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Background: Malignant bowel obstruction (MBO) is a common complication in advanced and recurrent gynecologic malignancies, with limited treatment options and poor prognosis. Self-expanding metallic stent (SEMS) insertion has emerged as an alternative palliative measure, yet data specific to gynecologic malignancies remains scarce., Methods: A retrospective analysis was conducted on 61 patients with gynecologic malignancies and malignant large bowel obstruction who underwent colorectal stenting between January 2002 and December 2023. Data, including demographics, procedural details, clinical outcomes, and complications, were collected from electronic medical records., Results: The mean age of patients was 65.7 years, with ovarian cancer being the most common malignancy (77%). "Technical success" of SEMS insertion was achieved in 91.4% of cases, with a "clinical success" rate of 76.7%. Major complications occurred in 2% and 5% of patients at 30- and 90 days post-procedure, respectively. Overall mortality rates were 4% at 30 days and 28% at 90 days., Conclusion: SEMS for managing MBO is a promising alternative to surgery in patients with advanced or recurrent gynecologic malignancies. It offers high technical and clinical success rates with acceptable complication rates. Further research is needed to delineate optimal patient selection criteria and refine procedural techniques to maximize outcomes in this challenging population., Competing Interests: Declarations. Disclosures: All authors, Eliahu Yonathan Bekhor, Erez Klein, Hila Shmilovich, Gad Marom, Yair Glazer, Genevieve Bouchard-Fortier, Mai Harris, Eran Shlomovitz, have no conflicts of interest or financial ties to disclose., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aims: The increased use of endoscopy as a minimally invasive therapeutic technique has created a great demand for endoscopic training. The Basic Endoscopic Skills Training (BEST) box provides a low-cost solution by adapting the Fundamentals of Laparoscopic Surgery (FLS) box for flexible endoscopic simulation. The BEST box consists of six endoscopic tasks with a 5-min time limit per task. This study aims to develop a scoring system for objective evaluation of user performance., Methods: A total of 165 participants were tested on the BEST box. Participants were divided into two groups: retrospective analysis (n = 100) and prospective analysis (n = 65). From the retrospective group, 55 individuals were also scored on the Global Assessment of Gastrointestinal Endoscopic Skills-Upper Endoscopy (GAGES-UE). Linear regression between user performance on BEST box and GAGES-UE was performed to develop the scoring system. Receiver Operating Characteristic curve was used to determine a threshold score to help users appreciate their endoscopic expertise. Prospective scoring of 65 individuals was then performed using the formula developed (20 experts and 45 trainees)., Results: The minimum and maximum possible scores are 30 and 110, respectively. Retrospective analysis showed that the scoring system was able to distinguish between experts and trainees (p < 0.001), correlated with GAGES-UE (p < 0.001), and had a reliability constant of r = 0.765 (p < 0.001). On prospective testing using the scoring system the expert group received a final average score of 92, whereas the average score for the trainee group was 61 (p < 0.001)., Conclusions: The developed BEST box scoring system correlates with the experience level of the test taker as well as with the GAGES-UE scoring system. The results of this study add further evidence to the validity of the BEST box as an effective, low-cost endoscopic simulator with the scores used by trainees to track their performance level overtime., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: As flexible endoscopy offers many advantages to patients, access to training should be aggressively encouraged. In 2014, the IRCAD-IHU-Strasbourg launched a year-long university diploma using advanced education methods to offer surgeons and gastroenterologists high-quality, personalized training in flexible endoscopy. This paper describes and critically reviews the first 5 years of the University Diploma in Surgical Endoscopy (UDSE)., Methods: The UDSE aims to progressively transmit theoretical knowledge, clinical judgment, and practical skills on basic and advanced flexible endoscopy. The 300-h year-long curriculum is composed of 100 h of online lectures with tests, 150 h of clinical rotations and 50 h of hands-on sessions. The hands-on training is delivered through validated mechanical simulators, virtual reality simulators, and specifically designed ex vivo and in vivo animal models. Participants' demographics, training, and clinical experience were recorded. Trainees' evaluations of each online lecture, hands-on training, and clinical rotations were assessed using a Likert scale from 1 (not satisfactory) to 5 (outstanding). Trainees' skill progression was evaluated using the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) proficiency test. Finally, clinical uptake was surveyed., Results: 162 (79.01% males) trainees from 38 countries enrolled and successfully completed the first 5 courses. The vast majority of the trainees were surgeons and 19.14% were gastroenterologist. Sixty-nine (42.59%) participants were residents and 97 (56.79%) had no prior experience in flexible endoscopy. The online lectures, on-site sessions, and clinical rotations were highly appreciated receiving an overall average score of 4.33/5, 4.56/5, 4.43/5, respectively. Trainees' endoscopic skills improved significantly (16.68 vs. 20.53 GAGES scores; p = 0.016). At an average of 18.83 months following the course, 31 alumni (77.50% of repliers) started to use a flexible endoscope in their practice., Conclusions: Over its 5-year evolution, the UDSE has proven to be a valid means to ease access to the fundamental knowledge, practical skills, and clinical judgment necessary to achieve proficiency in surgical endoscopy.

