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Background and study aims The Bethesda ERCP Skill Assessment Tool (BESAT) is a video-based assessment tool of technical endoscopic retrograde cholangiopancreatography (ERCP) skill with previously established validity evidence. We aimed to assess the discriminative validity of the BESAT in differentiating ERCP skill levels. Methods Twelve experienced ERCP practitioners from tertiary academic centers were asked to blindly rate 43 ERCP videos using the BESAT. ERCP videos consisted of native biliary cannulation and sphincterotomy and were recorded from 10 unique endoscopists of various ERCP experience (from advanced endoscopy fellow to > 10 years of ERCP experience). Inter-rater reliability, discriminative validity, and internal structure validity were subsequently assessed. Results The BESAT was found to reliably differentiate between endoscopists of varying levels of ERCP experience with experienced ERCPists scoring higher than novice ERCPists in 11 of 13 (85%) instrument items. Inter-rater reliability for BESAT items ranged from good to excellent (intraclass correlation range: 0.86 to 0.93). Internal structure validity was assessed with item-total correlations ranging from 0.53 to 0.83. Conclusions Study findings demonstrate that the BESAT, a video-based ERCP skill assessment tool, has high inter-rater reliability and has discriminative validity in differentiating novice from expert ERCP skill. Further investigations are needed to determine the role of video-based assessment in improving trainee learning curves and patient outcomes.

Endoscopic examination is not risk free. Not only are there well-known complications associated with the procedure, but malignant and pre-malignant lesions can be missed due to human factors or failures in organizational process. Duty of candor (DoC) is a legal requirement if significant harm occurs in delivery of healthcare. Post-colonoscopy colorectal cancer (PCCRC) and post-endoscopy upper gastrointestinal cancer (PEUGIC) audits have identified missed diagnoses that are associated with harm and require consideration of DoC. This article explores the new and unique challenges associated with DoC in endoscopy audits. There are unresolved questions around the place of DoC in retrospective audits, agreement of harm thresholds, and constitution of review teams. Involved departments must be committed to transparency and trained in governance processes. Fear of institutional and personal reputational damage, as well as future litigation, may influence decisions. Patient expectations need to be clarified, as do supportive structures for individual endoscopists who will be involved in DoC processes when significant lesions have been missed. Further consensus around DoC is required so that clear guidance can be given to endoscopy units.

Digestive endoscopy is a highly dynamic medical discipline, with the recent adoption of new endoscopic procedures. However, comprehensive guidelines on the role of antibiotic prophylaxis in these new procedures have been lacking for many years. The Guidelines Commission of the French Society of Digestive Endoscopy (SFED) convened in 2023 to establish guidelines on antibiotic prophylaxis in digestive endoscopy for all digestive endoscopic procedures, based on literature data up to September 1, 2023. This article summarizes these new guidelines and describes the literature review that fed into them.

Background and study aims Variation between trainers in providing traditional gastrointestinal endoscopy training, in which residents learn endoscopy by doing under the supervision of endoscopy trainers, may cause differences in endoscopy competence between residents. In this study, we explored endoscopy trainers’ views on the current status and desired future best practices regarding endoscopy training.

Inadequate bowel preparation is common despite various preprocedure interventions. There is a need for an intervention at the time of colonoscopy to combat poor preparation. In this retrospective, observational study of 46 patients, we evaluated the clinical efficacy and feasibility of implementing the third generation of the Pure-Vu EVS System, a US Food and Drug Administration-cleared over-the-scope-based intraprocedural cleansing device, into our practice at the Minneapolis VA Medical Center (Minneapolis, Minnesota, United States). To study clinical efficacy, we measured bowel preparation adequacy before and after using the device, as measured by the Boston Bowel Preparation Score, and reviewed colonoscopy surveillance interval recommendations. Technical success and feasibility of using the device were measured by procedure success rates and duration. We found that BBPS scores increased from 4.4 to 7.9 when using the device. Technical success was achieved 78.3% of the time (36/46 cases). Median colonoscopy duration was 46 minutes, although there was a trend toward shorter procedures over time. This is the first clinical evaluation of the third generation of an intraprocedural cleansing device. We found the device efficacious and easy to use with low procedure failure rates, but it does come with a learning curve. We suspect that adoption of this device mutually will benefit patients and health systems with the potential to improve resource utilization.

Optimizing the adenoma detection rate (ADR) is a major goal in colorectal cancer (CCR) screening, as it has long been established that ADR is inversely proportional to the risk of post-colonoscopy CRC occurrence. To achieve this goal, many optimization devices have been developed, and numerous randomized controlled trials have been conducted to evaluate the benefits of these devices compared with a "standard arm," which corresponds to date to high-definition white light (HD-WLI) colonoscopy. Numerous studies have confirmed the positive impact of various optimization devices, such as caps, computer-aided detection, and contrast-enhanced technologies. Moreover, the different ways in which the devices can impact ADR make them complementary. However, despite substantial and consistent data, practices remain unchanged, and HD-WLI colonoscopy, considered the "standard," is still routinely performed without any optimization devices. The objective of this viewpoint is to understand the barriers to change and to show why standard screening colonoscopy without the use of any optimization devices should no longer be considered relevant in 2024.

