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The European Society of Gastrointestinal Endoscopy (ESGE) presents a short list of performance measures for colonoscopy in inflammatory bowel disease (IBD) patients. Current performance measures for colonoscopy mainly focus on detecting (pre)malignant lesions. However, these performance measures are not relevant for all colonoscopy indications in IBD patients. Therefore, our aim was to provide endoscopy services across Europe and other interested countries with a tool for quality monitoring and improvement in IBD colonoscopy. Eight key performance measures and one minor performance measure were recommended for measurement and evaluation in daily endoscopy practice., Competing Interests: R. Bisschops has received research grants and speaker’s fees from Fujifilm, Norgine, and Pentax; he has provided consultancy for Fujifilm, Norgine, and Pentax. E. Dekker has received a research grant and has endoscopic equipment on loan from Fujifilm; she has received speakerʼs fees from Olympus, GI Supply, Norgine, Ipsen, Paion, and Fujifilm; she has provided consultancy for Fujifilm, Olympus, GI Supply, Paion, and Ambu. J.E. East has received speaker’s fees from Falk and Jenssen, has served on clinical advisory boards for Paion, and has served on the clinical advisory board and has share options in Satisfai Health. M. Iacucci has received research grants from Olympus, Pentax, and Fujifilm. M.F. Kaminski has equipment on loan from Fujifilm; he has received speaker’s fees from Boston Scientific, Ipsen, and Recordati, and a research grant from Olympus; he has provided consultancy for Olympus and ERBE. J.G. Karstensen has received speaker’s fees from Norgine and provided for consultancy from Ambu and SNIPR Biome. M. Keuchel has received speaker’s fees from Medtronic and Olympus, and study support from AnXRobotics; he has provided consultancy for Medtronic. M. Pellisé has provided consultancy to Norgine Iberia, GI Supply, and Fujifilm; she has served on the editorial board of Thieme, has been the ESGE equity and diversity working group chair and a councillor for SEED, and is president elect of AEG; her department has received research support from Fujifilm and Casen Recordat. L. Peyrin-Biroulet has received personal fees from Abbvie, Janssen, Takeda, and Celltrion. None of the above conflicts of interest are of relevance to this manuscript. M. Bugajski, C. Carretero, G. Cortas, E.J. Despott, M. Löwenberg, A. Monged, A. Murino, K.J. Nass, O.M. Nardone, H. Neumann, M. Omar, and M.D. Rutter declare that they have no conflict of interest., (European Society of Gastrointestinal Endoscopy. All rights reserved.)

Background and Aim: Upper gastrointestinal tumors account for 5% of upper gastrointestinal bleeds. These patients are challenging to treat due to the diffuse nature of the neoplastic bleeding lesions, high rebleeding rates, and significant transfusion requirements. TC-325 (Cook Medical, North Carolina, USA) is a hemostatic powder for gastrointestinal bleeding. The aim of this study was to examine the outcomes of upper gastrointestinal bleeds secondary to tumors treated with Hemospray therapy., Methods: Data were prospectively collected on the use of Hemospray from 17 centers. Hemospray was used during emergency endoscopy for upper gastrointestinal bleeds secondary to tumors at the discretion of the endoscopist as a monotherapy, dual therapy with standard hemostatic techniques, or rescue therapy., Results: One hundred and five patients with upper gastrointestinal bleeds secondary to tumors were recruited. The median Blatchford score at baseline was 10 (interquartile range [IQR], 7-12). The median Rockall score was 8 (IQR, 7-9). Immediate hemostasis was achieved in 102/105 (97%) patients, 15% of patients had a 30-day rebleed, 20% of patients died within 30 days (all-cause mortality). There was a significant improvement in transfusion requirements following treatment (P < 0.001) when comparing the number of units transfused 3 weeks before and after treatment. The mean reduction was one unit per patient., Conclusions: Hemospray achieved high rates of immediate hemostasis, with comparable rebleed rates following treatment of tumor-related upper gastrointestinal bleeds. Hemospray helped in improving transfusion requirements in these patients. This allows for patient stabilization and bridges towards definitive surgery or radiotherapy to treat the underlying tumor., (© 2021 The Authors. Journal of Gastroenterology and Hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: COVID-19 pandemic is an unprecedented global medical emergency. National and international gastrointestinal societies recommended that any endoscopic activity during the lockdown phase of the pandemic should be limited to emergency or non-deferrable procedures only. We assessed the financial implications and impact on endoscopy activity of the lockdown phase in a tertiary referral endoscopy unit., Methods: The number of endoscopy procedures canceled and performed in our endoscopy unit during our "delay phase" (16-22/03/2020) and "lockdown phase" (23/03-29/05/2020) was reviewed and compared with endoscopy activity conducted during the same period in 2019. The financial impact was subsequently analyzed., Results: Between 16/03/2020 and 29/05/2020, 683 procedures were canceled and 365 non-deferrable procedures were performed. In contrast, in 2019, 3437 procedures were performed over the same timeframe, resulting in a revenue contraction of approximately €2,062,857. We estimated that the number of lists required to recuperate the canceled endoscopic activity, ranges from 103-155, depending on the level of personal protective equipment required and mitigating policy relating to COVID-19., Conclusion: Our results highlight that COVID-19 pandemic had a substantial negative impact on our endoscopy activity and on the revenue generated by our endoscopy unit., Competing Interests: Conflict of Interest: Alberto Murino has acted as a consultant for Boston Scientific and GI supply; he has also received academic grants from Fujifilm, Aquilant Endoscopy, Norgine and Olympus. Edward J. Despott has acted as a consultant for Boston Scientific and Ambu. He has also received academic grants and speaker honoraria from Fujifilm, Aquilant Endoscopy, Norgine and Olympus. The rest of the authors have declared no conflict of interest, (Copyright: © Hellenic Society of Gastroenterology.)