Background: Cholecystostomy is commonly performed in high-risk patients with acute cholecystitis. However, internal drainage may be more desirable in patients as it is associated with lower complication rates. This paper describes an image-guided, percutaneous technique for internal gallbladder drainage using a covered lumen-apposing metal stent (LAMS) and assesses its feasibility and safety in a porcine model., Methods: Procedures were performed on 30-kg pigs. Under ultrasound and fluoroscopic guidance, a percutaneous puncture was performed through-and-through the gallbladder into the stomach. A guidewire was placed and a 12Fr sheath was advanced through which a 10-mm LAMS was deployed. Its distal flange was deployed in the gastric lumen, and its proximal flange in the gallbladder. The cholecystoenteric anastomosis was examined by means of endoscopy, laparoscopy, and necropsy., Results: Technical success was 100% (7/7). Procedure times decreased with experience and improvements in technique (median: 22 min). Contrast injection demonstrated free flow through the stent with no leakage. Necropsy confirmed appropriate stent position with good apposition of gallbladder and stomach, and no intraprocedural complications were detected., Conclusions: Image-guided, percutaneous, internal gallbladder drainage using a LAMS is safe and feasible in a porcine model. This technique may be an alternative to endoscopic ultrasound-guided stent placement and external cholecystostomy tube drainage.

Background: Both laparoscopy and endoscopy are image-based procedures, which are less intuitive than traditional open surgery and require extensive training to reach adequate proficiency. Currently, there is lack of understanding as to how the skills in one image-based procedure translate to another, such as endoscopy to laparoscopy and vice versa. The aim of our study was to explore the relationship between endoscopic and laparoscopic skills using a Fundamentals of Laparoscopic Surgery (FLS) trainer, a traditional virtual reality endoscopic trainer and a "desk-top" endoscopic physical simulator., Methods: Senior surgical residents from across Canada participating in an advanced laparoscopic foregut training course were enrolled in the study. Participants were assessed performing the FLS laparoscopic suturing task, the Endobubble 2 task (Simbionix, GI Mentor), and a forward viewing peg transfer on the novel Basics in Endoscopic Skills Training Box (BEST Box)., Results: There was significant correlation between the participant's skill in simulated laparoscopic suturing and simulated endoscopic skill using the BEST box (Pearson coefficient (r) was 0.551 (p = 0.033) and the coefficient of determination (r 2 ) was 0.304). There was a trend towards correlation between laparoscopic suturing time and Endobubble 2 score, but this did not reach statistical significance (r = 0.458, p = 0.086; r 2  = 0.210)., Conclusions: Performance in the two physical simulators, laparoscopic suturing and simulated flexible endoscopy using the BEST box, showed a correlation. This study adds to the growing body of evidence that laparoscopic and endoscopic skills are complementary and has the potential to impact simulation training involving both skill sets.