Background and study aims Use of fluoroscopy in gastrointestinal endoscopy is an essential aid in advanced endoscopic interventions. However, it also raises concerns about radiation exposure. This study aimed to develop consensus-based statements for safe and effective use of fluoroscopy in gastrointestinal endoscopy, prioritizing the safety and well-being of healthcare workers and patients. Methods A modified Delphi approach was employed to achieve consensus over three rounds of surveys. Proposed statements were generated in Round 1. In the second round, panelists rated potential statements on a 5-point scale, with consensus defined as ≥80% agreement. Statements were subsequently prioritized in Round 3, using a 1 (lowest priority) to 10 (highest priority) scale. Results Forty-six experts participated, consisting of 34 therapeutic endoscopists and 12 endoscopy nurses from six continents, with an overall 45.6% female representation (n = 21). Forty-three item statements were generated in the first round. Of these, 31 statements achieved consensus after the second round. These statements were categorized into General Considerations (n = 6), Education (n = 10), Pregnancy (n = 4), Family Planning (n = 2), Patient Safety (n = 4), and Staff Safety (n = 5). In the third round, accepted statements received mean priority scores ranging from 7.28 to 9.36, with 87.2% of statements rated as very high priority (mean score ≥ 9). Conclusions This study presents consensus-based statements for safe and effective use of fluoroscopy in gastrointestinal endoscopy, addressing the well-being of healthcare workers and patients. These consensus-based statements aim to mitigate risks associated with radiation exposure while maintaining benefits of fluoroscopy, ultimately promoting a culture of safety in healthcare settings., Competing Interests: Conflict of Interest Tyler Berzin - Consultant for: Medtronic, Boston Scientific, Wision AI, Microtech. Alan N. Barkun - Consultant for Olympus Inc and Medtronic Inc. Cecilia Binda – Lecturer for Steris, Fujifilm, Boston Scientific, Q3 Medical. Alessandro Fugazza – Consultant for Boston Scientific. Rogier P. Voermans - Consultancy and research grant for Boston Scientific, Research grant Prion Medical; Consultancy fee form from Cook Medical. Lecturer Viatris and Zambon. Nauzer Forbes – Speaker for Boston Scientific, Pentax Medical. Consultant for Boston Scientific, Pentax Medical and AstraZeneca. Mariano Villarroel – Consultant for Boston Scientific. Yen-I Chen – Consultant for Boston Scientific. President of Chess Medical. Robert Bechara – Consultant for Olympus, Pentax, Vantage, Medtronic, Pendopharm. Payal Saxena – Consultant for Boston Scientific, Ambu, Erbe. Amrita Sethi – Consultant for Boston Scientific, Interscope, Medtronic, Olympus; Research Support for Boston Scientific, Fujifilm and ERBE. Cesare Hassan: Fujifilm Co. (consultancy); Medtronic Co. (consultancy). Alessandro Repici: Fujifilm Co. (consultancy); Olympus Corp (consultancy); Medtronic Co. (consultancy). Bret Peterson – Consultant for Olympus, Pentax. Investigator for Boston Scientific and Ambu. Silvia Carrara – Consultant for Olympus and Aboca. Jeffrey D. Mosko – Speaker for Boston Scientific, Pendopharm, SCOPE rounds, Vantage, Medtronic. Medical Advisory Board for Pendopharm, Boston Scientific, Janssen, Pentax, Fuji. Grants and Research support from CAG. Christopher W. Teshima – Speaker for Medtronic and Boston Scientific, Consultant for Boston Scientific. Gary R. May – Consultant for Olympus. Speaker for Pentax, Fuji and Medtronic. Samir C Grover –Research grants and personal fees from AbbVie and Ferring Pharmaceuticals, personal fees from Takeda, Sanofi, and BioJAMP, education grants from Janssen, and has equity in Volo Healthcare. All the authors have no relevant financial disclosures or conflicts of interest to declare., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background and study aims Reduction of colorectal cancer morbidity and mortality is one of the primary objectives of colonoscopy. Post-colonoscopy colorectal cancers (PCCRCs) are critical outcome parameters. Analysis of PCCRC rates can validate quality assurance measures in colonoscopy. We assessed the effectiveness of implementing a gastroenterologist-led quality framework that monitors key procedure quality indicators (i.e., bowel preparation quality, adenoma detection rates, or patient satisfaction) by comparing the PCCRC rate before and after implementation. Patients and methods Individuals who had a colonoscopy between 2010 and 2017 at a single tertiary center in Queensland, Australia, were included and divided into two groups: baseline (2010-2014) and redesign phase (2015-2017). Data linkage of the state-wide cancer registry and hospital records enabled identification of subjects who developed colorectal cancers within 5 years of a negative colonoscopy. Costs associated with quality improvement were assessed for effectiveness. Results A total of 19,383 individuals had a colonoscopy during the study period. Seventeen PCCRCs were detected. The PCCRC rate was 0.376 per 1,000 person-years and the average 5-year PCCRC risk ranged from 0.165% to 0.051%. The rate of PCCRCs was higher at the beginning (0.166%; 95% confidence interval [CI] 0.15%-0.17%) compared with the later period with full implementation of quality control measures (0.027%; 95% CI 0.023%-0.03%). The quality process determined an incremental cost-effectiveness ratio of -$5,670.53 per PCCRC avoided. Conclusions This large cohort study demonstrated that a formal gastroenterologist-led quality assurance framework embedded into the routine operations of a clinical department not only reduces interval cancers but is also cost-effective regarding life