The impact of small-bowel (SB) capsule endoscopy and device-assisted enteroscopy on clinical practice, since their introduction 2 decades ago, has been remarkable. These disruptive technologies have transformed the investigation and management of SB pathology and now have a firmly established place in guidelines and clinical algorithms. Furthermore, recent years have witnessed innovations, driven by the demand of new goals in the management of inflammatory bowel disease (IBD), such as mucosal healing and evolving strategies based on tight monitoring and accelerated escalation of care. These developments in SB endoscopy have also been paralleled by refinement in dedicated radiological SB imaging technologies. This updated review highlights the current state of the art and more recent innovations with a focus on their role in IBD., Competing Interests: Conflict of Interest: Edward J. Despott has acted as a consultant for Fujifilm, Boston Scientific and Ambu. He has also received academic grants and speaker honoraria from Fujifilm, Aquilant Endoscopy, Pentax Medical, Norgine and Olympus, (Copyright: © Hellenic Society of Gastroenterology.)

Background and Aims: Buried bumper syndrome (BBS) is a rare adverse event of percutaneous endoscopic gastrostomy (PEG) placement in which the internal bumper migrates through the stomal tract to become embedded within the gastric wall. Excessive tension between the internal and external bumpers, causing ischemic necrosis of the gastric wall, is believed to be the main etiologic factor. Several techniques for endoscopic management of BBS have been described using off-label devices. The Flamingo set is a novel, sphincterotome-like device specifically designed for BBS management. We aimed to evaluate the effectiveness of the Flamingo device in a large, homogeneous cohort of patients with BBS., Methods: A guidewire was inserted through the external access of the PEG tube into the gastric lumen. The Flamingo device was then introduced into the stomach over the guidewire. This dedicated tool can be flexed by 180 degrees, exposing a sphincterotome-like cutting wire, which is used to incise the overgrown tissue until the PEG bumper is exposed. A retrospective, international, multicenter cohort study was conducted on 54 patients between December 2016 and February 2019., Results: The buried bumper was successfully removed in 53 of 55 procedures (96.4%). The median time for the endoscopic removal of the buried bumper was 22 minutes (range, 5-60). Periprocedural endoscopic adverse events occurred in 7 procedures (12.7%) and were successfully managed endoscopically. A median follow-up of 150 days (range, 33-593) was performed in 29 patients (52.7%), during which no significant adverse events occurred., Conclusions: Through our experience, we found this dedicated novel device to be safe, quick, and effective for minimally invasive, endoscopic management of BBS., (Copyright © 2021 American Society for Gastrointestinal Endoscopy. All rights reserved.)

Competing Interests: Dr. Despott and Dr. Murino receive research/education support from Aquilant Medical, Fujifilm, Olympus, and Pentax Medical. Professor Yano receives research/education support from Fujifilm. All other authors have no conflict of interest to disclose.

