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Objectives: Endoscopic papillectomy (EP) is a minimally invasive therapy for the management of ampullary adenomas (AA). We conducted this multicenter study to assess the incidence of and factors related to the recurrence of AA after EP in patients with familial adenomatous polyposis (FAP) compared to sporadic AA. Methods: We included patients who underwent EP for AA at 10 tertiary hospitals. Adenomatous tissue at the resection site at the time of surveillance endoscopies was considered recurrent disease. Results: In all, 257 patients, 100 (38.9%) with FAP and 157 (61%) patients with sporadic AA, were included. Over a median of 31 (range, 11–61) months, recurrence occurred in 48/100 (48%) of patients with FAP and 58/157 (36.9%) with sporadic AA (P = 0.07). Two (2%) FAP patients and 10 (6.3%) patients with sporadic AA underwent surgery for recurrence. On multivariable regression analysis, the recurrence in FAP was higher than in sporadic patients after the first year of follow‐up. AA size (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.001, 1.056), periampullary extension (HR 2.5, 95% CI 1.5, 4.01), and biliary duct dilation (HR 2.04, 95% CI 1.2, 3.4) increased the risk, while en bloc resection (HR 0.6, 95% CI 0.41, 0.9) decreased the risk of recurrence. Conclusion: Recurrence rates are high after EP. Most recurrences in sporadic patients occur within the first year of follow‐up, but after the first year of follow‐up in patients with FAP. Recurrences are higher with larger adenomas, biliary duct dilation, and periampullary extensions, and may be mitigated by en bloc resection. These factors should be considered in decision‐making with the patients. [ABSTRACT FROM AUTHOR]

Background: Long‐term placement of lumen apposing metal stents (LAMS) with high lumen apposing force may result in adverse events. The aim of the current study was to assess the long‐term efficacy and safety of a self‐approximating LAMS with lower lumen apposing force for endoscopic ultrasound‐guided choledochoduodenostomy (EUS‐CDS) and ‐gallbladder drainage (EUS‐GBD). Methods: Five Asian institutions participated in this study. Consecutive patients suffering from obstructive jaundice with failed ERCP or acute cholecystitis that were at high risk for cholecystectomy were recruited. We evaluated the technical and clinical success rates, adverse events rates, types of interventions through the stent and the patency profile. Results: From June 2017 to Oct 2018, a total of 53 patients received EUS‐CDS (26) and EUS‐GBD (27). The technical and clinical success rates were similar between the two groups (88.5% vs 88.9%, P = 1 and 88.5% vs 88.9%, P = 1 respectively). The differences in 30‐day mortality rates [2 (7.7%) vs 2 (7.7%), P = 1] and adverse events [3 (11.5%) vs 3 (11.5%), P = 1] did not reach significance. Regarding long‐term outcomes, two patients in each group suffered from adverse events (P = 1). One patient in the EUS‐GBD group who was on direct oral anticoagulant suffered from stent induced bleeding. Conclusion: The self‐approximating LAMS with lower lumen apposing force was effective and safe with a low risk of buried stent syndrome and bleeding in the longer term. The ClinicalTrials.gov Identifier was NCT03002051. [ABSTRACT FROM AUTHOR]

Background: A novel self‐approximating lumen‐apposing metallic stent (LAMS; Niti‐S Spaxus, Taewoong Medical, Gyeonggi‐do, Korea) has recently become available. The aim of the present study was to evaluate the outcomes for drainage of pancreatic fluid collections (PFC). Methods: This was a prospective international multicentered study conducted in six high‐volume institutions across Asia. Consecutive patients suffering from pancreatic pseudocyst or walled‐off pancreatic necrosis (WOPN) requiring endoscopic ultrasonography‐guided drainage were recruited. Outcomes included technical and clinical success, adverse events, procedural events, interventions through the stent and recurrence rates. Results: Between August 2016 and November 2017, 59 patients were recruited to this study. Thirty‐nine patients (66.1%) had WOPN and mean (SD) size of PFC was 11.5 (5.1) cm. Technical and clinical success rates were 100%. Mean (SD) procedural time was 35.0 (17.2) minutes. Sixteen‐millimeter stents were used in 66.1% of the patients. Fifty‐four sessions of necrosectomy were carried out with the stent in situ in 17 patients. Stent‐related adverse event (AE) rate was 6.8%. Three patients (5.1%) suffered from bleeding after stenting and one required angiographic embolization. Two patients (3.4%) suffered from recurrence during a mean (SD) follow‐up time of 325.6 (355.5) days. There were no differences in outcomes between those with pseudocysts or WOPN except for the duration of hospital stay (P = 0.012). Conclusion: Use of a self‐approximating LAMS for drainage of PFC was safe and effective. Endoscopic necrosectomy could be carried out through the stent with ease. The device was associated with a low rate of stent‐related AE. [ABSTRACT FROM AUTHOR]

Abstract: Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per‐oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short‐term to mid‐term follow‐up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group. [ABSTRACT FROM AUTHOR]

Hirschsprung's disease (HD) is a congenital disorder characterized by the absence of intrinsic ganglion cells in submucosal and myenteric plexuses of the hindgut; and presents with constipation, intestinal obstruction and/or megacolon. HD commonly involves the rectosigmoid region (short segment HD), although shorter and longer variants of the disease are described. Standard treatment involves pull-through surgery for short segment HD or posterior anorectal myotomy in selected ultrashort segment candidates. Third space endoscopy has evolved during the past few years. Per oral endoscopic myotomy and per oral pyloromyotomy are described for treatment of achalasia cardia and refractory gastroparesis, respectively. Using the same philosophy of muscle/sphincter disruption for spastic bowel segments, per rectal endoscopic myotomy could be considered as a treatment option for short segment HD. A 24-year-old male patient presented with refractory constipation since childhood, and habituated to high-dose laxative combinations. Diagnosis was confirmed as adult short segment HD by barium enema, colonoscopic deep suction mucosal biopsies and anorectal manometry. Histopathology confirmed aganglionosis in the distal 15 cm. By implementing principles of third space endoscopy, per rectal endoscopic myotomy 20 cm in length was successfully carried out. At 24-week follow up, the patient reported significant relief of constipation and associated symptoms. Sigmoidoscopy, anorectal manometry and barium enema confirm improved rectal distensibility and reduced rectal pressures. The present case report describes the first human experience of per rectal endoscopic myotomy for successful treatment of adult short segment HD. [ABSTRACT FROM AUTHOR]

