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Background and Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is the standard of care for the management of choledocholithiasis but carries risk of complications which may result in significant morbidity and mortality. While currently available guidelines endorse the use of ERCP for the management of symptomatic common bile duct stones, the need for ERCP in incidentally found asymptomatic choledocholithiasis is more controversial, and practice varies on a geographic and institutional level. This systematic review and meta-analysis is conducted to compare post-ERCP adverse events between asymptomatic and symptomatic choledocholithiasis patients. Methods: We searched PubMed/Embase/Web of Science databases to include all studies comparing post-ERCP outcomes between asymptomatic and symptomatic choledocholithiasis patients. The primary outcome was post-ERCP pancreatitis (PEP), while secondary outcomes included post-ERCP cholangitis, bleeding, and perforation. We calculated pooled risk ratios (RR) and 95% confidence intervals (CIs) using the Mantel–Haenszel method within a random-effect model. Results: Our analysis included six observational studies, totaling 2,178 choledocholithiasis patients (392 asymptomatic and 1786 symptomatic); 53% were female. Asymptomatic patients exhibited a higher risk of PEP compared with symptomatic patients (11.7% versus 4.8%; RR 2.59, 95% CI 1.56–4.31, p ≤ 0.001). No significant difference was observed in post-ERCP cholangitis, bleeding, or perforation rates between the two groups. Conclusions: Asymptomatic patients with choledocholithiasis appear to have a higher risk of PEP than symptomatic patients, while the risk of other post-ERCP adverse events is similar between the two groups. Interventional endoscopists should thoroughly discuss potential adverse events (particularly PEP) with asymptomatic patients before performing ERCP and utilize PEP-prevention measures more liberally in this subgroup of patients. [ABSTRACT FROM AUTHOR]

Introduction: Artificial intelligence (AI) has greatly transformed healthcare in developed countries. However, there is limited data describing the extent of AI adoption in African healthcare systems. The aim of this study was to understand the state of AI healthcare research in Africa. Methods: A scientometric analysis was conducted to visualize the state-of-the-art research of AI in healthcare in Africa. Results: Twenty-six relevant articles, published by 178 authors and affiliated with 96 organizations in 31 countries, were included. The most prolific African countries were South Africa, followed by Nigeria and Ghana. Some articles were published by authors affiliated with non-African countries. None of the contributing authors published more than 2 articles. Only 20 (11.2%) authors collaborated, forming a single cluster. The most common AI tools used in African health systems were deep learning neural networks applied in medical imaging, Adaptive Neuro-Fuzzy Inference Systems, and E-algorithms. Conclusion: Our results suggest that AI for healthcare in Africa is still in its developmental phase with limited published research. Our social network analysis highlighted a South and West African predominance in the research relational network of AI in healthcare. This discrepancy presents an opportunity for coordination and increased collaboration with healthcare institutions advanced in the use of AI within Africa and beyond. [ABSTRACT FROM AUTHOR]

Purpose of review: Artificial intelligence (AI) has been shown to be an increasingly powerful tool in the practice of medicine. There is great potential for AI to improve the quality of colorectal cancer screening. We will review recent progress that has been made in this area. Recent findings: The use of CADe polyp detection has shown potential to increase adenoma detection rate (ADR) and decrease the adenoma miss rate (AMR), while CADx polyp diagnosis has the potential to reduce the need for histopathology, supporting cost-saving strategies like "diagnose and leave" or "resect and discard" during colonoscopy. Computer vision algorithms can measure a variety of colonoscopy quality metrics including bowel preparation adequacy and cecal intubation. Natural language processing is making data abstraction and analytics for colonoscopy quality assessment easier and more efficient. Machine learning algorithms also have the potential to personalize screening recommendations for colorectal cancer based on demographics and laboratory blood tests. Although there are barriers to widespread utilization of these new technologies, there is great potential for artificial intelligence to improve the quality of colonoscopy for colorectal cancer screening. Summary: Recent advances in AI have demonstrated great potential for improving the quality of colorectal cancer screening by improving efficiency and outcomes, and in certain cases, offering a path towards decreasing healthcare costs. [ABSTRACT FROM AUTHOR]