ESGE recommends the "pull" technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer ("push") technique for PEG placement in cases where the "pull" method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed "blindly" at the patient's bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 - 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 - 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence., Competing Interests: T. Beyna receives consultancy honoraria and lecture fees from Olympus and Boston Scientific (ongoing), and lecture fees from Medtronic, the Falk Foundation, and Erbe. E.J. Despott has received consultancy fees and speaker’s honoraria from Boston Scientific, Ambu, and Fujifilm (2007 to 2019); his department has received educational grants from Fujifilm, Pentax, Olympus, Boston Scientific, Norgine, Cook, Erbe, Medtronic, Ankon, Diagmed, and US Endoscopy (2017 to 2019). S.M. Schneider has been a board member for Nutricia France (2016 to 2018); he has been or is a consultant for Laboratoires Grand Fontaine (2013), Nestlé Health Sciences (2020), and Baxter (2019). J.E. van Hooft has received lecture fees from Medtronic (2014 to 2015, 2019) and Cook Medical (2019), and consultancy fees from Boston Scientific (2014 to 2017); her department has received research grants from Cook Medical (2014 to 2019), and Abbott (2014 to 2017). M. Arvanitakis, A. Ballarin, K. Boeykens, P. Elbe, I. Gisbertz, P. Gkolfakis, A. Hoyois, O. Mosteanu, D. Sanders, and P. Thelin-Schmidt declare that they have no conflicts of interest., (European Society of Gastrointestinal Endoscopy. All rights reserved.)

ESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*., Competing Interests: T. Beyna receives consultancy honoraria and lecture fees from Olympus and Boston Scientific (ongoing), and lecture fees from Medtronic, the Falk Foundation, and Erbe (ongoing). E.J. Despott has received consultancy fees and speaker’s honoraria from Boston Scientific, Ambu, and Fujifilm (2007 to 2019); his department has received educational grants from Fujifilm, Pentax, Olympus, Boston Scientific, Norgine, Cook, Erbe, Medtronic, Ankon, Diagmed, and US Endoscopy (2017 to 2019). S.M. Schneider has been a board member for Nutricia France (2016 to 2018); he has been or is a consultant for Laboratoires Grand Fontaine (2013), Nestlé Health Sciences (2020), and Baxter (2019). J.E. van Hooft has received lecture fees from Medtronic (2014 to 2015, 2019) and Cook Medical (2019), and consultancy fees from Boston Scientific (2014 to 2017); her department has received research grants from Cook Medical (2014 to 2019), and Abbott (2014 to 2017). M. Arvanitakis, A. Ballarin, K. Boeykens, P. Elbe, I. Gisbertz, P. Gkolfakis, A. Hoyois, O. Mosteanu, D. Sanders, and P. Thelin-Schmidt declare that they have no conflicts of interest., (European Society of Gastrointestinal Endoscopy. All rights reserved.)

Competing Interests: Alberto Murino has acted as a consultant for Boston Scientific and GI Supply. He has also received academic grants from Fujifilm, Aquilant Endoscopy, Norgine, and Olympus. Edward J. Despott has acted as a consultant for Boston Scientific and Ambu. He has also received academic grants and speaker honoraria from Fujifilm, Aquilant Endoscopy, Norgine, and Olympus. The other authors declare that they have no conflict of interest.

