU/L) for the duodenal versus traditional RV techniques, respectively ( P = not significant). Conclusions In patients with a T-tube after liver transplantation, the duodenal RV technique was not associated with post-ERCP pancreatitis, presumably because of the reduction of stress on the major papilla. Cannulation by using the duodenal RV technique was faster compared with the traditional RV technique. These preliminary data point out the use of the duodenal RV technique as the first option to choose in case of failed cannulation before attempting the traditional RV technique. [ABSTRACT FROM AUTHOR]

Therapy and prognosis of pancreatic neuroendocrine tumors (PanNETs) are strictly related to the Ki-67 index, which defines tumor grading. The criterion standard for the assessment of grading of PanNETs is EUS-guided FNA (EUS-FBAFNA) or EUS-guided fine-needle biopsy sampling (EUS-FNB). Because data on diagnostic accuracy of EUS-FNA and EUS-FNB are heterogeneous, we aimed to analyze the variability in concordance between EUS grading and surgical grading. The MEDLINE, SCOPUS, and EMBASE databases were searched until November 2021 to identify studies reporting the concordance rate between EUS grading and surgical grading. The study was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled events were calculated using a random-effects model and expressed in terms of pooled prevalence rates. A multivariate meta-regression was performed to find possible sources of heterogeneity. Where available, individual data were analyzed. Twenty-six studies with 864 patients undergone EUS-FNA or EUS-FNB and surgical resection for PanNETs were included. The pooled estimate rate for the overall concordance of EUS grading and surgical grading was 80.3% (95% confidence interval, 75.6-85.1). Undergrading (EUS grading < surgical grading) was significantly more frequent with respect to overgrading (14.7% vs 3.5%, P <.001). Individual data analysis showed that among nonconcordant patients, the median Ki-67 difference was 3% (interquartile range, 2-6.15). The type of World Health Organization classification adopted and the median lesion diameter were significantly associated with heterogeneity at meta-regression. EUS is an accurate technique in defining grading in patients with PanNETs, but a margin of error still exists, which should be the focus of future studies to minimize the risk of over- and/or undertreatment. [ABSTRACT FROM AUTHOR]

Pancreatic cystic neoplasms (PCNs) represent a difficult preoperative diagnosis despite improvements in imaging. In this study, we compared preoperative and final pathologic diagnosis in a large cohort of resected PCNs, evaluating diagnostic accuracy with a specific focus on the value of EUS. A retrospective analysis of patients undergoing resection between 2009 and 2019 for presumed PCNs was performed. Preoperative workup was reviewed by analyzing the role of imaging and EUS. Patients with a benign histology who did not show absolute indication were categorized as "delayable surgery." Of 585 patients who were retrospectively analyzed, in 108 (18.5%) final histology did not confirm preoperative diagnosis. EUS was associated with a lower rate of incorrect diagnosis (16%; P =.03), but the risk of overtreatment was similar regardless of instrumental diagnostic path (33/131 vs 68/328, P =.298). Dilatation of the main pancreatic duct and cytologic sampling were the only variables independently associated with a correct diagnosis (P <.001 and P =.041, respectively). Based on clinical presentation and final histology, pancreatic resection could have been spared or delayed in 101 of 459 patients (22%), and this was influenced by age (odds ratio [OR],.97; P =.002), cyst larger than 30 mm (OR, 1.89; P =.005), and type of operation (OR, 3.46 [ P <.001] and 3.18 [ P =.023] for distal pancreatectomies and other resections, respectively). The overall risk of unnecessary immediate surgery for PCNs is about 22% in a high-volume referral center. EUS with cytologic sampling is a useful procedure in the diagnostic management of PCNs, improving their diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Background Diverticular disease is increasingly prevalent in Western societies and is associated with significant morbidity. Objective Two-stage endoscopic device development for inversion and secured ligation of colonic diverticula; first, human cadaver studies were performed to measure forces required for diverticular inversion; second, a novel set of devices (elastic spiked O-ring with delivery system) was tested in animals. Design Prospective, observational study of human cadavers and prospective, interventional study of a porcine model. Setting University hospital pathology laboratory and animal facility. Intervention Full-thickness inversion of the colonic wall with a pipelike delivery instrument to produce an inverted pseudodiverticulum that was secured with a spiked O-ring. Main Outcome Measurements The forces required for diverticular inversion, the secured closure of inverted pseudodiverticula, and the time until necrotic tissue falls off. Results A total of 248 of 248 of cadaveric sigmoid diverticula could be inverted by means of vacuum or forceps. The forces required for inversion ranged from 0.28 to 0.47 N (median, 0.37 N). Twenty-four spiked O-rings were delivered in 6 living pigs to produce 24 inverted pseudodiverticula. One animal died the day after the procedure of a pulmonary thromboembolism. In the remaining 5 pigs, all delivered spiked O-rings remained in place for 7 to 22 days. At necropsy, none of the inverted sites showed signs of perforation but rather full-thickness reparative scarring with ingrowth of connective tissue. Limitations Animal model, stiff pipelike delivery instrument, variations in diverticular location, diameter, and size. Conclusions Endoluminal inversion and securing of colonic diverticula induces tissue necrosis, diverticular sloughing, and full-thickness scarring. [ABSTRACT FROM AUTHOR]