Bile duct cancer is the second most common primary liver cancer, with most diagnoses occurring in the advanced stages. This leads to a poor survival rate, which means a technique capable of reliably detecting pre-cancer in the bile duct is urgently required. Unfortunately, radiological imaging lacks adequate accuracy for distinguishing dysplastic and benign biliary ducts, while endoscopic techniques, which can directly assess the bile duct lining, often suffer from insufficient sampling. Here, we report an endoscopic optical light scattering technique for clinical evaluation of the malignant potential of the bile duct. This technique employs an ultraminiature spatial gating fiber optic probe compatible with cholangioscopes and endoscopic retrograde cholangiopancreatography (ERCP) catheters. The probe allowed us to investigate the internal cellular composition of the bile duct epithelium with light scattering spectroscopy (LSS) and phenotypic properties of the underlying connective tissue with diffuse reflectance spectroscopy (DRS). In a pilot in vivo double-blind prospective study involving 29 patients undergoing routine ERCP procedures, the technique detected malignant transformation with 97% accuracy, showing that biliary duct pre-cancer can be reliably identified in vivo non-invasively. Diagnosis of bile duct cancer often occur in advanced stages, leading to poor survival. Here, the authors combine light scattering and diffuse reflectance spectroscopies in a minimally invasive endoscopic technique for directly assessing the malignant potential of the bile duct lining, and demonstrate 97% detection accuracy. [ABSTRACT FROM AUTHOR]

Background: The optimal timing of biliary drainage by endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute cholangitis remains controversial. The aim of our study was to determine if ERCP performed within 6 or 12 h of presentation was associated with improved clinical outcomes. Methods: Medical records for all patients with acute cholangitis who underwent ERCP at our institution between 2009 and 2018 were reviewed. Outcomes were compared between those who underwent ERCP within or after 12 h using propensity score framework. Our primary outcome was length of hospitalization. Secondary outcomes included in-hospital mortality, adverse events, ERCP failure, length of ICU stay, organ failure, recurrent cholangitis, and 30-day readmission. In secondary analysis, outcomes for ERCP done within or after 6 h were also compared. Results: During study period, 487 patients with cholangitis were identified, of whom 147 had ERCP within 12 h of presentation. Using propensity score matching, we selected 145 pairs of patients with similar characteristics. Length of hospitalization was similar between ERCP within or after 12 h (135.9 vs 122.1 h, p 0.094). No difference was noted in mortality, ERCP failure, adverse events, need and length of ICU stay, and recurrent cholangitis. However, 30-day readmission rates were lower when ERCP within 12 h (7.6 vs 15.2, p 0.042). No significant difference was noted in aforementioned outcomes between ERCP performed within or after 6 h. Conclusions: ERCP performed within 6 h or 12 h of presentation was not associated with superior clinical outcomes, however, may result in reduced re-hospitalization. [ABSTRACT FROM AUTHOR]

Purpose: To assess technical and clinical outcomes following lumen-apposing covered self-expanding metallic stent (LAMS) placement for symptomatic pancreatic fluid collections (PFC) with CT and MRI. Methods: In this retrospective study, patients with PFC who underwent LAMS placement between March 2015 and June 2018 were included. Primary outcomes included technical success, defined as successful stent placement with resolution of PFC, and clinical success, defined as lack of fluid recurrence after stent removal. Secondary outcomes included time duration from stent placement to removal, complications, and re-intervention need. Results: 28 consecutive patients (20 men, mean age: 53 years ± 17; range 21–75) who underwent endoscopic drainage of symptomatic walled-off necrosis (WON, 21/28, 75%), pseudocyst (PC, 5/28, 18%) or acute necrotic collection (ANC, 2/28, 7%) were included. LAMS were placed successfully in 27/28 (96%) patients. On follow-up imaging after at least one month (n = 24), the volume of the PFC decreased by 99.9% from 425 cm3 [IQR 214 – 636] to 0.6 cm3 [IQR 0–43.9]. After stent removal, 26/27 (96%) patients remained collection free. The median time duration from stent placement to removal was 42 days [IQR 34–71]. Complications (10/28; 36%) included stent occlusion (n = 1), stent migration (n = 3), intraprocedural bleeding (n = 2), postprocedural bleeding (n = 2), and pseudoaneurysm formation (n = 2). Re-intervention was required in 7/27 (26%). Conclusion: Following LAMS placement in patients with symptomatic PFC, high technical and clinical success rates of 96% and 96%, respectively, are achieved. Awareness of common complications seen on cross-sectional imaging might help radiologists and gastroenterologist in the patients' management. [ABSTRACT FROM AUTHOR]