The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize training in small-bowel endoscopy across European centers. The following criteria and framework for training in small-bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE), which aim to provide uniform and high quality training to ensure that small-bowel endoscopists are competent to operate independently, are based on the current literature and experience of experts in the field. Three main areas are covered: skills required prior to commencing training in small-bowel endoscopy; structured training for trainees to become independent endoscopists; and ways of ensuring competence is achieved. 1 : Centers providing training in SBCE should perform a minimum of 75 - 100 SBCEs/year. 2 : Experience in bidirectional endoscopies is desirable for structured training in SBCE. 3 : SBCE courses should consist of at least 50 % hands-on training and cover information on technology, indications and contraindications for SBCE, pathologies that can be encountered on SBCE, and standard terminology that should be used during reporting of SBCE. An SBCE course should be completed prior to achieving competence in SBCE reporting. 4 : Competence in SBCE can be assessed by considering a minimum of 30 SBCEs. Direct Observation of Procedural Skills, short SBCE videos, and multiple-choice questions can be useful to assess improvement in the skills of trainees. 5 : Centers offering training in DAE should aim to carry out at least 75 DAEs/year, should have direct links with an SBCE service, and should allow regular discussion of cases at a radiology small-bowel MDT. Training centers with lower numbers are encouraged to offer training by "buddying-up" with other centers, or using mentoring systems. 6 : DAE trainees must be independent in bidirectional endoscopies and have experience in level 1 polypectomy prior to commencement of training. They should also be competent in reviewing SBCEs. 7 : Training in DAE should be structured with a minimum of 75 procedures, including 35 retrograde DAEs, with therapeutic procedures undertaken in at least 50 % of the DAEs performed. Training should cover the indications, contraindications, complications including prevention, and technicalities of the DAE procedure; formal evaluation should follow. DAE trainees must acquire skills to independently manage and advise on small-bowel pathology following DAE procedures. 8 : It is highly recommended that international societies develop online modules and courses on DAE, which are currently lacking across Europe., Competing Interests: M. Arvanitakis has received lecture fees from Olympus (2019 – 2020). P. Baltes has received speakerʼs fees from Medtronic (2014 to present). R. Bisschops has received research support, speaker’s and consultancy fees from Medtronic, Cook, Pentax, and Fujifilm (2009 – 2020), he has also received consultancy and speaker’s fees from Norgine, GI supply, Medivators, and Boston Scientific (2009 – 2020). C. Carretero has received speakerʼs and consultancy fees from Medtronic (ongoing). E. Dekker has received speaker’s fees from Olympus (2018), Roche (2016, 2018), and GI Supply (2019), has provided consultancy to Fujifilm (2017), Olympus (2019), Tillots (2018), GI Supply (2018 to present), and CPP-FAP (2019); she has received equipment on loan from Fujifilm (2017 to present); she received a research grant from Fujifilm. E.J. Despott has received speakerʼs honoraria from Fujifilm and Aquilant Endoscopy (2017 to present), and educational grants from Fujifilm, Aquilant Endoscopy, Pentax Medical, and Olympus Medical (2017 to present). M. Dinis-Ribeiro is co-editor in-chief of Endoscopy. X. Dray is a co-founder and shareholder of Augmented Endoscopy (2019 to present), and has given training for Fujifilm and Medtronic (2010 – 2019); he also holds a patent related to the guideline: European patent EP18305275. J.E. East is on the clinical advisory boards of Boston Scientific, Lumendi (2017 – 2019) and Satisfai Health (2020). G. Johnson has received speakerʼs fees from Boston Scientific (2012 to present) and has been a faculty member for annual training courses supported by Olympus, Pentax, and Boston Scientific (2012 to present). M. Keuchel has received speakerʼs fees from Medtronic and Olympus (2015 to present); he is co-editor of the book Video Capsule Endoscopy published by Springer. A. Murino has acted as a consultant for Boston Scientific and GI supply (2019), he has received academic grants from Fujifilm, Aquilant Endoscopy, Norgine, and Olympus (2017 – 2020). T. Ponchon has received research support from Olympus (2020). S. Chetcuti Zammit, P. Pimentel-Nunes, D. S. Sanders, and R. Sidhu declare that they have no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Competing Interests: Edward J. Despott has acted as a consultant for Boston Scientific and Ambu. He has also received academic grants and speaker honoraria from Fujifilm, Aquilant Endoscopy, Norgine and Olympus.Alberto Murino has acted as a consultant for Boston Scientific and GI supply. He has also received academic grants from Fujifilm, Aquilant Endoscopy, Norgine and Olympus.Tomonori Yano has received educational and speaker honoraria from Fujifilm corporation.All other authors declare that they have no conflict of interest.

Competing Interests: E. J. Despott receives research support from Aquilant Medical, Olympus, Pentax Medical, and Fujifilm. A. Murino receives research support from Aquilant Medical, Olympus, Pentax Medical, and Fujifilm. All other authors disclosed no financial relationships relevant to this publication.