Background: New therapies are needed for pancreatic cancer. Objective: To determine the feasibility and safety of a new endoscopic treatment. Secondary endpoints were to determine effects on tumor growth measured with CT scan and to find the overall survival. Design: A cohort study of patients with local progression of advanced pancreatic adenocarcinoma after neoadjuvant therapy. The cryotherm probe (CTP), a flexible bipolar device that combines radiofrequency with cryogenic cooling, was used under EUS guidance. Setting: San Raffaele Hospital, Milan, Italy; University Medical Center, Hamburg-Eppendorf, Germany. Patients: A total of 22 patients (male/female 11/11; mean age 61.9 years) were enrolled from September 2009 to May 2011. Intervention: Radiofrequency heating: 18 W; pressure for cooling: 650 psi (Pounds per Square Inch); application time: depending on tumor size. Main Outcome Measurements: Feasibility was evaluated during the procedure. A clinical and radiologic follow-up was planned. Results: The CTP was successfully applied in 16 patients (72.8%); in 6 it was not possible because of stiffness of the GI wall and of the tumor. Amylase arose in 3 of 16 patients; none had clinical signs of pancreatitis. Late complications arose in 4 cases: 3 were mostly related to tumor progression. Median postablation survival time was 6 months. A CT scan was performed in all patients, but only in 6 of 16 was it possible to clearly define the tumor margins after ablation. In these patients, the tumor appeared smaller compared with the initial mass (P = .07). Limitations: Small sample of patients, difficulty of objectifying the size of the ablated zone by CT scan. Conclusion: EUS-guided CTP ablation is feasible and safe. Further investigations are needed to demonstrate progression-free survival and local control. [Copyright &y& Elsevier]

Background: About one-third of patients undergoing a Roux-en-Y anastomosis develop Roux stasis syndrome, likely because of disordered electrical conduction. GI electrical stimulation has been previously used successfully in the management of postsurgical gastroparesis. Objective: Endoscopic placement of temporary electrodes and GI electrical stimulation in the management of severe Roux stasis syndrome in a patient with esophagojejunostomy and to determine whether the patient would be a candidate for surgical permanent electrode placement. Design: Case report. Setting: Academic medical center. Patients: This study involved a patient with Roux stasis syndrome. Intervention: Upper endoscopy was performed, followed by endoscopic placement of two temporary electrodes, one each in the two jejunal limbs. Electrical stimulation was provided by an external stimulation device. The patient was re-evaluated 5 days later. Main Outcome Measurements: Electrogastrogram (EGG) parameters including frequency, amplitude, and frequency-amplitude ratio and total symptom score and health-related quality of life score. Results: There was a significant improvement in EGG parameters with electrical stimulation. Also, the patient had a marked improvement in total GI symptom score, from 11 to 4, with a dramatic improvement in the health-related quality of life score from −3 to +3. Limitations: Single case report. Conclusion: Endoscopic placement of temporary electrodes is feasible and safe. GI electrical stimulation of the jejunal limb is a potentially effective treatment for Roux stasis syndrome. [ABSTRACT FROM AUTHOR]

Background: Ablative therapies such as radiofrequency and cryotechnology are widely used in oncological intervention but not in the pancreatic field because of their high operative risks. A new flexible bipolar ablation device (Cryotherm probe [CTP]) was developed combining radiofrequency and cryotechnology. Objective: To evaluate the efficacy of the CTP in destroying neoplastic tissue of explanted pancreatic tumors of patients with pancreatic adenocarcinoma. Design: Ex vivo clinical study. Setting: Inpatient hospital setting. Patients: This study involved 16 explanted pancreatic tumors from 16 patients. Interventions: CTP application was performed on explanted pancreatic tumors. Anatomic specimens were divided into 4 groups; each group received a predefined application time of 120 to 600 seconds. Main Outcome Measurements: The coagulation diameter (short axis) perpendicular to the device''s longitudinal axis was used as the primary outcome measure. Results: All pancreatic specimens showed histological signs of coagulative necrosis. There was a positive correlation between the short axis of the obtained necrosis and duration of application (r = 0.74). Limitations: This study was an ex vivo study with all limitations typical of this kind of study. Conclusions: The CTP is effective in destroying neoplastic pancreatic tissue, creating an ablation zone, the extent of which is related to the duration of application. [Copyright &y& Elsevier]