Background: The paucity of readily accessible, cost-effective models for the simulation, practice, and evaluation of endoscopic skills present an ongoing barrier for resident training. We have previously described a system for conversion of the Fundamentals of Laparoscopic Surgery box (FLS) for flexible endoscopic simulation. Six endoscopic tasks focusing on scope manipulation, and other clinically relevant endoscopic skills are performed within a 5-min time limit per task. This study describes our experience and validation results with the first 100 participants., Methods: A total of 100 participants were evaluated on the simulator. Thirty individuals were classified as experts (having done over 200 endoscopic procedures), and 70 were classified as trainees (39 individuals reported having no prior endoscopy experience). Of the 100 participants, 55 individuals were retested on the simulator within a period of 4 months. These 55 individuals were also evaluated using the "Global Assessment of Gastrointestinal Endoscopic Skills" (GAGES). T-tests and Pearson correlations were used where appropriate, values less than 0.05 were considered significant., Results: Experts completed all six tasks significantly faster than trainees. For the 55 participants who were retested on the simulator, all tasks demonstrated evidence of test-retest reliability for both experts and trainees who did not practice in between tests. Moderate correlations between lower completion times and higher GAGES scores were observed for all tasks except the clipping task., Conclusions: The results from the first 100 participants provide evidence for the simulator's validity. Based on task completion times, we found that experts perform significantly better than trainees. Additionally, preliminary data demonstrate evidence of test-retest reliability, as well as GAGES score correlation. Additional studies to determine and validate a scoring system for this simulator are ongoing.

Background: The fundamentals of laparoscopic surgery (FLS) training box is a validated tool, already accessible to surgical trainees to hone their laparoscopic skills. We aim to investigate the feasibility of adapting the FLS box for the practice and assessment of endoscopic skills. This would allow for a highly available, reusable, low-cost, mechanical trainer., Methods: The design and development process was based on a user-centered design, which is a combination of the design thinking method and cognitive task analysis. The process comprises four phases: empathy, cognitive, prototyping/adaptation, and end user testing. The underlying idea was to utilize as many of the existing components of FLS training to maintain simplicity and cost effectiveness while allowing for the practice of clinically relevant endoscopic skills. A sample size of 18 participants was calculated to be sufficient to detect performance differences between experts and trainees using a two tailed t test with alpha set at 0.05, standard deviation of 5.5, and a power of 80%., Results: Adaptation to the FLS box included two fundamental attachments: a front panel with an insertion point for an endoscope and a shaft which provides additional support and limits movement of the scope. The panel also allows for mounting of retroflexion tasks. Six endoscopic tasks inspired by FLS were designed (two of which utilize existing FLS components). Pilot testing with 38 participants showed high user's satisfaction and demonstrated that the trainer was robust and reliable. Task performance times was able to discriminate between trainees and experts for all six tasks., Conclusions: A mechanical, reusable, low-cost adaptation of the FLS training box for endoscopic skills is feasible and has high user satisfaction. Preliminary testing shows that the simulator is able to discriminate between trainees and experts. Following further validation, this adaptation may act as a supplement to the FES program.

Introduction: Peroral endoscopic myotomy (POEM) is a novel intervention for the treatment of achalasia, which combines the advantages of endoscopic access and myotomy. The purpose of this study was to perform a systematic review of the literature to evaluate the efficacy and safety of POEM., Methods: The systematic review was conducted following the PRISMA guidelines. Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE (R) including in-process and non-indexed citations were searched for POEM studies using the keywords: esophageal achalasia, POEM, endoscopy, natural orifice surgery, laparoscopic Heller myotomy (LHM), and related terms. Eckardt score, lower esophageal sphincter (LES) pressure, and reported complications were the main outcomes. Two authors reviewed the search result independently. A third reviewer resolved all disagreements. Data abstraction was pilot-tested and approved by all authors. Data were examined for clinical, methodological, and statistical heterogeneity with the aim of determining whether evidence synthesis using meta- analysis was possible., Results: The search strategy retrieved 2894 citations. After removing duplicates and applying the exclusion criteria, 54 studies were selected for full-text review of which a total of 19 studies were considered eligible for further analysis. There were 10 retrospective and 9 prospective studies, including 1299 POEM procedures. No randomized control trial (RCT) was identified. Overall, the pre- and post-POEM Eckardt scores and LES pressure were significantly different. The most frequently reported complications were mucosal perforation, subcutaneous emphysema, pneumoperitoneum, pneumothorax, pneumomediastinum, pleural effusion, and pneumonia. The median follow-up was 13 months (range 3-24)., Conclusion: POEM is a safe and effective alternative for the treatment of achalasia. However, only short-term follow-up data compared with LHM are available. RCTs and long-term follow-up studies are needed to establish the efficacy and safety of POEM in the management of patients with achalasia.

