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Acute pancreatitis (AP) is known to result in endocrine dysfunction (prediabetes, diabetes). The objective of this study was to determine the temporal incidence of endocrine dysfunction after onset of AP and determine the risk factors in Indian patients.In this prospective study, enrolled patients diagnosed with AP between February 2019 and May 2019 were followed at 3, 6, and 12 months until May 2020. Patients with recurrent AP, chronic pancreatitis, and pre-existing endocrine dysfunction were excluded. Demographic and disease severity (clinical, laboratory, and radiological) data were recorded. Mann-Whitney U and Chi-square tests were used to compare groups. Temporal trend for development of endocrine dysfunction was evaluated using the Extended Mantel Haenszel Chi-square test for trend. Logistic regression was used to identify independent risk factors.Eighty-six patients (males 66, median [IQR] age 33.0 [26.0-44.2] years) who fulfilled enrolment criteria were finally analyzed. The most common etiology was alcohol (n=31 [36%]) followed by gallstones (n=17 [19.8%]). The proportion of patients with moderately severe acute pancreatitis and severe AP were 59.3% and 15.1%, respectively. Overall, the frequency of prediabetes and diabetes increased temporally across the follow-up period. These were 2 (2.33%) and 1 (1.16%) at 3 months, 11 (12.8%) and 5 (5.81%) at 6 months, and 20 (23.2%) and 9 (10.5%) at 1 year, respectively. On multivariable logistic regression, intervention for walled-off necrosis (WON) emerged as the single independent risk factor for endocrine dysfunction (odds ratio 9.01 [2.3-35.5]; p=0.002).Endocrine dysfunction is frequent after an episode of AP. Intervention for WON is an independent risk factor for endocrine dysfunction.

There is limited data on long-term outcomes of per-oral endoscopic myotomy (POEM). In this study, we aim to evaluate the efficacy of POEM in patients who completed a minimum follow-up of 5 years.Data of patients who underwent POEM and completed ≥ 5-year follow-up were analyzed, retrospectively. Primary outcome of study was clinical success (Eckardt ≤ 3) at ≥ 5 years after POEM. Secondary outcomes included predictors of dysphagia and symptomatic gastroesophageal reflux disease (GERD) on long-term follow-up.Three hundred nineteen patients (males 182, mean age 40.5 ± 14.2 years) completed a median of 73-(60-89) month follow-up. Esophageal motility disorders included idiopathic achalasia (type I 26.6%, type II 60.8%, type III 5.6%) and Jackhammer esophagus or distal esophageal spasm (2.8%). POEM was technically successful in 307 (96.2%) patients. Long-term success was 92.6% (overall), 92.1% (type I), 94.7% (type II), 87.5% (type III), and 75% (Jackhammer esophagus/distal esophageal spasm). Symptomatic GERD and reflux esophagitis were detected in 28.9% and 35.3% patients, respectively. On multivariate analysis, young age and female gender were independent risk factors for recurrent dysphagia (p = 0.037) and symptomatic GERD after POEM (p = 0.025), respectively. Lower post-POEM lower esophageal sphincter pressure was an independent predictor for reflux esophagitis (p = 0.016).POEM is an effective and durable treatment for achalasia and non-achalasia spastic motility disorders. Young patients and females may be at higher risk for recurrent dysphagia and symptomatic GERD, respectively.

Background and study aims Endoscopic ultrasound-guided gastro-enterostomy(EUS-GE) is a recently described novel minimally invasive endoscopic procedure for patients having malignant gastric outlet obstruction (GOO). The safety of EUS-GE in the presence of ascites with GOO is not known. The objective of the study was to evaluate the feasibility and safety of EUS-GE in patients with GOO and ascites. Patients and methods Consecutive patients with GOO who underwent EUS-GE between January 2019 and March 2021 constituted the study population. EUS-GE was performed using either EPASS or free-hand technique. The technical success, clinical success, adverse events, and survival times were evaluated. The outcomes were compared between patients with and without ascites. Results A total of 31 patients with GOO underwent EUS-GE of whom 29 (93.5 %) had malignant and two (6.4 %) had benign etiologies. Ascites was observed in 12 out of 31 (38.7%) patients and all had underlying malignancy. Majority (27, 87 %) of the EUS-GE procedures were performed using EPASS technique, and 4 (13 %) underwent free-hand technique. Eleven of 12 patients with ascites and GOO underwent EUS GE using EPASS technique. The technical success (91.6 % vs. 89.4 %; P = 0.841), clinical success (83.3 % vs. 89.4 %; P = 0.619), mean procedure time (32 vs. 31.6 min; P = 0.968) and adverse events (0 % vs. 10.5 %; P = 0.245) were not significantly different between patients with or without ascites. However, the median survival time was significantly low in patients with ascites when compared to without ascites (36 vs. 290 days; P Conclusions Ascites is a common occurrence in patients with malignant GOO. EUS GE is feasible in presence of ascites with EPASS technique.

