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Background and study aims Transoral incisionless fundoplication (TIF) is a safe and effective minimally invasive endoscopic technique for treating gastroesophageal reflux disease (GERD). The learning curve for this technique has not been reported. We studied the learning curve for TIF when performed by a gastroenterologist by identifying the threshold number of procedures needed to achieve consistent technical success or proficiency (consistent creation of TIF valve ≥ 270 degrees in circumference, ≥ 2 cm long) and efficiency after didactic, hands-on and case observation experience. Patients and methods We analyzed prospectively collected data from patients who had TIF performed by a single therapeutic endoscopist within 17 months after basic training. We determined thresholds for procedural learning using cumulative sum of means (CUSUM) analysis to detect changes in achievement rates over time. We used breakpoint analysis to calculate procedure metrics related to proficiency and efficiency. Results A total of 69 patients had 72 TIFs. The most common indications were refractory GERD (44.7 %) and proton pump inhbitor intolerance (23.6 %). Proficiency was achieved at the 18th to 20th procedure. The maximum efficiency for performing a plication was achieved after the 26th procedure, when mean time per plication decreased to 2.7 from 5.1 minutes (P Conclusions TIF can be safely, successfully, and efficiently performed in the endoscopy suite by a therapeutic endoscopist. The TIF learning curve is steep but proficiency can be achieved after a basic training experience and 18 to 20 independently performed procedures.

Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques. Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon–patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication. These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.

Introduction Antithrombotic therapy is often interrupted before the placement of a percutaneous endoscopic gastrostomy (PEG) tube because of potentially increased risk of hemorrhagic events. The aim of our study was to evaluate the risk of bleeding events and overall complication rates after PEG in patients on uninterrupted antiplatelet and anticoagulation therapy in a high-volume center. Methods Data regarding demographics, diagnoses, comorbidities, and clinical outcomes pertinent to PEG were collected from 2010 to 2016. Furthermore, data regarding antithrombotic therapy along with the rate of minor or major complications including bleeding associated with this procedure were analyzed. Significant bleeding was defined as postprocedure bleeding from PEG site requiring a blood transfusion and/or surgical/endoscopic intervention. Results We included 1,613 consecutive PEG procedures in this study, of which 1,540 patients (95.5%) received some form of uninterrupted antithrombotic therapy. Of those patients, 535 (34.7%) were on aspirin, 256 (16.6%) on clopidogrel, and 119 (7.7%) on both aspirin and clopidogrel. Subcutaneous heparin was uninterrupted in 980 (63.6%), intravenous heparin in 34 (2.1%), warfarin in 168 (10.9%), and direct-acting oral anticoagulation in 82 (5.3%) patients who overlapped on multiple drugs. We observed 6 significant bleeding events in the entire cohort (0.39%), and all were in subcutaneous heparin groups either alone or in combination with aspirin. No clinically significant bleeding was noted in patients on uninterrupted aspirin, warfarin, clopidogrel, or direct-acting oral anticoagulation groups. Only 5 patients (0.31%) had PEG-related mortality. Discussion The risk of significant bleeding associated with the PEG placement was minimal in patients on uninterrupted periprocedural antithrombotic therapy.

Background and study aims Peroral endoscopic myotomy (POEM) is increasingly being used as the preferred treatment option for achalasia. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of POEM versus pneumatic balloon dilation (PD). Methods We performed a comprehensive review of studies that reported clinical outcomes of POEM and PD for the treatment of achalasia. Measured outcomes included clinical success (improvement of symptoms based on a validated scale including an Eckardt score ≤ 3), adverse events, and post-treatment gastroesophageal reflux disease (GERD). Results Sixty-six studies (6268 patients) were included in the final analysis, of which 29 studies (2919 patients) reported on POEM and 33 studies (3050 patients) reported on PD and 4 studies (299 patients) compared POEM versus PD. Clinical success with POEM was superior to PD at 12, 24, and 36 months (92.9 %, vs 76.9 % P = 0.001; 90.6 % vs 74.8 %, P = 0.004; 88.4 % vs 72.2 %, P = 0.006, respectively). POEM was superior to PD in type I, II and III achalasia (92.7 % vs 61 %, P = 0.01; 92.3 % vs 80.3 %, P = 0.01; 92.3 %v 41.9 %, P = 0.01 respectively)Pooled OR of clinical success at 12 and 24 months were significantly higher with POEM (8.97; P = 0.001 & 5.64; P = 0.006). Pooled OR of GERD was significantly higher with POEM (by symptoms: 2.95, P = 0.02 and by endoscopic findings: 6.98, P = 0.001). Rates of esophageal perforation (0.3 % vs 0.6 %, P = 0.8) and significant bleeding (0.4 % vs 0.7 %, P = 0.56) were comparable between POEM and PD groups. Conclusions POEM is more efficacious than PD in the treatment of patients with achalasia during short-term and long-term follow-up, albeit with higher risk of abnormal esophageal acid exposure.