Background: Esophageal obstruction is a known complication of laparoscopic adjustable gastric band (LAGB) and usually occurs in the context of band slippage. Current reports of pseudoachalasia post-LAGB describe that in some patients esophageal function improves after band removal. For those without improvement, current treatments include division of the fibrotic band post-LAGB or revisional surgery. Our hypothesis, illustrated in the submitted video, is that an endoscopic division of LAGB-induced stricture will improve esophageal function., Methods: This video presents the case of a patient presenting with dysphagia post-LAGB removal. The preoperative high-resolution manometry was compatible with a type I achalasia. Using a high-definition endoscope and the equipment used for per-oral endoscopic myotomy (POEM) procedure, the intramural fibrotic tissue caused by the LAGB is divided, thus releasing the stricture and restoring baseline esophageal function. This is demonstrated with intraoperative endoscopic functional lumen imaging probe (EndoFLIP; Crospon Ltd, Galway, Ireland)., Results: Similar to the POEM technique, a 12-cm tunnel and 8-cm myotomy were performed. No intra-procedural or post-procedural complications were noted. Using impedance planimetry, the division of the LAGB-induced stricture induced an increase in the minimal diameter from 5.3 to 8.6 mm. The cross-sectional area increased from 22 to 58 mm(2). The patient denies any residual dysphagia, regurgitation, or heartburn at 6-month follow-up. On the postoperative high-resolution manometry, significant improvement in LES pressure parameters was seen post-myotomy with return of 30 % peristalsis., Discussion: In LAGB patients with pseudoachalasia in which removal of fluid from the band does not result in clinical or manometric improvement, laparoscopic removal of the band with division of the peri-esophageal scar tissue has been advocated. This video illustrates that an endoscopic division of the LAGB-induced esophageal fibrosis is another potential treatment for adjustable gastric band-induced achalasia.

Background: Roux-en-Y gastric bypass (RYGB) is considered to be an optimal surgical treatment option for GERD in the morbidly obese patient. Nevertheless, a subgroup of patients suffer from recurrent or persistent GERD after their gastric bypass. Unfortunately, limited treatment options are available in these patients. Fundoplication via mobilization of the remnant stomach and radiofrequency treatment of the lower esophageal sphincter have been described with some success. Our objective is to illustrate a safe and durable surgical option in the treatment of patients with medically refractory GERD post-RYGB., Methods: After placing five trocars in the usual position for a foregut laparoscopic surgery, a lysis of adhesions and standard dissection of the hiatus is performed. The anterior and posterior vagal nerves associated phrenoesophageal tissue bundles are identified. A primary crural repair with interrupted nonabsorbable sutures is performed. Four full-length nonabsorbable sutures are placed sequentially through the anterior and posterior phrenoesophageal bundle, posterior fundus and finally through the pre-aortic fascia. The repair is calibrated on a 44 French bougie. The sutures are tied from medial to lateral in the order of their placement under endoscopic guidance., Results: No peri-procedural complications were encountered. Standard post-antireflux surgery clinical follow-up with the patient completing a validated GERD clinical questionnaire at 1 and 6 months after the surgery demonstrated excellent GERD symptom control without any dysphagia. A pH study and EGD performed at 6 months post-Hill procedure show the absence of pathological reflux with an intact Hill mechanism., Conclusion: The Hill procedure is a valid treatment for the post-bariatric surgical patient with GERD in which the gastric fundus is absent or inaccessible thus eliminating standard fundoplication as a reasonable option. This also represents a safe and durable treatment of GERD in this uniquely challenging patient population.

Introduction: Obtaining an adequate mucosal closure is one of the crucial steps in per-oral endoscopic myotomy (POEM). Thus far, there have been no objective data comparing the various available closure techniques. This case-controlled study attempts to compare the application of endoscopic clips versus endoscopic suturing for mucosotomy closure during POEM cases., Methods: A retrospective review of our prospective POEM database was performed. All cases in which endoscopic suturing was used to close the mucosotomy were matched to cases in which standard endoclips were used. Overall complication rate, closure time and mucosal closure costs between the two groups were compared., Results: Both techniques offer good clinical results with good mucosal closure and the absence of postoperative leak. Closure time was significantly shorter (p = 0.044) with endoscopic clips (16 ± 12 min) when compared to endoscopic suturing (33 ± 11 min). Overall, the total closure cost analysis showed a trend toward lower cost with clips (1502 ± 849 USD) versus endoscopic suturing (2521 ± 575 USD) without reaching statistical significance (p = 0.073)., Conclusion: The use of endoscopic suturing seems to be a safe method for mucosal closure in POEM cases. Closure time is longer with suturing than conventional closure with clips, and there is a trend toward higher overall cost. Endoscopic suturing is likely most cost-effective for difficult cases where conventional closure methods fail.