Background Recently updated guidelines for choledocholithiasis stratify suspected patients into high, intermediate, and low likelihood, with the aim to reduce risk of diagnostic endoscopic retrograde cholangiopancreatography. This approach has increased proportion of patients in intermediate likelihood making it heterogenous. We aim to substratify intermediate group so that diagnostic tests (endoscopic ultrasound/magnetic resonance cholangiopancreatography) are judicially used. Methods This is a single-center retrospective analysis of prospectively maintained data. We used subset of patients who met intermediate likelihood of American Society of Gastrointestinal Endoscopy (ASGE) criteria from previously published data (PMID:32106321) as derivation cohort. Binominal logistic regression analysis was used to define independent predictors of choledocholithiasis. A composite score was derived by allotting 1 point for presence of each independent predictor. The diagnostic performance of a composite score of ≥ 1 was evaluated in validation cohort. Results A total of 678 (mean age [standard deviation]: 47.0 [15.9] years; 48.1% men) and 162 (mean age 47.8 [14.8] years; 47.4% men) patients in ASGE intermediate-likelihood group were included as derivation cohort and validation cohort, respectively. Binominal logistic regression analysis showed that male gender (p = 0.024; odds ratio [OR] = 1.92), raised bilirubin (p = 0.001; OR = 2.40), and acute calculus cholecystitis (p = 0.010; OR = 2.04) were independent predictors for choledocholithiasis. A composite score was derived by allotting 1 point for presence of independent predictors Using ≥ 1 as cutoff, sensitivity and specificity for detection of choledocholithiasis were 80% (95% confidence interval [CI]: 68.2–88.9) and 36.2% (95% CI: 32.2–40.0), respectively, in derivation cohort. Applying composite score in independent validation cohort showed sensitivity and specificity of 73.3% (95% CI: 44.9–92.2) and 40.1% (95% CI: 30.1–48.5), respectively. Conclusion Substratification of intermediate-likelihood group of ASGE criteria is feasible. It may be useful in deciding in whom confirmatory tests should be performed with priority and in whom watchful waiting may be sufficient.

Background Recent guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and American Society for Gastrointestinal Endoscopy (ASGE) recommend risk stratification according to liver function test (LFT) and abdominal ultrasound in patients with suspected choledocholithiasis. We evaluated and validated the clinical utility of these new risk stratification criteria for choledocholithiasis. Methods We retrospectively analyzed prospectively maintained data of patients with suspected choledocholithiasis between January 2016 and December 2018 in patients undergoing cholecystectomy. Patients with common bile duct stricture, cirrhosis, and portal biliopathy were excluded. After LFT and ultrasound, all patients were stratified according to ESGE and ASGE criteria into high, intermediate, and low likelihood of choledocholithiasis. Results 1042 patients were analyzed. Using ESGE guidelines, 213 patients (20.4 %) met high likelihood criteria, 637 (61.1 %) met intermediate, and 192 (18.4 %) met low likelihood criteria. Using ASGE guidelines, 230 (22.1 %), 678 (65.1 %), and 134 (12.9 %) met high, intermediate, and low likelihood criteria, respectively. Specificity and positive predictive value (PPV) of ASGE high likelihood criteria were 96.87 % (95 % confidence interval [CI] 95.37 – 97.98) and 89.57 % (95 %CI 85.20 – 92.75) for choledocholithiasis compared with 98.96 % (95 %CI 97.95 – 99.55) and 96.24 % (95 %CI 92.76 – 98.09), respectively, for ESGE criteria. ASGE classified 17 (7.4 %) additional patients as high likelihood compared with ESGE, only one of whom had choledocholithiasis. ASGE classified 58 (8.6 %) additional patients as intermediate, none of whom had choledocholithiasis. Conclusion This study validates the clinical utility of new ESGE and ASGE criteria for predicting choledocholithiasis. ESGE risk stratification appears more specific than ASGE.

Background and AimPer-oral endoscopic myotomy (POEM) is emerging as an effective treatment for pediatric achalasia. There are limited data on the long-term efficacy of POEM in children and adolescents with achalasia. In this study, we aim to evaluate the outcomes of POEM at ≥4 years follow-up.MethodThe data of consecutive children who underwent POEM (September 2013–July 2021) and completed at least 4 years follow-up were analyzed retrospectively. The primary outcome was clinical success (Eckardt ≤ 3) at ≥4 years follow-up. The secondary outcomes included the prevalence of gastroesophageal reflux disease (GERD) and predictors of recurrent symptoms (Eckardt ≥2) after POEM.ResultsA total of 69 children underwent POEM for achalasia during the study period. Of these, 41 (59.4%) children completed ≥4 years [mean 68.5 months (range 48–94)] follow-up, and 38 were included in the final analysis. The subtypes of achalasia included type I (28.9%), type II (60.5%), and type III (2.6%). There was a history of prior treatment in 11 children (28.9%). Clinical success was recorded in 36 (94.7%) patients who successfully underwent POEM. Recurrent symptoms (Eckardt ≥ 2) were noticed in 12 (31.6%) children at ≥4 years. On multivariate analysis, there were no identifiable factors which predicted recurrent symptoms after POEM. Symptomatic GERD and erosive esophagitis were detected in 13.8% (4/29) and 57.1% (8/14) of the children, respectively.ConclusionPOEM is a durable treatment modality for achalasia in the pediatric population irrespective of the sub-type of achalasia and history of prior treatment.