BACKGROUND At our academic tertiary care medical center, we have noted patients referred for endoscopic retrograde cholangiopancreatography (ERCP) who increasingly require advanced cannulation techniques. This trend is noted despite increased endoscopist experience and annual ERCP volume over the same period. AIM To evaluate this phenomenon of perceived escalation in complexity of cannulation at ERCP and assessed potential underlying factors. METHODS Demographic/clinical variables and records of ERCP patients at the beginning (2008), middle (2013) and end (2018) of the last decade were reviewed retrospectively. Cannulation approaches were classified as “standard” or “advanced” and duodenoscope position was labeled as “standard” (short position) or “non-standard” (e.g., long, semi-long). RESULTS Patients undergoing ERCP were older in 2018 compared to 2008 (69.7 ± 15.2 years vs 55.1 ± 14.7, P < 0.05). Increased ampullary distortion and peri-ampullary diverticula were noted in 2018 (P < 0.001). ERCPs were increasingly performed with a non-standard duodenoscope position, from 2.2% (2008) to 5.6% (2013) and 16.1% (2018) (P < 0.001). Utilization of more than one advanced cannulation technique for a given ERCP increased from 0.7% (2008) to 0.9% (2013) to 6.6% (2018) (P < 0.001). Primary mass size > 4 cm, pancreatic uncinate mass, and bilirubin > 10 mg/dL predicted use of advanced cannulation techniques (P < 0.03 for each). CONCLUSION Complexity of cannulation at ERCP has sharply increased over the past 5 years, with an increased proportion of elderly patients and those with malignancy requiring advanced cannulation approaches. These data suggest that complexity of cannulation at ERCP may be predicted based on patient/ampulla characteristics. This may inform selection of experienced, high-volume endoscopists to perform these complex procedures.

Background Flexible endoscopic myotomy has been increasingly performed for Zenker’s diverticulum using various endoscopic techniques and devices. The main aims of this study were to assess practice patterns and compare outcomes of endoscopic myotomy for Zenker’s diverticulum. Methods Procedures performed at 12 tertiary endoscopy centers from 1/2012 to 12/2018 were reviewed. Patients (≥ 18 years) with Zenker’s diverticulum who had dysphagia and/or regurgitation and underwent endoscopic myotomy were included. Outcomes assessed included technical success, clinical success, and adverse events. Results 161 patients were included. Traditional endoscopic septotomy was performed most frequently (137/161, 85.1 %) followed by submucosal dissection of the septum and myotomy (24/161, 14.9 %). The hook knife (43/161, 26.7 %) and needle-knife (33/161, 20.5 %) were used most frequently. Overall, technical and clinical success rates were 98.1 % (158/161) and 78.1 % (96/123), respectively. Adverse events were noted in 13 patients (8.1 %). There was no significant difference in technical and clinical success between traditional septotomy and submucosal dissection groups (97.1 % vs. 95.8 %, P = 0.56 and 75.2 % vs. 90.9 %, P = 0.16, respectively). Clinical success was higher with the hook knife (96.7 %) compared with the needle-knife (76.6 %) and insulated tip knife (47.1 %). Outcomes were similar between centers performing > 20, 11 – 20, and ≤ 10 procedures. Conclusions Flexible endoscopic myotomy is an effective therapy for Zenker’s diverticulum, with a low rate of adverse events. There was no significant difference in outcomes between traditional septotomy and a submucosal dissection approach, or with centers with higher volume, though clinical success was higher with the hook knife.