Background and Aims: Small-bowel varices (SBVs) are an uncommon consequence of portal hypertension. Radiologic intervention is usually considered for first-line management. When radiologic intervention is not possible, management options become very limited. The aim of this study was to evaluate the usefulness of double-balloon enteroscopy (DBE)-facilitated cyanoacrylate-injection endotherapy of SBVs., Methods: This was a retrospective review of DBE-facilitated cyanoacrylate-injection endotherapy of SBVs (December 2015 to October 2016)., Results: Ten DBEs were performed in 6 patients (4 women; median age, 68.5 years). No radiologic or surgical options were deemed feasible. Thirteen nests of SBVs were identified and injected with cyanoacrylate glue without hemorrhagic or embolic adverse events. At the 30-day follow-up after therapy, only 1 patient had experienced a mild recurrence of mid-gut bleeding; this was managed conservatively. One patient presented with acute GI bleeding 7 months later, and a repeat DBE with cyanoacrylate-injection endotherapy was successfully performed. One patient succumbed to his underlying advanced cholangiocarcinoma after 2 months. The remaining patients had a median follow-up of 12 months without any recurrent GI bleeding., Conclusions: DBE-facilitated cyanoacrylate-injection endotherapy of SBVs appears to be a safe and effective option when other first-line options are not feasible., (Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.)

The European Society of Gastrointestinal Endoscopy (ESGE) together with the United European Gastroenterology (UEG) recently developed a short list of performance measures for small-bowel endoscopy (i. e. small-bowel capsule endoscopy and device-assisted enteroscopy) with the final goal of providing endoscopy services across Europe with a tool for quality improvement. Six key performance measures for both small-bowel capsule endoscopy and for device-assisted enteroscopy were selected for inclusion, with the intention being that practice at both a service and endoscopist level should be evaluated against them. Other performance measures were considered to be less relevant, based on an assessment of their overall importance, scientific acceptability, and feasibility. Unlike lower and upper gastrointestinal endoscopy, where performance measures had already been identified, this is the first time that small-bowel endoscopy quality measures have been proposed., Competing Interests: S. Adler gives teaching seminars in capsule endoscopy sponsored by Medtronic (2015 to present). C. Bennett owns and works for Systematic Research Ltd., and received a consultancy fee from ESGE to provide scientific, technical, and methodological expertise for the present project (2014 – 2018). R. Bisschops has received: speaker’s fees from Covidien (2009 – 2014) and Fujifilm (2013); speaker’s fee and hands-on training sponsorship from Olympus Europe (2013 – 2014); speaker’s fee and research support from Pentax Europe; and an editorial fee from Georg Thieme Verlag as co-editor of Endoscopy. M. Bretthauer receives fees for being a member of the Norwegian government CRC screening advisory group (2012 to present) and receives funds from the American College of Physicians for editorial work for Annals of Internal Medicine. E. Despott has received honoraria from Fujifilm and Olympus (2017 – 2019) and academic and research funding from Fujifilm, Olympus, and Pentax Medical (2017 – 2019). M. Dinis-Ribeiro receives funds from Georg Thieme Verlag for editorial work for Endoscopy. I. Fernández-Urién receives consultancy fees from Given Imaging, Covidien, and Medtronic (2010 – 2018). M. Kaminski receives speakers and teaching fees and travel support from Olympus Erbe. M. Keuchel has received speaker fees from Medtronic and Olympus (2002 – 2019), Given Imaging study support (2010 – 2013), and DGVS – guideline quality in endoscopy (2012 – 2015). M. McAlindon receives consultancy fees from Medtronic (2016 – 2019) and receives research support from Ankon Ltd. and Intromedic Ltd. (2017 – 2019). D. McNamara was a member of the Colon Expert Group at the Medtronic session in Tarquinia. J.-C. Saurin has provided consultancy for Intromedic Capsovision Medtronic (2014 – 2018). C. Senore’s department received PillCAM2 Colon devices from Medtronic to conduct a comparative study (2014 – 2017); along with C. Belissario and S. Minozzi, he also received consultancy fees from ESGE to provide methodological expertise (PICOs evaluation, literature searches, and evidence summaries) for the present project (2014 – 2017). S. Panter has received support for Ad boards from Medtronic (from 2010), for a capsule course from Diagmed (from 2005), and for training guideline development from the JAG training working group (from 2010). He was also a member of the Colon Expert Group at the Medtronic session in Tarquinia. C. Spada receives consultancy fees from Medtronic (2016 to present), and speakers and teaching fees and travel support from Olympus (2018 – 2019). R. Valori is a director of AnderVal Ltd., a company providing endoscopy skills training (2015 to present). B. D. Cash, D. Domagk, C. Hassan, H. Ivekovic, C. J. Rees, and M. Rutter have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Dr. Despott has received research and education support from Fujifilm, Aquilant Medical, Pentax, and Olympus. Dr. Murino has received research and education support from Fujifilm and Aquilant Medical., (© Georg Thieme Verlag KG Stuttgart · New York.)