Background and objectives EUS is frequently utilized for tissue acquisition in adult patients. However, the literature is limited regarding the utility of EUS-guided fine-needle aspiration or biopsy (FNA or FNB) in children. In this study, we aim to evaluate the feasibility, safety, and diagnostic utility of EUS-FNA/FNB in children with various gastrointestinal diseases. Methods The data of children (≤18 years) who underwent EUS-FNA/FNB from March 2014 to June 2020 were analyzed, retrospectively. The following parameters were analyzed: technical success, adverse events, and impact on the final diagnosis. Results Sixty-seven children (32 - boys, 14.8 ± 2.9 years, range 8-18 years), underwent EUS-guided tissue acquisition procedures using standard therapeutic echoendoscope during the study period. The indications included solid pancreatic lesions in 29 (43.3%), mediastinal or abdominal lymphadenopathy in 30 (44.7%), cystic pancreatic lesions in 5 (7.5%), subepithelial lesions in 2 (3%), and retroperitoneal mass in 1 (1.5%). EUS-FNA and-FNB were performed in 42 and 25 children, respectively. All the procedures could be successfully performed and there was no major procedure-related adverse event. Minor adverse events included self-limiting throat pain (10) and abdominal pain (3), self-limited bleeding at puncture site (3), and transient fever (1). EUS-FNA/FNB provided a histopathological diagnosis in 59 (88.1%) children. Conclusion EUS-guided tissue acquisition using standard echoendoscope is feasible and safe in the pediatric age group. EUS-FNA/FNB establishes diagnosis in majority of the children when performed for appropriate clinical indication.

Disconnected pancreatic duct (DPD) is a frequent occurrence in cases with walled-off necrosis (WON). The impact of DPD on recurrence of collection after removal of metal stents is not clear. Also, association between DPD and new-onset diabetes mellitus (DM) is not well known. In a large cohort of patients with WON, we observed DPD in majority (3/4th) of the cases. The presence of DPD was a significant risk factor for the recurrence of fluid collections as well as new-onset DM. However, the incidence of recurrent fluid collections and the requirement of reintervention was low (

Background and aim Endoscopic retrograde cholangiopancreatography (ERCP) is treatment modality of choice for management of pancreatobiliary disorders. However, safety of ERCP in the patients with cirrhosis is not adequately studied. This study was aimed to evaluate adverse events in the patients with cirrhosis undergoing ERCP and the predictors of adverse events and mortality. Methods The present study was a retrospective analysis of patients with cirrhosis who underwent ERCP from January 2012 to December 2016. Binary logistic regression analysis was performed to ascertain the risk factors for adverse events and mortality at 1 month. Results A total of 261 patients underwent ERCP (80.8% men, mean age 53.49 ± 12.6years). There were 36 (16.1%) overall adverse events in patients undergoing ERCP for biliary indication, whereas no adverse event in pancreatic indication. On univariate analysis, ascites, encephalopathy, high Child-Pugh-Turcotte (CTP) and model for end-stage liver disease (MELD) score, and creatinine levels were significantly associated; however, on multivariable analysis, CTP class C (p value 0.033; odds ratio [OR] 3.5, 95% confidence interval [CI] 1.1–11.5) and MELD > 18 (p value 0.004; OR 5.6, 95% CI 1.7–17.9) were independent risk factors for adverse events. There were 19 (8.5%) mortalities. On univariate analysis, presence of ascites, encephalopathy, cholangitis, biliary sphincterotomy, high CTP, low albumin, and high creatinine were significantly associated, whereas, on multivariable analysis, presence of cholangitis (p 0.017; OR 3.8, 95% CI 1.3–11.4) was associated increased mortality. Conclusion Although endoscopic sphincterotomy might be safe for the patients with cirrhosis undergoing ERCP; advanced liver cirrhosis may be independent risk factor for post-ERCP adverse events. Cholangitis at admission is an independent risk factor for mortality.