Background and Aims Endoscopic ultrasound (EUS), magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiogram (IOC) are the recommended diagnostic modalities for patients with intermediate probability for choledocholithiasis (IPC). The relative cost-effectiveness of these modalities in patients with cholelithiasis and IPC is understudied. Methods We developed a decision tree for diagnosing IPC (base case probability: 50%; range 10%-70%); patients with a positive test were modeled to undergo therapeutic ERCP. The strategies tested include (1) Laparoscopic cholecystectomy with IOC (LC-IOC), (2) MRCP, (3) single-session EUS + ERCP, and (4) separate session EUS + ERCP. Costs and probabilities were extracted from the published literature. Effectiveness was assessed by (1) assigning utility scores to health states, (2) the average proportion of true positive diagnosis of IPC, and (3) the mean length of stay (LOS) per strategy. Cost-effectiveness was assessed by extrapolating a net-monetary benefit (NMB), and average cost per true positive diagnosis. Results LC-IOC was the most cost-effective strategy to diagnose IPC (base-case probability of 50%) among patients with cholelithiasis in health state-based effectiveness analysis (NMB of $34,612), diagnostic test accuracy-based effectiveness analysis (average cost of $13,260 per true positive diagnosis), and LOS-based effectiveness analysis (mean LOS of 4.13) compared with strategy 2 (MRCP), 3 (single-session EUS+ERCP), and 4 (separate-session EUS+ERCP). These findings were robust on deterministic and probabilistic sensitivity analyses. Conclusion For patients with cholelithiasis with IPC, LC-IOC is a cost-effective approach that should limit preoperative testing and may shorten length of hospital stay. Our findings may be used to design institutional and organizational management protocols.

With the development of reliable endoscopic closure techniques and tools, endoscopic full-thickness resection (EFTR) is emerging as a therapeutic option for the treatment of subepithelial tumors and epithelial neoplasia with significant fibrosis. EFTR may be categorized as "exposed" and "nonexposed." In exposed EFTR, the full-thickness resection is undertaken with a tunneled or nontunneled technique, with subsequent closure of the defect. In nonexposed EFTR, a secure serosa-to-serosa apposition is achieved before full-thickness resection of the isolated lesion. This document reviews current techniques and devices used for EFTR and reviews clinical applications and outcomes.

Background/Aim There is no standard salvage chemotherapy for metastatic periampullary adenocarcinoma and duodenal adenocarcinoma and the prognosis of those who fail oxaliplatin, irinotecan, and 5FU is dismal. We examined nanoparticle albumin‐bound paclitaxel (nab‐paclitaxel) as salvage therapy for these two malignancies. Methods Patients who failed oxaliplatin, irinotecan, and 5FU and whose archival tumors stained immunohistochemical (IHC) tumor positive for CK7 or MUC1 received nab‐paclitaxel and gemcitabine therapy with or without cisplatin. Results Three patients, 2 with metastatic ampullary adenocarcinoma and 1 with duodenal adenocarcinoma with positive IHC staining for CK7 or MUC1 who failed 2 lines of chemotherapy with oxaliplatin, irinotecan, and 5FU received nab‐paclitaxel and gemcitabine with or without cisplatin. All achieved excellent tumor response on CT scans with marked falls in tumor markers CA19‐9 and CEA as well as ≥1 year of progression‐free survival. All 3 have continued to survive 2‐3 years since diagnosed with stage 4 metastatic adenocarcinoma. Conclusions Nab‐paclitaxel plus gemcitabine with or without cisplatin should be investigated as a standard‐of‐care chemotherapy regimen for patients with ampullary adenocarcinoma and duodenal adenocarcinoma.

Background and Aims Lithotripsy is a procedure for fragmentation or destruction of stones to facilitate their removal or passage from the biliary or pancreatic ducts. Although most stones may be removed endoscopically using conventional techniques such as endoscopic sphincterotomy in combination with balloon or basket extraction, lithotripsy may be required for clearance of large, impacted, or irregularly shaped stones. Several modalities have been described, including intracorporeal techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy, as well as extracorporeal shock-wave lithotripsy (ESWL). Methods In this document, we review devices and methods for biliary and pancreatic lithotripsy and the evidence regarding efficacy, safety, and financial considerations. Results Although many difficult stones can be safely removed using ML, endoscopic papillary balloon dilation (EPBD) has emerged as an alternative that may lessen the need for ML and also reduce the rate of adverse events. EHL and laser lithotripsy are effective at ductal clearance when conventional techniques are unsuccessful, although they usually require direct visualization of the stone by the use of cholangiopancreatoscopy and are often limited to referral centers. ESWL is effective but often requires coordination with urologists and the placement of stents or drains with subsequent procedures for extracting stone fragments and, thus, may be associated with increased costs. Conclusions Several lithotripsy techniques have been described that vary with respect to ease of use, generalizability, and cost. Overall, lithotripsy is a safe and effective treatment for difficult biliary and pancreatic duct stones.