Fatty pancreas is a newly recognized condition which is poorly investigated until today as compared to nonalcoholic fatty liver disease. It is characterized by pancreatic fat accumulation and subsequent development of pancreatic and metabolic complications. Association of fatty pancreas have been described with type 2 diabetes mellitus, acute and chronic pancreatitis and even pancreatic carcinoma. In this review article, we provide an update on clinical implications, pathogenesis, diagnosis, treatment and outcomes. [ABSTRACT FROM AUTHOR]

Background: There is limited data regarding the prevalence and clinical impact of sedation-related adverse events (SRAEs) during radiofrequency ablation (RFA) for dysplastic Barrett's esophagus (BE).Aim: Our primary aim was to measure SRAE during RFA. Secondary aims were to identify risk factors for adverse events, and to determine whether SRAEs impacted the number of RFA treatments to achieve complete eradication of dysplasia (CE-D).Methods: We conducted a retrospective analysis of 120 consecutive patients undergoing initial RFA for dysplastic BE between 2008 and 2014. The main outcome measures were SRAEs and the number of RFA sessions required to achieve CE-D.Results: Of 120 initial RFA procedures, 83 % were performed with MAC and 17 % with GET. SRAEs occurred in 32 %, including 25 % of MAC patients (25/100) and 65 % (12/20) GET patients. The most frequent SRAE was hypotension (23 %, n = 27/120), followed by hypoxia (n = 9/120), arrhythmia (n = 4/120), and one unplanned intubation. There were no premature procedure terminations. After adjusting for length of BE mucosa and ASA score, the occurrence of a SRAE was associated with requiring more (>4) RFA sessions to achieve CE-D, OR 3.45 (95 % CI 1.49-7.99). Mean RFA sessions required to achieve CE-D was 5 ± 1 in patients with SRAE, compared to 3 ± 0.7 in patients without SRAE during the first treatment session (p < 0.001).Conclusions: SRAE during RFA for dysplastic BE occurs at a rate typical of other advanced endoscopic procedures. Patients who experience minor events related to anesthesia during the first RFA are likely to require more RFA treatment sessions to achieve CE-D. [ABSTRACT FROM AUTHOR]

Background and Aims: Although there is substantial literature addressing double-balloon enteroscopy, evidence is more limited with regard to the clinical utility of single-balloon enteroscopy (SBE) in evaluating and treating small-bowel diseases. We sought to determine the diagnostic and therapeutic yield of SBE in patients with suspected small-bowel disorders, as well as the impact of preceding capsule endoscopy (CE) on these outcomes. Methods: We performed a retrospective analysis of a prospectively collected database at a tertiary-care academic medical center between 2011 and 2013 for all patients referred for SBE. Results: A total of 150 patients underwent 170 SBE procedures during the study period. The most frequent indications for SBE included anemia, overt or occult gastrointestinal bleeding, and suspected mass. CE was performed prior to SBE in 113 of 150 patients (75 %). The overall diagnostic yield for small-bowel disease by CE was 62 %. Therapeutic interventions included hemostasis, polypectomy, and foreign body removal. Total diagnostic and therapeutic yield of SBE was 60 and 28 %, respectively. The diagnostic yield of SBE with prior CE was 68 versus 44 % for SBE without prior CE ( P = 0.002). The therapeutic yield of SBE with prior CE was 35 versus 12 % without prior CE ( P = 0.001). One endoscopic complication was observed out of 170 procedures, and there were no deaths. Conclusions: SBE appears to be a safe and effective technique for the diagnosis and treatment of small-bowel disease; however, we recommend performing a CE prior to SBE to improve the diagnostic and therapeutic yield of the procedure. [ABSTRACT FROM AUTHOR]