Objectives Disconnected pancreatic duct syndrome (DPDS) is frequently encountered in cases with walled off necrosis (WON). The impact of DPDS on the outcomes of pancreatic fluid collections (PFCs) is not well known. In this study, we aim to evaluate the incidence of DPDS and its clinical impact on the outcomes of endoscopic ultrasound (EUS)-guided drainage of PFC in children. Methods All children with symptomatic WON who underwent EUS-guided drainage using metal stents were included in the study. At 4 weeks, pancreatic ductal anatomy was evaluated, and metal stents removed. All the children were followed at regular intervals and evaluated for the recurrence of PFC and the development of new-onset diabetes. Results A total of 32 children (28 boys, median age 15 years) underwent EUS-guided drainage of WON. Resolution of WON was documented in all children at 4 weeks. Pancreatic ductal anatomy using magnetic resonance retrograde cholangiopancreatography and endoscopic retrograde pancreatography was available in 30 (93.7%) children. Of these, DPDS was documented in 25 (83.3%) children including proximal disconnection in 12 and distal disconnection in 13 children. Recurrent PFC and new-onset diabetes were found in 5 (20%) and 2 (8%) children with DPDS, respectively. Of the 5 recurrences of PFC, endoscopic reintervention was required in 3 children. Conclusions Majority of the children with DPDS do not develop a symptomatic recurrence of PFC after the removal of cystogastric stents. DPDS may be a risk factor for the development of new-onset diabetes. However, future prospective studies are needed.

ObjectiveIn patients with an intermediate likelihood of choledocholithiasis, European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) to diagnose choledocholithiasis to make the indication for endoscopic retrograde cholangiopancreatography (ERCP) treatment; there is no randomised control trial to compare both in this setting.DesignPatients with suspected choledocholithiasis satisfying ESGE guideline’s intermediate likelihood were screened for this single-centre randomised controlled trial between November 2019 and May 2020. The enrolled patients were randomised to either EUS or MRCP. ERCP was performed in stone positive cases or if clinical suspicion persisted during follow-up. Negative cases underwent a further 6-month clinical follow-up. Main outcome was accuracy (sensitivity/specificity) of both tests to diagnose choledocholithiasis, with ERCP or follow-up as a gold standard.ResultsOf 266 patients, 224 patients (mean age: 46.77±14.57 years; 50.9 % female) were enrolled; overall prevalence of choledocholithiasis was 49.6%, with a higher frequency in the MRCP group (63/112 vs 46/112 for EUS). Both sensitivity of EUS and MRCP were similarly high (92%–98%), without significant differences between the two groups. The negative predictive value and likelihood ratio + were significantly higher in EUS arm (pConclusionThe performance parameters of both EUS and MRCP are comparable for detecting choledocholithiasis in the intermediate-risk group of choledocholithiasis and the choice of a test should be based on local expertise, availability of resources and patient preference.Trial registration numberNCT04173624.

Endoscopic resection is recommended for small duodenal neuroendocrine tumors DNETs. However, there is limited data on the outcomes of endoscopic submucosal dissection (ESD) in DNETs. In this study, we aimed to evaluate the outcomes of ESD in DNETs. Data of consecutive patients who underwent ESD for DNETs from January 2018 to December 2019 were analyzed, retrospectively. All the cases of ESD were performed with or without traction using rubber band and two endoclips. En-bloc resection, complete endoscopic resection (C-ER), complete pathological resection (C-PR), adverse events, and recurrence were evaluated. Twenty patients (19 males, 57.50 ± 9.32 years) underwent ESD for DNETs. DNETs measured ≤ 10 mm (7), 10–15 mm (12), and > 15 mm (1). ESD was performed with and without traction in 10 cases each. Mean operating time was 61 ± 17.38 min. En-bloc resection, C-ER, and C-PR were recorded in 90%, 95%, and 75%, respectively. Vertical margins were positive in five patients. Adverse events included perforations in 4 (20%) cases and major bleeding in one case. There was no recurrence at a mean follow-up of 17.20 ± 7.37 months. ESD is feasible and effective for the management of DNETs. However, caution is advised due to a high risk of adverse events and pathologically incomplete resection.

Esophageal epiphrenic diverticula (EED) are rare pulsion-type outpouchings at the lower end of esophagus. Traditionally, surgery has been performed in EED. More recently, per-oral endoscopic myotomy with septotomy (D-POEM) has emerged as an option in these cases. In this study, we aim to determine the efficacy and safety of D-POEM in cases with EED. The data of cases who underwent D-POEM in cases with EED from March 2013 to Nov 2020 were analyzed, retrospectively. The primary outcome of the study was clinical success. Secondary outcomes included technical success, procedure duration, reflux esophagitis, and adverse events. 13 patients (males 9, 48.07 ± 17.55 years) with EED underwent D-POEM during the study period. Median size of the EED was 45 mm (range 25–70). Associated esophageal motility disorder was found in 10 (76.9%) cases including type II achalasia (3), type I (3), hypercontractile esophagus (2), and unspecified (2). Technical success was achieved in 12 (92.3%) cases. Median length of total and gastric myotomies were 10 cm (range 6–20) and 3 cm (1–3), respectively. At a median follow-up of 25 months, clinical success was achieved in 84.6% cases. Mean integrated relaxation pressures reduced significantly after POEM procedure (25.80 ± 13.24 vs 9.40 ± 3.10, p = 0.001). There was one major adverse event requiring surgical intervention. D-POEM is an effective procedure in cases with EED. Long-term follow-up studies are required to ascertain the durability of response in these cases.