The American Society for Gastrointestinal Endoscopy (ASGE) 2010 guidelines for suspected choledocholithiasis were recently updated by proposing more specific criteria for selection of high-risk patients to undergo direct ERCP while advocating the use of additional imaging studies for intermediate- and low-risk individuals. We aim to compare the performance and diagnostic accuracy of 2019 versus 2010 ASGE criteria for suspected choledocholithiasis.We performed a retrospective chart review of a prospectively maintained database (2013-2019) of over 10,000 ERCPs performed by 70 gastroenterologists in our 14-hospital system. We randomly selected 744 ERCPs in which the primary indication was suspected choledocholithiasis. Patients with a history of cholecystectomy or prior sphincterotomy were excluded. The same patient cohort was assigned as low, intermediate, or high risk according to the 2010 and 2019 guideline criteria. Overall accuracy of both guidelines was compared against the presence of stones and/or sludge on ERCP.Of 744 patients who underwent ERCP, 544 patients (73.1%) had definite stones during ERCP and 696 patients (93.5%) had stones and/or sludge during ERCP. When classified according to the 2019 guidelines, fewer patients were high risk (274/744, 36.8%) compared with 2010 guidelines (449/744, 60.4%; P .001). Within the high-risk group per both guidelines, definitive stone was found during ERCP more frequently in the 2019 guideline cohort (226/274, 82.5%) compared with the 2010 guideline cohort (342/449, 76.2%; P .001). In our patient cohort, overall specificity of the 2010 guideline was 46.5%, which improved to 76.0% as per 2019 guideline criteria (P .001). However, no significant change was noted for either positive predictive value or negative predictive value between 2019 and 2010 guidelines.The 2019 ASGE guidelines are more specific for detection of choledocholithiasis during ERCP when compared with the 2010 guidelines. However, a large number of patients are categorized as intermediate risk per 2019 guidelines and will require an additional confirmatory imaging study.

Background and aim Endoscopic gastrointestinal anastomosis using lumen-apposing metal stents (EGAL) is a new technique that is used as an alternative method to bypass benign or malignant strictures. Endoscopists take advantage of 2 bowel loops that are close to each other and place a stent between the lumen of these 2 bowel loops. The authors performed this systematic review and meta-analysis to evaluate the efficacy and safety of this rising procedure. Methods Electronic database searches were conducted for full eligible articles that were published from the inception to July 2019 using the EGAL procedure to bypass malignant or benign obstruction or to restore bowel integrity after a gastrointestinal altering surgery. The primary outcome of this meta-analysis was to assess efficacy through technical and clinical success. Secondary outcomes were to assess safety through adverse events and to assess the rate of stent maldeployment and the rate of reintervention during the study period. Results Eight studies were eligible, providing data on 269 patients who underwent 271 EGAL procedures. The median age was 65 years (interquartile range: 63 to 66) with 46% male individuals. Out of 269 patients, 203 underwent EGALs because of malignant etiology and 66 underwent EGAL for benign etiology. The median duration of follow-up was 114 days (interquartile range: 78 to 121). Technical success rate was 94.1% [95% confidence interval (CI), 91.4%-96.9%]. Clinical success rate was 91.4% (95% CI, 88.1%-94.7%). Adverse events rate was 8.5% (95% CI, 4.7%-12.3%). Stent maldeployment rate was 9.5% (95% CI, 3.5%-15.4%) of the total performed EGALs and the reintervention rate was 6.0% (95% CI, 2.3%-9.8%). Conclusion EGAL procedure has high efficacy and a relatively safe profile and it can be performed in selected patients. Comparison between EGAL and other conventional therapies is difficult because of the lack of randomized trials.

Background and Aims EMR is the preferred endoscopic therapy for duodenal adenomas (DAs) but is associated with an overall adverse event rate of 26%. Cryotherapy using a Cryoballoon Focal Ablation System (CbFAS) can safely and effectively eradicate esophageal intestinal metaplasia. We report our first experience with cryoballoon ablation for treatment of flat DAs. Methods This was an American, multicenter, retrospective study involving 5 centers. DAs (Paris 0-IIa and 0-IIb) were treated with nitrous oxide for 5 to 12 seconds using CbFAS. Follow-up EGD was performed at 3 to 12 months. Results Seventeen DAs (mean size, 22.7 ± 14.3 mm; 12 tubular, 5 tubulovillous) from 13 patients (mean age, 66.5 ± 9.99 years; 61.5% males) were included in the study. Thirteen of 17 DAs (76.5%) had failed previous treatment, and 4 of 17 (23.5%) were treatment naIve. All procedures were technically successful and achieved a >50% decrease in size after cryoballoon ablation There was no increase in size or progression of disease for any lesions. Overall, treatment was completed in 15 of 17 patients, and recurrence-free survival was achieved in 12 of 17 (71%) after a median follow-up of 15.5 months (interquartile range [IQR], 6.8-19.4). The median cryoablation time per polyp was 4 minutes (IQR, 1-7.5 minutes), and the median total procedure time was 25 minutes (IQR, 22-30.5 minutes). There were no intra- or postprocedural adverse events. Conclusions Nitrous oxide cryoballoon ablation of nonpolypoid DAs is feasible, with promising safety and efficacy.