Introduction: Zenker's diverticulum (ZD) is a rare upper esophageal pathology that is most prevalent in the sixth and seventh decade. Three different therapeutical options are available: (1) open trans-cervical approach, (2) rigid endoscopy and (3) flexible endoscopy. Our hypothesis is that a flexible endoscopic cricomyotomy represents a safe and effective treatment of ZD as well as cricopharyngeal spasm., Methods: A retrospective analysis of all patients that underwent a flexible endoscopic cricomyotomy at our institution between October 2008 and May 2014 was performed. Preoperative and postoperative (1 month and long-term follow-up) symptom scores and clinical outcomes were collected. Briefly, the ZD is carefully identified endoscopically and the common wall is divided using needle knife cautery with the help of an endoscopic cap. Clips are used to close the mucosal defect starting with the apex., Results: Twenty-six patients underwent a flexible endoscopic myotomy for a ZD. Of 26 patients, five (19.2 %) had a history of previous open or stapled trans-oral myotomy and four (15.4 %) underwent a concomitant foregut procedure. Mean length of stay was 1.5 days (range 1-11). Mean operative time was 68 min (range 28-149). One patient presented with a postoperative leak, and one patient presented with a retained clip. Both were treated endoscopically. Recurrent weekly dysphagia was present in 3/26 (11.5 %). One patient (3.8 %) underwent an endoscopic bougie dilatation postoperatively. With regard to clinical outcomes, there was a statistically significant improvement in both short-term (1 month) and long-term (median follow-up 21.8 months; range 1-68.2 months) dysphagia (p < 0.001; p < 0.001), regurgitation (p = 0.001; p = 0.017), cough (p = 0.006; p = 0.025) and aspiration (p = 0.013; p = 0.013)., Conclusion: Flexible endoscopic cricomyotomy offers durable relief of dysphagia, regurgitation, cough and aspiration in ZD patients. It appears to have a good safety profile with symptomatic recurrence occurring in up to 11.5 % of cases.

Introduction: Gastroparesis is a condition characterized by delayed gastric emptying, and a constellation of symptoms, including nausea, vomiting, early satiety, and bloating. Although current surgical options such as pyloroplasty have been shown to be effective, an endoscopic submucosal myotomy technique may be applied to divide the pyloric sphincter without surgical access. Such endoscopic technique may provide the benefits of a natural orifice procedure, and improve gastric emptying in gastroparetic patients., Methods and Procedures: Per-oral pyloromyotomy (POP) was performed in seven female patients aged 33-65 years (mean 51 years). All patients had a pre-operative work-up that included upper endoscopy, and a gastric emptying study. A pH study, and esophageal manometry were also performed when a concomitant fundoplication was considered., Results: POP was technically successful in all seven cases. There were no immediate procedural complications. Perioperative, complications included: one patient with an upper GI bleed 2 weeks post-procedure, necessitating transfusions, and endoscopic clipping of a pyloric channel ulcer; one patient who experienced difficulty swallowing post operatively, delaying discharge by 1 day; and one patient who developed a hospital-acquired pneumonia, delaying discharge by several days. Six of the seven patients experienced significant symptomatic improvement following the procedure. Three month follow-up nuclear medicine solid-phase gastric emptying studies are currently available for 5 of the 7 patients. Normal gastric emptying at 4 h was noted in four of five patients (80 %). One patient did not respond to endoscopic management subsequently underwent an uneventful laparoscopic pyloroplasty, which also failed to significantly improve her symptoms., Conclusion: POP is a technically safe and feasible endoscopic procedure. Early follow-up suggests promising symptomatic improvement as well as objective improvement in gastric emptying. Additional clinical experience is required to establish the role of this technique in the management of gastroparesis.