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Acute gastrointestinal perforations occur either from spontaneous or iatrogenic causes. However, particular attention should be made in acute iatrogenic perforations as timely diagnosis and endoscopic closure prevent morbidity and mortality. With the increasing use of diagnostic endoscopy and advances in therapeutic endoscopy worldwide, the endoscopist must be able to recognize and manage perforations. Depending on the size and location of the defect, a variety of endoscopic clips, stents, and suturing devices are available. This review aims to prepare and guide the endoscopist to use the right tools and techniques for optimal patient outcomes. [ABSTRACT FROM AUTHOR]

Background and Aim: Cholecystectomy and endoscopic retrograde cholangiopancreatography are the gold standard for managing acute cholecystitis and malignant biliary obstruction, respectively. Recent advances in therapeutic endoscopic ultrasound (EUS) have provided alternatives for managing patients in whom these approaches fail, namely, EUS‐guided gallbladder drainage (EUS‐GB) and EUS‐guided bile duct drainage (EUS‐BD). We aimed to assess the technical and clinical success of these techniques in the largest multicenter cohort published to date. Methods: A retrospective, multicenter, observational study involving 17 centers across Australia and New Zealand was conducted. All patients who had EUS‐GB or EUS‐BD performed in a participating center using a lumen apposing metal stent between 2016 and 2020 were included. Primary outcome was technical success, defined as intra‐procedural successful drainage. Secondary outcomes included clinical success and 30‐day mortality. Results: One hundred and fifteen patients underwent EUS‐GB (n = 49) or EUS‐BD (n = 66). EUS‐GB was technically successful in 47 (95.9%) while EUS‐BD was successful in 60 (90.9%). All failed cases were due to maldeployment of the distal flange outside of the targeted lumen. Clinical success of EUS‐GB was achieved in 39 (79.6%). No patients required subsequent cholecystectomy. Clinical success of EUS‐BD was achieved in 52 (78.8 %). Thirty‐day mortality was 14.3% for EUS‐GB and 12.1% for EUS‐BD. Conclusions: EUS‐guided gallbladder drainage and EUS‐BD are promising alternatives for managing nonsurgical candidates with cholecystitis and malignant biliary obstruction following failed endoscopic retrograde pancreatography. Both techniques delivered high technical success with acceptable clinical success. Further research is needed to investigate the gap between technical and clinical success. [ABSTRACT FROM AUTHOR]

▪ Obesity is reaching pandemic proportions globally, with overweight or obesity affecting at least two-thirds of Australian adults. ▪ Bariatric surgery is an effective weight loss strategy but is constrained by high resource requirements and low patient acceptance. ▪ Multiple endoscopic bariatric therapies have matured, with well established and favourable safety and efficacy profiles in multiple randomised controlled trials (RCTs), and are best used within a multidisciplinary setting as an adjuvant to lifestyle intervention. ▪ Three types of intragastric balloon are currently in use in Australia offering average total weight loss ranging from 10% to 18%, with others available internationally. ▪ Endoscopic sleeve gastroplasty produces average total weight loss of 15-20% with low rates of severe complications, with RCT data anticipated in December 2021. ▪Bariatric and metabolic endoscopy is rapidly evolving, with many novel, promising therapies currently under investigation. [ABSTRACT FROM AUTHOR]

