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The primary aim of this study was to assess the reliability, intra- and inter-observer variation of the SPICE, Mucosal protrusion angle (MPA) and SHYUNG scores in differentiating a subepithelial mass (SEM) from a bulge.This retrospective multicentre study analysed the 3 scores, radiological studies, enteroscopy and/or surgical findings.100 patients with a potential SEM (mean age 57.6years) were recruited with 75 patients having pathology. In patients with a SEM the mean SPICE score was 2.04 (95% CI 1.82-2.26) as compared to 1.16 (95% CI 0.81-1.51) without any pathology (AUC 0.74, p0.001), with a fair intra-observer agreement (Kappa 0.3, p0.001) and slight inter-observer agreement (Kappa 0.14, p0.05). SPICE had a 37.3% sensitivity and 92.0% specificity in distinguishing between a SEM and bulge, whereas MPA90˚ had 58.7% and 76.0% respectively, with poor intra-observer(p = 0.05) and interobserver agreement (p = 0.64). The SHYUNG demonstrated a moderate intra-observer (Kappa 0.44, p0.001) and slight inter-observer reliability (Kappa 0.18, p0.001). The sensitivity of an elevated SHYUNG score (≥4) in identifying a SEM was 18.7% with a specificity of 92.0% (AUC 0.71, p = 0.002).Though these scores are easy to use, they have, at best, slight to moderate intra and inter-observer agreement. Their overall diagnostic performances are limited.

In recent years, panintestinal capsule endoscopy (PCE) with double-headed capsules has been used to perform complete, single-sitting exploration of both small bowel and colon in different clinical conditions. Double-headed capsules for colonic examination (CCE) have been exploited first in this setting, followed by newer generations of capsules (i.e. PillCam Crohn, PCC) specifically engineered for this purpose. The aim of this study was to evaluate the feasibility of PCE in the form of a systematic review. We performed a comprehensive literature search to identify papers in which CE was specifically used for a PCE of the gastrointestinal tract. Data on CE, bowel preparation regimen, rate of cleanliness and completeness, and data on transit times were analyzed. The primary outcome was to assess the feasibility of a whole-gut exploration with CE. Sixteen (n = 16) studies including 915 CE procedures with CCE1 (n = 134), CCE2 (n = 357) and PCC (n = 424) were included. 13/16 studies were performed in the setting of Crohn's disease. Cleanliness and completeness rates were acceptable in all studies, ranging from 63.9% and 68.6% to 100%, respectively. In conclusion, PCE is a feasible technique, although further structured studies are needed to explore its full potential.

After more than 15 years since its introduction into clinical practice, indications for device-assisted enteroscopy have greatly expanded. Alongside the consolidated indications such as the diagnosis and treatment of small bowel bleeding, Crohn's disease, hereditary polyposis, small-bowel tumors and complicated celiac disease, device-assisted enteroscopy is nowadays largely used to perform endoscopic retrograde cholangiopancreatography in patients with altered anatomy, stent placement, retrieval of foreign bodies, direct insertion of jejunal feeding tubes, and in selected cases of incomplete colonoscopy. This has been made possible by the technical improvements of the enteroscopes and accessories and by the widespread use of the method. Device-assisted enteroscopy endotherapy currently offers a safe and effective alternative to major surgery and often represents the preferred option for treatment of small-bowel pathology. Its safety profile is favourable even in the elderly patient, provided that it is performed in high-volume and experienced centers. The evolution of the enteroscopy technique is a challenge for the future and could be facilitated by the new enteroscopes models. These prototypes need a thorough clinical and safety assessment especially for the complex therapeutic procedures. Large prospective, multicenter studies should be performed to assess whether the use of device-assisted enteroscopy leads to improved patients' long-term outcomes.

Background and Aims Little is known about small-bowel (SB) capsule endoscopy (CE) in patients with a history of gastric surgery. This study aims to evaluate the feasibility and diagnostic yield (DY) of orally ingested SB-CE in patients with surgically altered gastric anatomy. Methods Twenty-four European centers retrospectively identified patients who had SB-CE after total or subtotal gastrectomy. The primary outcome was the DY of SB-CE (intermediate P1 to highly P2 relevant findings). Secondary outcomes were gastric and SB transit times, completion, cleanliness, and adverse event rates. Results Studied were 248 procedures from 243 patients (mean age, 62 years) with a history of partial gastrectomy (Billroth I, 13.1%; Billroth II, 34.6%), total gastrectomy (7.4%), Whipple procedure (12.8%), sleeve gastrectomy (7.2%), or gastric bypass surgery (24.7%). Obscure GI bleeding was the most frequent indication (85.1%). SB completion rate was 84.3%. One capsule retention in the SB was noted (adverse event rate, .4%). Median SB transit time was 286 minutes (interquartile range [235; 387]). Cleanliness was rated as adequate in 92.1% of procedures. After exclusion of abnormalities found at the upper anastomotic site, the DY was 43.6%, with inflammatory/ulcerated lesions observed more frequently (23.4%) than vascular lesions (21.0%). Conclusions SB-CE seems to be feasible and safe in selected patients with a history of major gastric surgery and comes with a high DY. The spectrum of abnormal SB findings in these patients may be different from what is known from the literature in nonoperated patients.