Background To compare fully covered bi-flanged metal stents (BFMS) and lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainage/debridement of pancreatic walled-off necrosis (WON). Methods Patients with WON managed by EUS-guided therapy were divided into those who underwent: 1) drainage using BFMS; and 2) drainage using LAMS and scheduled direct endoscopic necrosectomy (DEN). Clinical success (resolution of the WON), technical success (successful stent placement), and adverse events (AEs) were evaluated. Results 387 patients underwent WON endoscopic drainage, 205 using BFMS and 182 using LAMS. The clinical success in the BFMS or LAMS groups were similar (197 [96.1%] vs. 174 [95.6%]; P=0.81). Median number of procedures required for WON resolution was significantly lower in BFMS compared to LAMS (2 vs. 3, P

BACKGROUND AND AIM Even though ductal interventions in chronic pancreatitis (CP) are known to improve pain, its impact on diabetes is unclear. In this cohort study, we evaluated the impact of ductal interventions on diabetes in these patients. METHODS Consecutive patients with CP visiting the pancreas clinic between August 1, 2011, and July 21, 2012, were enrolled and followed until December 2018. Detailed clinical, laboratory, imaging, and treatment data were recorded at enrolment and follow-up. Patients were followed up every 6 months through hospital visit and/or telephonic interview. Risk factors for diabetes were evaluated using logistic regression. The impact of ductal interventions on diabetes was evaluated using Kaplan-Meier survival analyses and Cox proportional hazards. RESULTS A total of 644 patients were enrolled of which 137 were excluded. Of these, 326 (64.3%) patients had idiopathic CP, and 283 (55.8%) patients underwent ductal intervention. The cumulative incidence of diabetes was 57.9%. Median duration between symptom onset and ductal intervention was similar irrespective of diabetes (2.6 [0.6-6.0] vs 3.0 [1.0-5.5] years; P = 0.69). Alcohol intake and pancreatic ductal calculi were independent risk factors for diabetes (odds ratio [95% confidence interval] of 2.05 (1.18-3.55), P = 0.01, and 2.05 (1.28-3.28), P = 0.003, respectively). Kaplan-Meier analyses revealed that diabetes free interval was significantly longer in patients undergoing ductal interventions, predominantly in those with idiopathic CP with obstructive ductal calculi (hazard ratio [95% confidence interval] 0.39 [0.28-0.55]; P

Background Although endoscopic ultrasound (EUS) features and criteria have been described in chronic pancreatitis, challenges remain with interoperator variability and ease of adoption. The aim of this study was to define and validate the EUS features of chronic pancreatitis in a multicenter prospective study in Asia. Method The study was divided into two parts: the first part was conducted to derive the EUS features of chronic pancreatitis with adequate interoperator agreement; the second was to prospectively evaluate these features in a multicenter cross-sectional study and determine the optimal combination of features for the diagnosis of chronic pancreatitis. Prospectively enrolled cases had standard internationally validated radiologic or histologic features of chronic pancreatitis, and controls were patients without chronic pancreatitis who underwent EUS examination. Results The top six EUS features that had good interobserver agreement (mean kappa 0.73, range 0.60 – 0.90) were selected to be further evaluated in part II of the study. These included: hyperechoic foci with shadowing, lobularity with honeycombing, cysts, dilated main pancreatic duct, dilated side branches, and calculi in the main pancreatic duct. A total of 284 subjects (132 cases, 152 controls) were enrolled from 12 centers in Asia. All six features had high accuracy ranging from 63.3 % to 89.1 %. Two or more of these six EUS features accurately defined chronic pancreatitis (sensitivity 94.7 %, specificity 98.0 %), with an area under the receiver operating curve of 0.986. Conclusion This multicenter Asian study characterized and defined the EUS features of chronic pancreatitis. This provides a useful tool in clinical practice and further research in pancreatic cancer surveillance.

Spastic esophageal motility disorders (SEMD) are a rare group of motility disorders including type III achalasia, distal esophageal spasm (DES), and Jackhammer esophagus (JHE). Limited data suggest that per-oral endoscopic myotomy (POEM) may be effective in these disorders. In this study, we aimed to evaluate the long-term outcomes of POEM in SEMD.The data of patients with SEMD who underwent POEM (January 2013 to December 2019) were analyzed, retrospectively. The following outcomes were recorded: POEM procedure details, technical and clinical success, adverse events, and gastroesophageal reflux disease (GERD). Clinical success was classified as immediate (1 y), short-term (1 to 3 y), medium term (3 to 5 y), and long-term (5 y).A total of 1115 POEM procedures were performed during the study period for achalasia and nonachalasia spastic motility disorders. POEM was performed for SEMD in 74 (6.6%) patients including type III in 53, DES in 11, and JHE in 10 patients. Technical success was achieved in all the patients. The median follow-up for the entire group was 47.5 months (range: 2 to 77 mo). Clinical success at short-term (1 to 3 y) and long-term follow-up (5 y) was attained in 85.2% and 82.6% patients, respectively. There was no significant difference in the clinical success between type III achalasia and JHE/DES. Mild and moderate adverse events were recorded in 21 (28.4%) cases. GERD was detected in 23 (56.1%) patients with 24-hour pH study. Erosive esophagitis and symptomatic GERD were found in 36 (48.6%) and 16 (21.6%) patients, respectively.POEM is a safe, effective, and durable treatment modality for spastic motility disorders of the esophagus. However, GERD is found in about half of the patients mandating close monitoring after POEM.