years gained and quality-adjusted life years., Competing Interests: Conflict of Interest HM has previously received grants from Olympus and Satisfai. Speaker fees from Dr Falk Pharma, Olympus, Norgine, IPSEN, medupdate and Erbe. Consultation fees from Olympus, Ambu, Boston Scientific, Covidien and Takeda. All other authors have no conflicts of interest to disclose., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Endoscopic examination is not risk free. Not only are there well-known complications associated with the procedure, but malignant and pre-malignant lesions can be missed due to human factors or failures in organizational process. Duty of candor (DoC) is a legal requirement if significant harm occurs in delivery of healthcare. Post-colonoscopy colorectal cancer (PCCRC) and post-endoscopy upper gastrointestinal cancer (PEUGIC) audits have identified missed diagnoses that are associated with harm and require consideration of DoC. This article explores the new and unique challenges associated with DoC in endoscopy audits. There are unresolved questions around the place of DoC in retrospective audits, agreement of harm thresholds, and constitution of review teams. Involved departments must be committed to transparency and trained in governance processes. Fear of institutional and personal reputational damage, as well as future litigation, may influence decisions. Patient expectations need to be clarified, as do supportive structures for individual endoscopists who will be involved in DoC processes when significant lesions have been missed. Further consensus around DoC is required so that clear guidance can be given to endoscopy units., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background and study aims Although esophagogastroduodenoscopy (EGD) is a widely used technique, the procedure is often associated with discomfort. This study aimed to analyze painful situations, their frequency, and factors associated with patient discomfort during EGD. Patients and methods This prospective observational study included patients scheduled to undergo EGD. Seven endoscopists recruited patients scheduled for EGD screening or surveillance. Each endoscopist enrolled 20 patients, performing 10 EGD procedures using ultraslim endoscopes and 10 with standard-sized endoscopes. Data regarding painful situations and frequency were collected using specialized buttons pressed by the patients during EGD. A survey about overall discomfort was conducted after the procedure. Results We analyzed data from 140 patients. Esophageal insertion and duodenal observation were associated with the highest incidence of pressing the pain button, accounting for 59.3% and 40.7% of the cases, respectively. The factor associated with pressing the pain button during esophageal insertion was endoscopist experience (< 10 years). In contrast, younger age and female sex were the factors associated with pressing the pain button during duodenal observation. In the post-procedure survey, 63.6% of patients reported discomfort. Factors associated with patient discomfort included pressing the pain button during esophageal insertion (odds ratio [OR]: 2.84, P = 0.01) and previous painful EGD experience (OR: 2.41, P = 0.03). Concusions This study provides objective data on painful situations, their frequency, and related factors during EGD. Further research and interventions focusing on pain reduction during endoscopic procedures are warranted. The results of this study will help endoscopists manage painful situations and potentially improve skills., Competing Interests: Conflict of Interest This research was conducted with funding provided by Fujifilm Corporation., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Background and study aims: This study aimed to conduct a clinical audit of adverse events (AEs) arising from gastrointestinal endoscopy, utilizing the AGREE classification for AEs and establishing its correlation with the ASGE classification. This study further integrated the economic repercussions of AEs into the AGREE classification through the AIG-AGREE modification. Patients and methods: A prospective observational study was conducted at the Asian Institute of Gastroenterology, Hyderabad, India, from July 1, 2021, to December 31, 2021. The study included all patients who underwent diagnostic or therapeutic endoscopic procedures. AEs were categorized using the American Society of Gastrointestinal Endoscopy (ASGE) and AGREE classifications. A quality indicator questionnaire containing 15 questions was graded based on the latest ASGE and European Society of Gastrointestinal Endoscopy guidelines. The grading scale ranged from 1 to 3 (poor), 4 to 6 (average), 7 to 9 (excellent), to 10 (outstanding). In addition, the AIG-AGREE modification divided the economic impact into five scales (α, β, γ, δ, and ε) based on multiples of the baseline amount. (ClinicalTrials.gov Identifier: NCT05228353) Results: Over the 6-month study period, a total of 42,471 endoscopic procedures were performed, identifying 220 AEs. Analysis revealed a significant positive correlation (Pearson correlation coefficient = 0.79; P < 0.001) between the grades of AEs in the AGREE and ASGE classifications. The median score for all quality indicators was 8, indicating excellent services based on feedback from 13,042 surveyed patients. Notably, patients with more severe AEs (AGREE III-V) exhibited higher economic impact categories (β, γ, δ, ε) compared with those with less severe AEs (AGREE I-II). Conclusions: The AIG-AGREE modification stands as a pioneering effort that highlights the importance of considering economic factors in the evaluation of AEs in gastrointestinal endoscopy., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)