Background: General endotracheal (GET) anesthesia is often used during single-balloon enteroscopy (SBE). However, there is currently limited data regarding monitored anesthesia care (MAC) without endotracheal intubation for this procedure. Aims: The aim of the study was to determine the safety and efficacy of MAC sedation during SBE and to identify risk factors for adverse events. Methods: All patients who underwent SBE and SBE-assisted endoscopic retrograde cholangiopancreatography between June 2011 and July 2013 at a tertiary-care referral center were studied in a retrospective analysis of a prospectively collected database. Patients received MAC anesthesia or GET. The main outcome measurements were sedation-related adverse events, diagnostic yield, and therapeutic yield. Results: Of the 178 cases in the study, 166 cases (93 %) were performed with MAC and 12 (7 %) with GET. Intra-procedure sedation-related adverse events occurred in 17 % of cases. The most frequent event was transient hypotension requiring pharmacologic intervention in 11.8 % of procedures. In MAC cases, the diagnostic yield was 58.4 % and the therapeutic yield was 30.1 %. Anesthesia duration was strongly associated with the occurrence of a sedation-related adverse event ( P = 0.005). Conclusions: MAC is a safe and efficacious sedation approach for most patients undergoing SBE. Sedation-related complications in SBE are uncommon, but are more frequent in longer procedures. [ABSTRACT FROM AUTHOR]

Background and Aim: Simultaneous dilatation of the common bile duct and pancreatic duct, 'double-duct sign' (DDS), is an ominous finding concerning for pancreaticobiliary malignancy. Little evidence exists to guide the initial evaluation and subsequent follow-up for patients with DDS in the absence of jaundice or focal mass noted on computed tomography (CT)/ magnetic resonance imaging (MRI). Endoscopic ultrasound (EUS) is often recommended in the evaluation of such patients, however, the prevalence of malignancy remains unclear. We sought to determine the prevalence of pancreaticobiliary neoplasm in this patient group on initial EUS evaluation and on subsequent clinical follow-up. Methods: We performed a retrospective analysis of a prospective database at a tertiary-care academic medical center between 2010 and 2012. Eighty-two patients were identified who underwent EUS evaluation for DDS without evidence of a mass on CT/MRI and without jaundice. Results: Sixty-eight of 82 patients had confirmed DDS on EUS with biductal dilation. Six (9 %) of 68 patients were found to have a mass lesion on EUS. In these patients, final diagnoses were pancreatic carcinoma ( n = 4), ampullary carcinoma ( n = 1) and ampullary adenoma ( n = 1). In the 62 patients without evidence of a focal mass on initial EUS, the most common diagnoses were benign ductal dilation ( n = 42), chronic pancreatitis ( n = 9) and choledocholithiasis ( n = 8). Fifty-eight (94 %) of 62 patients had documented median follow-up of 13 months, and none developed subsequent evidence of previously unrecognized malignancy. Conclusions: The presence of double-duct sign on EUS in patients without jaundice or mass lesion on CT/MRI is most frequently associated with benign conditions. When a mass is not detected on EUS, subsequent evidence of malignancy is unlikely. [ABSTRACT FROM AUTHOR]

Background: Providing the appropriate anesthesia for endoscopic retrograde cholangiopancreatography (ERCP) cases is challenging. Aim: The aim of our study was to prospectively assess the safety of anesthesia directed deep sedation (ADDS) in non-intubated patients compared to general endotracheal anesthesia (GET) during an ERCP. Methods: We conducted a prospective observational study in patients undergoing an ERCP. The choice of anesthetic-ADDS or GET-was made by the anesthesiologist. The pre-anesthesia assessment, intraoperative vital signs, and medications administered were collected. A standardized study instrument was used to record the number of procedure interruptions, intraprocedure and recovery room adverse events (AE). Results: A total of 393 (89.7 %) patients received ADDS (no intubation) and 45 (10.2 %) received a GET. Age and comorbidities were similar in ADDS and GET groups. BMI was higher in the GET (32.6 ± 9.5) versus in the ADDS (27.3 ± 6.1) group; p < 0.001. The number of ASA 2 patients was higher in the ADDS versus the GET group (38.7 versus 22.2 %; p < 0.04); the number of ASA 4 patients was 15.6 % of GET versus 6.6 % of the ADDS cases ( p = 0.05). During the procedure 16 (3.7 %) ADDS patients were intubated and converted to a GET anesthetic; 4 (25 %) of the converted ADDS cases were ASA 4 versus 6.4 % of ADDS patients ( p = 0.006). Intraprocedure events occurred in 35.6 % of GET and 25.7 % of ADDS cases, without significant complications. Conclusion: Our data suggest that the administration of anesthesia without intubation for prone ERCP cases is feasible especially in non-obese, healthier patients. [ABSTRACT FROM AUTHOR]