Familial adenomatous polyposis (FAP) syndrome is a complex entity, which includes FAP, attenuated FAP, and MUTYH-associated polyposis. These patients are at significant risk for colorectal cancer and carry additional risks for extracolonic malignancies. In this guideline, we reviewed the most recent literature to formulate recommendations on the role of endoscopy in this patient population. Relevant clinical questions were how to identify high-risk individuals warranting genetic testing, when to start screening examinations, what are appropriate surveillance intervals, how to identify endoscopically high-risk features, and what is the role of chemoprevention. A systematic literature search from 2005 to 2018 was performed, in addition to the inclusion of seminal historical studies. Most studies were from worldwide registries, which have compiled years of data regarding the natural history and cancer risks in this cohort. Given that most studies were retrospective, recommendations were based on epidemiologic data and expert opinion. Management of colorectal polyps in FAP has not changed much in recent years, as colectomy in FAP is the standard of care. What is new, however, is the developing body of literature on the role of endoscopy in managing upper GI and small-bowel polyposis, as patients are living longer and improved endoscopic technologies have emerged.

Roux-en-Y gastric bypass is a common bariatric procedure. Its configuration creates an excluded gastric remnant, which is subject to potential acute complications such as bleeding, perforation, and necrosis. A retrospective analysis of a prospective database including all patients presenting between 2007 and 2019 to our institution with acute gastric remnant complications after RYGB was performed. Seven patients were included, including 3 hemorrhages, two of which were treated with double-balloon enteroscopy, as well as 3 perforations and 1 necrosis, all of which required emergent surgery. Overall gastric remnant complication rate was 0.3% in this series. Acute gastric remnant complications after RYGB are infrequent, but their diagnosis and management can be challenging. Double-balloon enteroscopy has diagnostic and therapeutic value for selected patients. Emergent surgery remains the standard of care for unstable patients and should not be delayed.

Zenker's diverticulum (ZD), a pulsion diverticulum of hypopharynx is a rare but treatable cause of morbidity in geriatric population. Traditionally a surgical disease but due to its associated high morbidity, flexible endoscopy has become a lucrative option. We reviewed 997 patients from 23 original studies who underwent flexible endoscopic diverticulotomy (FED) of ZD. Composite technical and clinical success rate for the study cohort was 99.4% and 87.9%, respectively. Composite failure rate was 10.0% but close to half of them (45.3%) had success with repeat endoscopic intervention. Composite rate for symptom recurrence after long-term follow-up was 13.6% but more than half (61.8%) had success with repeat endoscopic intervention. Bleeding (6.6%) and perforation (5.3%) were 2 most common complications of FED. All bleeding events were successfully managed with observation or endoscopic therapy. Majority of perforation events (4.4%) were successfully managed with conservative care and only 0.9% required invasive management. No mortality was reported. Efficacy and safety of FED of ZD remained same irrespective of diverticulum size or prior surgical/endoscopic treatment. FED with diverticuloscope (FEDD) and FED with cap (FEDC) had comparable technical success rate (99.6% vs. 100.0%) but FEDD had higher clinical success rate compared with FEDC (86.8% vs. 75.4%). FEDD had twice the risk of symptom recurrence than FEDC (16.5% vs. 9.5%). FEDD had a comparable bleeding risk to FEDC (3.3% vs. 4.0%) but a much lower perforation rate (2.3% vs. 10.3%). Upper esophageal sphincterotomy and adequate length of septotomy are the cornerstones of FED. FED can be considered a safe and efficacious treatment modality for patients with ZD.