Background: Despite the high diagnostic yield of EUS-guided FNA, room for technical improvements remains. Recently, the EchoBrush (Cook Endoscopy, Winston-Salem, NC), a disposable cytologic brush, was introduced to the market. To date, only 1 study, limited to 10 pancreatic cyst cases, using this device has been published. Objective: To assess the diagnostic yield of the EchoBrush in a cohort of consecutive patients, irrespective of the target lesion. Design: Case series. Setting: Tertiary care university hospital (Molinette Hospital, Turin, Italy). Patients: Thirty-nine consecutive patients (12 with solid pancreatic masses, 12 with pancreatic cysts, 7 with enlarged lymph nodes, and 8 with submucosal masses) were enrolled. Interventions: The material collected with the EchoBrush and with a standard FNA needle was double-blind evaluated by 2 cytopathologists. Main Outcome Measurements: Adequacy of the sample and sensitivity and specificity of the EchoBrush method. Results: Adequate material for cytologic analysis was collected in 17 of 39 patients (43.6%) with a single pass of the EchoBrush. Results were better for pancreatic lesions (for solid and cystic lesions, the adequacy was 58.3% and 50%, respectively); adequacy was low (28.6% and 25%, respectively) for lymph nodes and submucosal masses. The overall sensitivity and specificity were 57.9% and 31.2%, respectively. There were no adverse events with the procedure. Limitation: Preliminary study. Conclusions: This report suggests that the EchoBrush may provide adequate cellularity to diagnose solid and cystic pancreatic lesions. More extensive studies are needed to compare the EchoBrush and standard needles. [Copyright &y& Elsevier]

In the management of gastric outlet obstruction (GOO), EUS-guided gastroenterostomy (EUS-GE) seems to be safe and more effective than enteral stent placement. However, comparisons with laparoscopic GE (L-GE) are scarce. Our aim was to perform a propensity score–matched comparison between EUS-GE and L-GE. An international, multicenter, retrospective analysis was performed of consecutive EUS-GE and L-GE procedures in 3 academic centers (January 2015 to May 2020) using propensity score matching to minimize selection bias. A standard maximum propensity score difference of.1 was applied, also considering underlying disease and oncologic staging. Overall, 77 patients were treated with EUS-GE and 48 patients with L-GE. By means of propensity score matching, 37 patients were allocated to both groups, resulting in 74 (1:1) matched patients. Technical success was achieved in 35 of 37 EUS-GE–treated patients (94.6%) versus 100% in the L-GE group (P =.493). Clinical success, defined as eating without vomiting or GOO Scoring System ≥2, was achieved in 97.1% and 89.2%, respectively (P =.358). Median time to oral intake (1 [interquartile range {IQR},.3-1.0] vs 3 [IQR, 1.0-5.0] days, P <.001) and median hospital stay (4 [IQR, 2-8] vs 8 [IQR, 5.5-20] days, P <.001) were significantly shorter in the EUS-GE group. Overall (2.7% vs 27.0%, P =.007) and severe (.0% vs 16.2%, P =.025) adverse events were identified more frequently in the L-GE group. For patients with GOO, EUS-GE and L-GE showed almost identical technical and clinical success. However, reduced time to oral intake, shorter median hospital stay, and lower rate of adverse events suggest that the EUS-guided approach might be preferable. [ABSTRACT FROM AUTHOR]

Background: More than 200,000 new cases of kidney cancer are diagnosed annually. The reported incidence of inferior vena cava (IVC) involvement in patients with renal-cell carcinoma (RCC) ranges from 4% to 10%. Standard imaging modalities are unable to distinguish the inner structure of a thrombus and whether the vessel wall is invaded. Objective: To assess the utility of EUS for investigating IVC thrombosis because of RCC, particularly the thrombus characteristics and the involvement of the IVC, and the right and left renal veins. Design, Setting, and Patients: EUS was used to investigate 3 patients with RCC and IVC involvement. The endosonographer was blinded to the results of other imaging techniques. Interventions: A diagnostic EUS was performed with the patient under deep sedation (propofol) in 2 patients, and the third patient was given midazolam and fentanyl intravenously. Main Outcome Measurement: EUS identified a possible neoplastic invasion of the renal veins and/or IVC, distinguishing between the neoplastic hypoechoic and non-neoplastic hyperechoic thrombus in the IVC lumen and indicated the solidity of the inner structure of the clot. Results: EUS is useful in the vascular staging of RCC with suspected neoplastic involvement and thrombosis of either the renal veins, the IVC, hepatic veins, or the right atrium. EUS helped establish the consistency of the IVC thrombus and provided useful information to the surgeon for planning the use of a temporary, intraoperative caval filter. Limitations: The limitation of this study was the small number of patients. More cases are needed before stating that EUS could be useful in the staging of the neoplastic thrombi because of RCC. Conclusions: Diagnostic EUS can help in the detection and the staging of IVC thrombosis because of RCC. Further data are needed to evaluate its real impact on surgical management. [Copyright &y& Elsevier]