Background Acute calculous cholecystitis (ACC) is the most frequent complication of gallstones requiring cholecystectomy. These patients may have coexisting choledocholithiasis. We aimed to evaluate the role of current guidelines for choledocholithiasis in patients with ACC. Methods In this retrospective study, we included all patients diagnosed with ACC between December 2018 and May 2019. These patients were substratified according to the guidelines of the American and European Societies of Gastrointestinal Endoscopy (ASGE and ESGE) as having high, intermediate, or low likelihood of choledocholithiasis, and the diagnostic performance was measured. Binomial logistic regression analysis was applied to ascertain independent risk factors for choledocholithiasis. Results A total of 173 patients with ACC, mean age (±standard deviation) 49.89±15.74 years and 60.1% male, were included. Sixty-three (36.4%) had confirmed choledocholithiasis. ASGE high likelihood criteria had sensitivity and specificity of 61.9% (95% confidence interval [CI] 48.8-73.9) and 83.4% (95%CI 75.4-90.0) for predicting choledocholithiasis. ESGE high likelihood criteria had sensitivity and specificity of 49.2% (95%CI 36.4-62.1) and 87.3% (95%CI 79.6-92.9). On logistic regression analysis, an alkaline phosphatase level above the upper limit of normal (P=0.003; odds ratio [OR] 4.26, 95%CI 1.66-10.96) and a dilated common bile duct on ultrasound (P=0.001; OR 9.97, 95%CI 4.65-21.36) were independent positive predictors for choledocholithiasis, while acute biliary pancreatitis was an independent negative predictor (P=0.030; OR 0.36, 95%CI 0.14-0.91). Conclusions The performance of the ASGE and ESGE guidelines' risk stratification criteria is inadequate in patients with ACC. We suggest the utilization of a separate predictive model for suspected choledocholithiasis in these patients.

Background and aims Anemia is one of the most common extraintestinal manifestations of celiac disease (CD), with iron deficiency anemia (IDA) being the predominant cause. However, anemia in CD can have varied etiologies, including mixed nutritional deficiency. We aimed to study the prevalence and etiology of anemia in CD in a north Indian population. Methods In this prospective observational study, consecutive patients with documented CD between January 2012 and December 2013 were included, and all patients underwent detailed clinical assessment; hematological investigations including iron profile, serum folate, and vitamin B12 levels; and esophageoduodenoscopy with duodenal biopsies for histopathological examination. Prevalence of anemia and different deficiencies were calculated, and a correlation between hematological parameters and histological findings was found. Results Of the 103 patients studied, anemia was detected in 96 patients, giving a prevalence of 93.2% with a baseline hemoglobin of 8.94 ± 2.54 g/dL. Overall, iron deficiency was seen in 84 (81.5%) patients, followed by vitamin B12 deficiency in 14 (13.6%) and folate deficiency in 11 (10.7%) patients; 17 (16.5%) patients had anemia due to mixed nutritional deficiencies, and 4 (3.9%) patients had anemia of chronic disease. The mean hemoglobin and median ferritin levels were significantly lower in patients with severe villous atrophy compared to those with mild atrophy. Conclusion Anemia in patients with CD is multifactorial. Even though iron deficiency is the most common cause, other nutrient deficiencies should always be explored.

Background and Aims EUS-guided drainage using plastic stents may be inadequate for treatment of walled-off necrosis (WON). Recent studies report variable outcomes even when using covered metal stents. The aim of this study was to evaluate the efficacy of a dedicated covered biflanged metal stent (BFMS) when adopting an endoscopic "step-up approach" for drainage of symptomatic WON. Methods We retrospectively evaluated consecutive patients with symptomatic WON who underwent EUS-guided drainage using BFMSs over a 3-year period. Reassessment was done between 48 and 72 hours for resolution. Endoscopic reinterventions were tailored in nonresponders in a stepwise manner. Step 1 encompassed declogging the blocked lumen of the BFMS. In step 2, a nasocystic tube was placed via BFMSs with intermittent irrigation. Step 3 involved direct endoscopic necrosectomy (DEN). BFMSs were removed between 4 and 8 weeks of follow-up. The main outcome measures were technical success, clinical success, adverse events, and need for DEN. Results Two hundred five WON patients underwent EUS-guided drainage using BFMSs. Technical success was achieved in 203 patients (99%). Periprocedure adverse events occurred in 8 patients (bleeding in 6, perforation in 2). Clinical success with BFMSs alone was seen in 153 patients (74.6%). Reintervention adopting the step-up approach was required in 49 patients (23.9%). Incremental success was achieved in 10 patients with step 1, 16 patients with step 2, and 19 patients with step 3. Overall clinical success was achieved in 198 patients (96.5%), with DEN required in 9.2%. Four patients failed treatment and required surgery (2) or percutaneous drainage (2). Conclusions The endoscopic step-up approach using BFMSs was safe, effective, and yielded successful outcomes in most patients, reducing the need for DEN.