Small bowel capsule endoscopy (SBCE) was introduced into clinical practice almost 20 years ago and, nowadays, it is an essential tool for the study of the small bowel. SBCE allows a radiation-free examination of the entire mucosal surface of the small bowel with high-quality images, limited invasivity and a good safety profile. Nevertheless, the main limitation of SBCE is the lack of any possible direct therapeutic intervention. Indications for SBCE have evolved throughout the years, from "old" ones such as suspected small bowel bleeding (still the main indication for SBCE) to newer ones such as refractory celiac disease, hereditary polyposis syndromes and Crohn's disease. Thus, nowadays SBCE has a key role in the diagnostic algorithms in many conditions. Furthermore, the introduction in the SBCE field of cutting-edge technologies, as artificial intelligence systems, is likely to shorten the reading time making SBCE even more effective and easy to perform. Preliminary data are extremely promising and solid evidence is being gathered by current studies.

Pancreatic fluid collections (PFCs) develop as a result of damage to the major or peripheral pancreatic ducts, complication due to acute or chronic pancreatitis, trauma or iatrogenic causes. PFCs include pancreatic pseudocysts (PPs) and walled-off necrosis (WON). PFCs usually resolve spontaneously and are asymptomatic, but if they persist, increase in dimension or became symptomatics, therapeutic intervention is required. Available therapeutic interventions include surgical, percutaneous, and endoscopic drainage. The endoscopic approach is nowadays considered the first line-treatment of PFCs due to various advantages when compared with surgical or percutaneous drainage: decreased morbidity, length of hospital stay, and reduced costs. In the last few years, the endoscopic ultrasound (EUS)-guided transmural drainage, initially with plastic stents, gained popularity. More recently, fully covered self-expanding lumen-apposing metal stents (LAMS) have been demonstrated to be both, safe and effective with high clinical and technical success, reducing the risk of perforation, peritoneal leakage, migration and facilitating the drainage of necrotic contents. In the last few years, several studies evaluating the safety and efficacy of LAMS and their differences with plastic stents have been performed, but literature on the removal timing of this device and associated complications is still limited. The aim of this review is to analyze studies reporting information about the retrieval timing of LAMS and the related adverse events.

Background and aim of the work: Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are cystic lesions with malignant potential. Given their increasing incidence in the latest years, a precise characterization and management of these lesions have become more and more crucial: even though the majority of IPMN has a benign and indolent course, it is fundamental to early recognize and stratify patients in order to accurately plan a tailored follow-up and to individuate those that would benefit of surgical treatment. The aim of this paper is to highlight the most recent evidence on IPMN available in the current literature. Methods: We performed a review of the recent literature and of the recent guidelines about pancreatic cystic lesions, especially IPMN. Results: The incidence of IPMN is now on the rise: an increasing number of patients, possibly because of the increasing diagnostic yield of imaging techniques, is being diagnosed with pancreatic cystic lesions, a great part of which are IPMN. The possibility of malignant transformation requires a careful approach to these patients, in the need of tailoring the follow-up and the therapy. Conclusion: A detailed diagnosis, the determination of risk factors for malignant transformation and a multisciplinary approach are of foremost importance for an effective management of IPMN. (www.actabiomedica.it)

We report a rare case of gastric fistulization in a patient with main-duct (MD) intraductal papillary mucinous neoplasm (IPMN). Fistulization to adjacent organs is a rare complication of this disease, mainly affecting the duodenum; the fact that the stomach was the only organ involved makes this case even more peculiar. The diagnosis of the fistula was made after examination with endoscopic ultrasound, since a previous computed tomography scan could not detect it.

Zollinger-Ellison syndrome (ZES) is a clinical syndrome characterized by gastric acid hypersecretion due to the ectopic secretion of gastrin by a gastrinoma, a neuroendocrine tumor (NET) which mostly develops in the duodenum and in the pancreas. This syndrome was first described by Zollinger and Ellison in 1964; if left untreated, ZES can lead to multiple complications mainly due to gastric hypersecretion and some patients can suffer from the complications of an advanced metastatic disease. Although its clinical features are considered typical, the diagnosis of ZES is often challenging for the clinician. A previous review was published in 2005 by our group, but in 12 years many things have changed: the diagnostic tools have been improved and many different therapeutical options are now available.