Purpose of review: Indeterminate biliary strictures present a balancing act between the potential morbidity from redundant operations and the risk of missed malignancy and disease progression. This review aims to compare and assess the efficacy of the different diagnostic techniques. Recent findings: Until today, endoscopic retrograde cholangiopancreatography with tissue sampling was considered the standard for distinguishing benign from malignant biliary strictures. However, it is hampered by a low diagnostic yield. Summary: Indeterminate biliary strictures remain a difficult clinical problem. Invariably, expert evaluation and review at an MDT setting should be the first step. If the diagnosis remains elusive despite the initial strategies including clinical evaluation, imaging with CT or MRI and initial sampling with either EUS or ERCP brushing, the patient should then be considered for expert IDBS evaluation. These patients should be selected for cholangioscopy with direct visualisation, direct sampling and, if available, advanced interpretive techniques such as confocal laser endomicroscopy and FISH etc. These techniques can assist in improving diagnosis and minimise delay to essential treatment and avoid unnecessary surgery. PSC remains a challenge; however, recent advances in cholangioscopy classification are proving useful in managing this cohort. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this retrospective study was to assess the prevalence of taurodont molars among an Indian population. The goal was also to determine sexual dimorphism, distribution of taurodontism as well as any association between taurodontism and simultaneously occurring syndromes and anomalies. Materials and Methods: Full-mouth periapical radiographs of a total of 1360 patients were screened. A total of 9792 molars (including third molars) were evaluated. The relative incidence and the correlations regarding the location of taurodonts (right versus left side and maxillary versus mandibular) were analysed using the Z test. Results: The overall incidence of subjects with taurodont molars among this Indian population was 2.5% (34/1360). Sexual distribution showed female dominance (21 females, 13 males), but this was statistically insignificant (P > 0.05). Maxillary second molars (35/118) were the most commonly involved teeth, followed by mandibular second molars (32/118). No significant differences were obtained for distribution by side (right vs left; P > 0.05) or interarch distribution (maxillary vs mandibular; P > 0.05). Out of 34 subjects with taurodonts, 50% (17/34) were associated with pyramidal molars and 32.35% (11/34) had impacted molars. Conclusions: Taurodontism is not uncommon in the Indian population and it might be associated with other conditions, such as pyramidal molars and impaction. Further larger scale studies are required to assess its prevalence in the general population and to establish any associations. [ABSTRACT FROM AUTHOR]

The aim of the study is to evaluate the minimum number of renal scans required to follow pediatric patients postpyeloplasty. We prospectively reviewed the renal scans of 145 children with unilateral pelvi-ureteric junction obstruction who underwent dismembered pyeloplasty. Patients were then divided into four groups based on preoperative split renal function. All patients were followed with renal scan and ultrasound for minimum of 4 years. Renal scan and ultrasound were done after stent removal at 3, 6, and 12 months and then yearly after surgery. Drainage pattern (T1/2) was seen in all groups, except in patients where there was no comment on drainage pattern. Statistical analysis was performed using the Friedman ANOVA and Wilcoxon signed-ranks test as a post hoc test with Bonferroni correction and Kruskal–Wallis test with Mann–Whitney U-test as a post hoc test with Bonferroni correction. On comparison of the pattern of drainage with time in Groups 1–4, it was found that there was no significant difference with time in Group 1. Then, further, using Wilcoxon signed-rank test as post hoc test for Friedman ANOVA, Group 2 showed statistically significant difference in drainage pattern in scans between 6 months and 1 year, Group 3 showed statistically significant difference in drainage pattern in scans between 3 months and 1 year, and Group 4 showed statistically significant difference in drainage pattern in scans done between 3 and 6 months (P < 0.05). Minimum of three renal scans were required for paediatric patients post pyeloplasty at 3 months, 6 months and 1 year in the follow up period. [ABSTRACT FROM AUTHOR]

Introduction. Adenocarcinomas account for approximately 40% of small bowel cancers. They are typically mucosal lesions with distinctive features on endoscopy. We describe a rare case of duodenal adenocarcinoma presenting as a subepithelial lesion which posed a diagnostic challenge. Case. An 85-year-old male patient presented for investigation of iron deficiency anaemia. Initial upper endoscopy found a subepithelial duodenal lesion with central depression but otherwise normal appearing mucosa. Superficial biopsies of the duodenal lesion were unremarkable. Subsequent antegrade single balloon enteroscopy revealed active bleeding from the lesion which was refractory to endoscopic treatment. A complete local excision of the lesion via laparotomy was necessary to achieve haemostasis. Histopathology from the lesion showed a moderately differentiated duodenal adenocarcinoma with invasion into the submucosa but no evidence of lymphovascular spread. Conclusion. Duodenal adenocarcinomas are rare gastrointestinal tumours associated with a poor prognosis. This case report outlines a rare presentation of duodenal adenocarcinoma and highlights the importance of judicious assessment of lesions found on endoscopy. Advances in endoscopic diagnostic modalities could facilitate early diagnosis and improve therapeutic outcomes. [ABSTRACT FROM AUTHOR]