Therein lies the challenge in the use of G-POEM for treatment of refractory gastroparesis. Therefore, although the study by Pioppo I et al i . is significant in confirming that G-POEM has several advantages over laparoscopic pyloromyotomy, it falls short to answer two very important clinical questions - (i) who should undergo G-POEM and (ii) is it possible to predict response to G-POEM before performing the procedure. Early response to G-POEM at 1-month post-therapy (OR 8.75, I P i < 0.001) has also been reported as a positive predictor of response.7 It is logical to recommend that pylorus physiology be assessed before G-POEM, and pylorotomy be performed only in the context of confirmed pylorospasm. It concluded that G-POEM increased maximal but not minimal diameter and distensibility, suggesting G-POEM enhanced pyloric opening but may not impair pyloric closure.13 GES is already being performed as part of the diagnostic workup for gastroparesis. [Extracted from the article]

Background and Aim Endoscopic transmural drainage ( ETMD) of peripancreatic fluid collections ( PFC) is an effective alternative to surgical drainage. Conventional drainage using plastic stents has its limitations. A wide-bore short-length wide flange fully covered self-expandable metallic stent ( FCSEMS) has recently been developed. The present study evaluates the efficacy of this new FCSEMS for ETMD of PFC. Methods This was a retrospective, multicenter study. Patients with PFC undergoing endoscopic ultrasound ( EUS)-guided drainage of PFC using specially designed FCSEMS were included. Parameters evaluated were technical success of stent placement, clinical success as defined by resolution of PFC without any further surgical intervention, ability to carry out endoscopic necrosectomy, complications and feasibility of endoscopic stent removal. Results Twenty-one PFC in 19 patients were drained using FCSEMS. Technical and clinical success for drainage was seen in all patients (100%). Endoscopic necrosectomy was carried out in seven (33%) PFC. Complications occurred in two patients (10.5%). Stents could be endoscopically removed in all patients (100%). Conclusions The new specially designed FCSEMS is safe and effective for drainage of PFC. Necrosectomy can be carried out through the stent. Stent can be removed endoscopically at the end of the treatment period. [ABSTRACT FROM AUTHOR]

A new endoscopic ultrasound processor ( EU- ME2 Premier Plus) has recently been developed. It improves fundamental imaging and enables three new functions; namely, tissue harmonic echo ( THE), elastography, and contrast harmonic endoscopic ultrasonography ( CH-EUS). However, many aspects regarding the usefulness of these three functions in the diagnosis of pancreatobiliary diseases remain unknown. In connection with and prior to the convening of Endoscopy Forum Japan 2014, endoscopic ultrasonography using EU- ME2 Premier Plus was carried out for pancreatic, bile duct, and gallbladder cases at 12 participating institutions ( Japan [ n = 10]; other Asian countries [ n = 2]). A questionnaire survey was conducted regarding the usefulness of EU- ME2 Premier Plus for each EUS case. In addition, participants' views were surveyed by asking them to vote as to whether or not the three functions of EU- ME2 Premier Plus were useful for several items under pancreatic, bile duct, and gallbladder indications. According to the participants' views, THE (particularly THE- P mode) is essential for the diagnosis of cystic lesions. Many participants viewed elastography as useful in only extremely limited cases. Although CH-EUS was not considered useful for all cases, its indications covered a broad range. Additional studies are warranted to clarify the functions of EU- ME2 Premier Plus in more detail. [ABSTRACT FROM AUTHOR]

Background and Aim Endoscopic ultrasonography (EUS)-guided drainage of walled-off necrosis (WON) may be carried out by placement of multiple plastic stents (MPS) or specially designed fully covered bi-flanged metal stents (BFMS). Comparative data on efficacy of these two stent types for WON drainage are limited. This retrospective study compares outcomes of WON drainage using BFMS and MPS. Methods During a 10-year period, 133 patients underwent EUS-guided WON drainage. MPS or BFMS were placed in a WON cavity through a single puncture, and direct endoscopic necrosectomy (DEN) was carried out whenever clinically necessary. Data in the two cohorts were retrospectively compared for primary outcomes - clinical success, adverse events and mortality; and secondary outcomes - DEN requirement, mean DEN sessions, need for salvage surgery and hospital stay. Results MPS were placed in 61 and BFMS in 72 patients. Patients undergoing BFMS drainage required fewer DEN sessions (mean 1.46 vs 2.74, P < 0.05), had fewer adverse events (5.6% vs 36.1%, P < 0.05), needed salvage surgery less often (2.7% vs 26.2%, P < 0.05), and had significantly shorter hospital stay (4.1 vs 8 days, P < 0.05) compared to those undergoing MPS drainage. There was no difference in DEN requirement ( P = 0.217) and mortality ( P = 0.5) in both groups. Overall clinical success with BFMS was superior to MPS (94% vs 73.7%, P < 0.05). Conclusion BFMS appear to be superior to MPS for EUS-guided WON drainage in terms of clinical success, number of DEN sessions, adverse events, need for salvage surgery and hospital stay. [ABSTRACT FROM AUTHOR]