Biodegradable (BD) stents have been used for the management of various esophageal strictures (ES) but the experience of its use in caustic strictures is limited. The present study, aimed at evaluating efficacy of BD stents for the treatment of refractory caustic-induced ES, was a retrospective multi-center study conducted at three tertiary care centers in India wherein adult patients with refractory caustic induced strictures underwent placement of a BD stent. Patients were followed up for immediate complications and long term outcome. All 13 patients (39.3 ± 15.1 years) underwent successful BD stent placement. Retrosternal chest pain occurred in 2 patients and stent migration in 1 (7.6%) patient. At 3 months, restenosis with recurrence of dysphagia was seen in nine (69.2%) patients, at 6 months, 10 (77%) patients had dysphagia of whom three underwent surgery and the remaining seven patients required dilatations. At 1 year, one patient remained asymptomatic while nine had dysphagia. The requirement for dilatation was once in 3 months in seven patients & once in a month in two patients. At 2 years, the requirement of dilatations was further reduced to once in 4–6 months in all patients. Over a 3 year follow up three (23%) patients had undergone surgery, one was free of symptoms while nine patients continued to be on periodic dilatation although the requirement had reduced to once in 4–6 months. Efficacy of BD stents in patients with caustic-induced ES is limited and the short term radial force applied by the currently available BD stents is inadequate to provide long term relief in such patients.

Narrow band imaging (NBI) with magnification better visualizes the duodenal microsurface and mucosal vascularity. NBI delineates villous atrophy better than conventional white light endoscopy. This study was conducted to evaluate the diagnostic accuracy of narrow band imaging with magnification (NBI-ME) in celiac disease (CD). In this prospective study, consecutive patients of suspected CD and controls were subjected to tissue transglutaminase antibody test and endoscopic evaluation initially with white light followed by NBI-ME, and biopsies were taken from duodenum. Duodenal villous patterns on NBI were interpreted as normal, blunted distorted, and absent. Severity of villous atrophy was reported according to the modified Marsh criteria. One hundred and twenty-two patients (mean age of 27.53 ± 13.37 years and a male to female ratio of 1:1.26) and 40 controls were studied. The sensitivity and specificity of NBI-ME in predicting villous atrophy were found to be 95.54% and 90%, respectively. The specificity and negative predictive value of NBI-ME in predicting villous atrophy amongst controls was 100% and 97.5%, respectively. Abnormal findings (blunted and absent villous patterns) combined with elevated transglutaminase antibody (> 5-fold) were found to have high accuracy in predicting villous atrophy. NBI with magnification has high sensitivity and specificity in predicting villous atrophy in patients with celiac disease.

Introduction The primary aim of this study was to evaluate efficacy, safety and short-term pain relief after ESWL for large pancreatic calculi in over 5000 patients at a single center. Methods This is a retrospective analysis of prospectively collected data. Patients with painful calculi >5 mm, located in the head, neck and body region in the MPD, who were not amenable for extraction by the standard procedure of endoscopic pancreatic sphincterotomy were subjected to ESWL using a third generation dual focus lithotripter. Patients were followed up at 6 months for outcome evaluation. Results A total of 5124 patients (66% males) were subjected to ESWL. Majority of stones (79.2%) were radiopaque. Single calculi were seen in 3851 (75.1%).The majority of stones were located in head region of MPD in 2824 (55.1%) patients. 4386 (85.5%) patients required 3 or less sessions for fragmentation and complete stone clearance was achieved in 3722 (72.6%). EPS was performed in 5022 (98%) while PD stenting was required in 3536 (69%) patients. Of the 4280 patients followed up for 6 months, 3529 (82.6%) patients were pain free. Another 512 (11.9%) patients had significant reduction in VAS score. In 229 (5.3%) there was no decrease in pain intensity. Minor and self-limiting complications were reported in 1153 (22.5%). Discussion Our study confirms the safety and efficacy and short-term pain relief of ESWL for large calculi in the MPD. In properly selected patients, this should be offered as the first line of therapy for all large MPD calculi not amenable to the standard techniques of stone extraction.