General dentists should be aware that extraoral dental cutaneous lesions can be confused with dermatologic lesions. We report two cases of cutaneous lesions of dental origin that were initially misdiagnosed as being dermatologic in origin. Multiple treatments were performed, including plastic surgery, but the lesions did not resolve. Then, the lesions' dental etiology was identified. Endodontic intervention resulted in resolution of the problem, confirming the initial misdiagnosis. A dental etiology, as part of a differential diagnosis, should be kept in mind with orofacial skin lesions. (Quintessence Int 2011;42:455-458) [ABSTRACT FROM AUTHOR]

This article presents two cases of detection and management of four-rooted mandibular first molars. The occurrence of four-rooted mandibular first molars is very rare and the reported incidence is less than 1%. The cases were managed using radiographs taken from different planes (otherwise, the distolingual root of the teeth would have been missed). The contralateral side also showed the same morphological variation. [ABSTRACT FROM AUTHOR]

Background and Study Aim: Standard endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) procedures involve use of no-suction or suction aspiration techniques. A new aspiration method, the stylet slow-pull technique, involves slow withdrawal of the needle stylet to create minimum negative pressure. The aim of this study was to compare the sensitivity of EUS-FNA using stylet slow-pull or suction techniques for malignant solid pancreatic lesions using a standard 22-gauge needle.Patients and Methods: Consecutive patients presenting for EUS-FNA of pancreatic mass lesions were randomized to the stylet slow-pull or suction techniques using a 22-gauge needle. Both techniques were standardized for each pass until an adequate specimen was obtained, as determined by rapid on-site cytology examination. Patients were crossed over to the alternative technique after four nondiagnostic passes.Results: Of 147 patients screened, 121 (mean age 64 ± 13.8 years) met inclusion criteria and were randomized to the stylet slow-pull technique (n = 61) or the suction technique (n = 60). Technical success rates were 96.7 % and 98.3 % in the slow-pull and suction groups, respectively (P > 0.99). The sensitivity for malignancy of EUS-FNA was 82 % in the slow-pull group and 69 % in the suction group (P = 0.10). The first-pass diagnostic rate (42.6 % vs. 38.3 %; P = 0.71), acquisition of core tissue (60.6 % vs. 46.7 %; P = 0.14), and the median (range) number of passes to diagnosis (2 1 2 3 vs. 1 1 2; P = 0.71) were similar in the slow-pull and suction groups, respectively.Conclusions: The stylet slow-pull and suction techniques both offered high and comparable diagnostic sensitivity with a mean of 2 passes required for diagnosis of solid pancreatic lesions. The endosonographer may choose either technique during FNA. [ABSTRACT FROM AUTHOR]

To the Editor: We read with interest Tanaka et al.'s [1] case series raising the importance of preventing aspiration pneumonia as an anesthesia consideration specific to peroral endoscopic myotomy (POEM). [...]

Esophageal perforations can be spontaneous or iatrogenic. Although they are a rare occurrence, they are associated with a significant morbidity and mortality. Traditionally, management of esophageal perforation consisted of surgery. However, endoscopic management is now emerging as the primary treatment modality and is less invasive and morbid than surgery. Endoscopic modalities include through-the-scope clips (TTS), over-the-scope clips (OTSC), placement of covered stents, and suturing. Suturing can be used for primary closure of the perforation as well as anchoring of stents to prevent migration. Smaller defects (<2 cm) can be closed with clips (TTS or OTSC), whereas larger defects require a stent placement or suturing to achieve closure. If the perforation is associated with a mediastinal collection, drainage is mandatory and can be done via CT-guided percutaneous drainage, surgery, or endoscopic vacuum therapy. [ABSTRACT FROM AUTHOR]

Achalasia is a primary esophageal motility disorder. It is the absence of peristalsis in the esophageal body and inability of the lower esophageal sphincter to relax, which characterizes this rare condition. Its features typically include dysphagia, regurgitation, chest pain, and weight loss. The ultimate goal in treating achalasia is to relieve the patient's symptoms, improve esophageal emptying, and prevent further dilatation of the esophagus. Current treatment modalities targeted at achalasia include pharmacological therapy, endoscopic therapy, and surgery. This review focuses on the current therapeutic options and explores the role of peroral endoscopic myotomy in the management armamentarium. [ABSTRACT FROM AUTHOR]