Background: Depression and post-traumatic stress disorder have been described after surgical procedures, but not after gastrointestinal endoscopy.Aims: The aim of our retrospective survey was to determine if new-onset, persistent (>1 month) psychological and/or physical symptoms develop after gastrointestinal endoscopy. We also sought to assess how endoscopy teams respond to patient discomfort during the procedure.Methods: We conducted in-person interviews among 57 gastroenterologists and endoscopy nurses at two large academic medical centers and a community hospital. Response rate was 81% (57/70).Results: Among gastroenterologists surveyed, 62% had encountered at least one patient with persistent new-onset unexplained physical symptoms, and 48% had encountered at least one patient with persistent new-onset psychological symptoms that started after an endoscopic procedure. A total of 44 such patients were identified, and most were women between 20 and 40 years of age. Common new symptoms that developed after gastrointestinal endoscopy were abdominal discomfort, diarrhea, globus sensation, anxiety disorder and depression. Duration of these symptoms was 1 month to 3 years. Gastroenterologists reported that 4% and endoscopy nurses reported that 10% of patients undergoing endoscopy gestured or requested that the endoscopic procedure be prematurely stopped due to discomfort. Only 11/29 (38%) physicians reported that while obtaining consent for endoscopic procedures, they routinely discuss the possibility of stopping prematurely if the patient becomes uncomfortable. Conclusion Persistent physical or psychological symptoms can develop in some patients after endoscopic procedures. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented regarding intraductal papillary mucinous neoplasm in heterotopic pancreas.

Esophageal adenocarcinoma is the most rapidly growing cancer in America. Although the prognosis after diagnosis is unfavorable, the chance of a successful outcome increases tremendously if detected early while the lesion is still dysplastic. Unfortunately, the present standard-of-care, endoscopic surveillance, has major limitations, since dysplasia is invisible, often focal, and systematic biopsies typically sample less than one percent of the esophageal lining and therefore easily miss malignancies. To solve this problem we developed a multispectral light scattering endoscopic imaging system. It surveys the entire esophageal lining and accurately detects subcellular dysplastic changes. The system combines light scattering spectroscopy, which detects and identifies invisible dysplastic sites by analyzing light scattered from epithelial cells, with rapid scanning of the entire esophageal lining using a collimated broadband light beam delivered by an endoscopically compatible fiber optic probe. Here we report the results of the first comprehensive multispectral imaging study, conducted as part of routine endoscopic procedures performed on patients with suspected dysplasia. In a double-blind study that characterized the system's ability to serve as a screening tool, 55 out of 57 patients were diagnosed correctly. In addition, a smaller double-blind comparison of the multispectral data in 24 patients with subsequent pathology at locations where 411 biopsies were collected yielded an accuracy of 90% in detecting individual locations of dysplasia, demonstrating the capability of this method to serve as a guide for biopsy.

Pancreatic cancers are usually detected at an advanced stage and have poor prognosis. About one fifth of these arise from pancreatic cystic lesions. Yet not all lesions are precancerous, and imaging tools lack adequate accuracy for distinguishing precancerous from benign cysts. Therefore, decisions on surgical resection usually rely on endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Unfortunately, cyst fluid often contains few cells, and fluid chemical analysis lacks accuracy, resulting in dire consequences, including unnecessary pancreatic surgery for benign cysts and the development of cancer. Here, we report an optical spectroscopic technique, based on a spatial gating fibre-optic probe, that predicts the malignant potential of pancreatic cystic lesions during routine diagnostic EUS-FNA procedures. In a double-blind prospective study in 25 patients, with 14 cysts measured in vivo and 13 postoperatively, the technique achieved an overall accuracy of 95%, with a 95%confidence interval of 78-99%, in cysts with definitive diagnosis., Competing Interests: Competing financial interests The authors declare no competing financial interests.