The most common cause of pulmonary hypertension is left heart disease, arising in response to increased left ventricular or left a trial filling pressures[1,2,3]. During the 5th World Symposium held in Nice, France, in 2013, the consensus was reached to maintain the general scheme of previous clinical classifications, placing the Pulmonary Hypertension due to left heart disease in Group 2 [4]. PH is defined by a mean pulmonary arterial pressure >25 mmHg. In the case of PH associated with LHD, this is associated with a pulmonary capillary wedge pressure >15 mmHg or left ventricular end-diastolic pressure (LVEDP) > 18 mm Hg [1,5]. Pulmonary hypertension due to left-sided heart disease is associated with higher morbidity and mortality [6,7,8]. This study is done to know the pattern of clinical presentation of pulmonary hypertension and to see the gender difference.

Background and Aim Endoscopic drainage of pancreatic fluid collections (PFC) is the standard of care in adult patients. The literature is limited in children. In the present study, we aim to evaluate the safety and long-term efficacy of endoscopic ultrasound (EUS)-guided drainage of PFC in children. Methods Data of all children (

Objectives Endoscopic ultrasound (EUS)-guided drainage with fully covered self-expanding metallic stents (FCSEMS) has been successfully used in adult patients. The utility of FCSEMS in children with walled-off necrosis (WON) is, however, unknown. The aim of present study was to evaluate the feasibility, safety, and efficacy of EUS drainage of WON using FCSEMS in children. Methods We retrospectively evaluated the data of children (18 years or younger) who underwent EUS drainage of WON using FCSEMS at our institution. All FCSEMS were removed between 1 and 3 months. Feasibility, safety, and efficacy were analysed. Results Twenty-one children (20 boys, mean age 14.9 ± 2.34 years, range 9-18 years) underwent EUS-guided drainage of WON with FCSEMS. The median size of WON was 88 mm (55-148 mm). The median interval between onset of acute pancreatitis and EUS guided drainage was 58 days (range 30-288 days). The technical and clinical success rates were 100% and 95%, respectively. Nasocystic tube was placed in 3 children for lavage. Endoscopic necrosectomy was not required in any of the children. There were no major complications. Minor complications included bleeding (2), stent migration (1), and difficulty in removal of stent (1). After a median follow-up of 360 days (range: 30-1020 days), there was 1 recurrence of WON. Conclusions EUS drainage of WON using specially designed FCSEMS is safe and efficacious in children. The utility of FCSEMS in children should be further explored and compared with plastic stents.

Percutaneous coronary intervention (PCI) is a potential alternative to bypass surgery for patients with unprotected left main (LM) coronary artery stenosis. However, PCI for LM bifurcation is technically demanding and has been associated with high rates of adverse clinical events. Randomized

A 44-year-old man presentedwith a large, symptomatic pancreatic fluid collection (PFC) 6 weeks after an episode of alcoholrelated acute necrotizing pancreatitis. Imaging confirmed an area of walled-off necrosis (WON) measuring 15×12mm and containing solid debris. He underwent endoscopic ultrasound (EUS)-guided drainage with the aim of placing a dedicated fully covered self-expanding metal stent (SEMS; Nagi stent, Taewoong Medical, Seoul, South Korea) of 16mm in diameter and 20mm in length. The initial steps of the drainage procedure via the stomach (needle puncture, creation of a cystogastric fistula using a coaxial over-the-wire 6-Fr cystotome, and smallcaliber balloon dilation) were uneventful. During deployment of the SEMS, the distal end opened appropriately inside theWON (confirmedonEUSand fluoroscopy); however, at the point of final SEMS release, there was an excessive gush of turbid, purulent fluid into the stomach,which obscured the endoscopic visualization of the SEMS (within the deliverycatheter) and its yellow marker (which indicates the proximal end of the SEMS). After its release, the proximal (gastric end) of the SEMS was noted tobewithin the cystwall. The guidewire was still in position passing through the stent (●" Fig.1). This untoward event was immediately identified, but unfortunatelyefforts to reposition theSEMS failed. A 6-Fr nasocystic catheter was therefore placed over the guidewire to drain the collection. There were no post-procedure adverse events. After 48 hours, a gastroscope (Olympus; diameter 9.2mm) was passed over the nasocystic catheter keeping the guidewire, which had been re-routed through the oral cavity, inside. The fistulous opening was dilated with 12-mm controlled radial expansion (CRE) balloon (Boston Scientific, Natick, Massachusetts, USA). On entering the cavity, the internally migrated Nagi stent was caught at its proximal edge with rat-tooth forceps and gently pulled back and repositioned in the desired place (●" Video 1). The patient remained asymptomatic until his discharge. At 6 weeks, after resolution of the WON, the Nagi SEMSwas removed. Technical success rates are generally high when placing a dedicated SEMS for EUSguided drainage of PFCs [1–4]. A SEMS that is misplaced inside the PFC poses a challenge in terms of repositioning and may require either its removal or placement of a plastic stent through it. An inappropriately placed SEMS in a PFC can be salvaged with repositioning and reuse of same stent provided the guidewire is in place.