Background and Objectives: We present a multicenter study of a new endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) needle (Acquire, Boston Scientific, Natick, MA). The aim of the study was to analyze the needle's clinical performance when sampling solid lesions and to assess the safety of this device. Methods: We performed a multicenter retrospective study of patients undergoing EUS-FNB during July 1–November 15, 2016. Results: Two hundred patients (121 males and 79 females) underwent EUS-FNB of solid lesions with the Acquire needle. Lesions included solid pancreatic masses (n = 109), adenopathy (n = 45), submucosal lesions (n = 34), cholangiocarcinoma (n = 8), liver lesions (n = 6), and other (n = 8). Mean lesion size was 30.6 mm (range: 3–100 mm). The mean number of passes per target lesion was 3 (range: 1–7). Rapid onsite cytologic evaluation (ROSE) by a cytologist was performed in all cases. Tissue obtained by EUS-FNB was adequate for evaluation and diagnosis by ROSE in 197/200 cases (98.5%). Data regarding the presence or absence of a core of tissue obtained after EUS-FNB were available in 145/200 procedures. In 131/145 (90%) of cases, a core of tissue was obtained. Thirteen out of 200 patients (6.5%) underwent some form of repeat EUS-based tissue acquisition after EUS-FNB with the Acquire needle. There were no adverse events. Conclusion: Overall, this study showed a high rate of tissue adequacy and production of a tissue core with this device with no adverse events seen in 200 patients. Comparative studies of different FNB needles are warranted in the future to help identify which needle type and size is ideal in different clinical settings.

Biliary strictures after orthotopic liver transplantation (OLT) are typically managed by sequential ERCP procedures, with incremental dilation of the stricture and stent exchange (IDSE) and placement of new stents. This approach resolves80% of strictures after 12 months but requires costly, lengthy ERCPs with significant patient radiation exposure. Increasing awareness of the harmful effects of radiation, escalating healthcare costs, and decreasing reimbursement for procedures mandate maximal efficiency in performing ERCP. We compared the traditional IDSE protocol with a sequential stent addition (SSA) protocol, in which additional stents are placed across the stricture during sequential ERCPs, without stent removal/exchange or stricture dilation.Patients undergoing ERCP for OLT-related anastomotic strictures from 2010 to 2016 were identified from a prospectively maintained endoscopy database. Procedure duration, fluoroscopy time, stricture resolution rates, adverse events, materials fees, and facility fees were analyzed for IDSE and SSA procedures.Seventy-seven patients underwent 277 IDSE and 132 SSA procedures. Mean fluoroscopy time was 64.5% shorter (P .0001) and mean procedure duration 41.5% lower (P .0001) with SSA compared with IDSE. SSA procedures required fewer accessory devices, resulting in significantly lower material (63.8%, P .0001) and facility costs (42.8%, P .0001) compared with IDSE. Stricture resolution was95%, and low adverse event rates did not significantly differ.SSA results in shorter, cost-effective procedures requiring fewer accessory devices and exposing patients to less radiation. Stricture resolution rates are equivalent to IDSE, and adverse events do not differ significantly, even in this immunocompromised population.

This clinical guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the management of patients with malignant hilar obstruction (MHO). This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses primary drainage modality (percutaneous transhepatic biliary drainage [PTBD] vs endoscopic biliary drainage [EBD]), drainage strategy (unilateral vs bilateral), and stent selection (plastic stent [PS] vs self-expandable metal stent [SEMS]). Regarding drainage modality, in patients with MHO undergoing drainage before potential resection or transplantation, the panel suggests against routine use of PTBD as first-line therapy compared with EBD. In patients with unresectable MHO undergoing palliative drainage, the panel suggests PTBD or EBD. The final decision should be based on patient preferences, disease characteristics, and local expertise. Regarding drainage strategy, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placement of bilateral stents compared with a unilateral stent in the absence of liver atrophy. Finally, regarding type of stent, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placing SEMSs or PSs. However, in patients who have a short life expectancy and who place high value on avoiding repeated interventions, the panel suggests using SEMSs compared with PSs. If optimal drainage strategy has not been established, the panel suggests placing PSs. This document clearly outlines the process, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics.

Cholangitis is a GI emergency requiring prompt recognition and treatment. The purpose of this document from the American Society for Gastrointestinal Endoscopy's (ASGE) Standards of Practice Committee is to provide an evidence-based approach for management of cholangitis. This document addresses the modality of drainage (endoscopic vs percutaneous), timing of intervention ( 48 hours), and extent of initial intervention (comprehensive therapy vs decompression alone). Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to formulate recommendations on these topics. The ASGE suggests endoscopic rather than percutaneous drainage and biliary decompression within 48 hours. Additionally, the panel suggests that sphincterotomy and stone removal be combined with drainage rather than decompression alone, unless patients are too unstable to tolerate more extensive endoscopic treatment.