Small-Bowel Capsule Endoscopy (sbce): 1: ESGE recommends that prior to SBCE patients ingest a purgative (2 L of polyethylene glycol [PEG]) for better visualization.Strong recommendation, high quality evidence.However, the optimal timing for taking purgatives is yet to be established. 2: ESGE recommends that SBCE should be performed as an outpatient procedure if possible, since completion rates are higher in outpatients than in inpatients.Strong recommendation, moderate quality evidence. 3: ESGE recommends that patients with pacemakers can safely undergo SBCE without special precautions.Strong recommendation, low quality evidence. 4: ESGE suggests that SBCE can also be safely performed in patients with implantable cardioverter defibrillators and left ventricular assist devices.Weak recommendation, low quality evidence. 5: ESGE recommends the acceptance of qualified nurses and trained technicians as prereaders of capsule endoscopy studies as their competency in identifying pathology is similar to that of medically qualified readers. The responsibility of establishing a diagnosis must however remain with the attending physician.Strong recommendation, moderate quality evidence. 6: ESGE recommends observation in cases of asymptomatic capsule retention.Strong recommendation, moderate quality evidence.In cases where capsule retrieval is indicated, ESGE recommends the use of device-assisted enteroscopy as the method of choice.Strong recommendation, moderate quality evidence., Device-Assisted Enteroscopy (dae): 1: ESGE recommends performing diagnostic DAE as a day-case procedure in patients without significant underlying co-morbidities; in patients with co-morbidities and/or those undergoing a therapeutic procedure, an inpatient stay is recommended.Strong recommendation, low quality evidenceThe choice between different settings also depends on sedation protocols.Strong recommendation, low quality evidence. 2: ESGE suggests that conscious sedation, deep sedation, and general anesthesia are all acceptable alternatives: the choice between them should be governed by procedure complexity, clinical factors, and local organizational protocols.Weak recommendation, low quality evidence. 3: ESGE recommends that the findings of previous diagnostic investigations should guide the choice of insertion route.Strong recommendation, moderate quality evidence.If the location of the small-bowel lesion is unknown or uncertain, ESGE recommends that the antegrade route should be generally preferred.Strong recommendation, low quality evidence.In the setting of massive overt bleeding, ESGE recommends an initial antegrade approach.Strong recommendation, low quality evidence. 4: ESGE recommends that, for balloon-assisted enteroscopy (i. e., single-balloon enteroscopy [SBE] and double-balloon enteroscopy [DBE]), small-bowel insertion depth should be estimated by counting net advancement of the enteroscope during the insertion phase, with confirmation of this estimate during withdrawal.Strong recommendation, low quality evidence.ESGE recommends that, for spiral enteroscopy, insertion depth should be estimated during withdrawal.Strong recommendation, moderate quality evidence. Since the calculated insertion depth is only a rough estimate, ESGE recommends placing a tattoo to mark the identified lesion and/or the deepest point of insertion.Strong recommendation, low quality evidence. 5: ESGE recommends that all endoscopic therapeutic procedures can be undertaken at the time of DAE.Strong recommendation, moderate quality evidence.Moreover, when therapeutic interventions are performed, additional specific safety measures are needed to prevent complications.Strong recommendation, high quality evidence., Competing Interests: S. Adler receives honoraria for giving seminars in capsule endoscopy, sponsored by Medtronic. E. J. Despott has received educational and travel grants and speaker’s honoraria from Fujifilm, Aquilant, Diagmed, and Medtronic (2007 to present); his department has received educational and travel grants and speaker’s honoraria from Olympus (2012 to present). I. Fernandez-Urien has received consultancy fees from Medtronic (2016 to 2017). A. Koulaouzidis is receiving material support for research from SynMed UK and IntroMedic (ongoing); his department is receiving material support from Aquilant/OMOM (ongoing); he received a research grant from Given Imaging (2011 to 2012). A. May receives speaker’s honoraria from FALK and Fujifilm; her department is receiving research support from Fujifilm (2014 to 2018), Olympus (2014 to 2018), and Interscope (2017 to 2019). S. Panter has received sponsorship support from Diagmed and Given to attend conferences and educational events (2005 to present); his department has received research fellowship funding from Aquilant and Fuji (2013 to 2015), and support for the delivery of capsule course infrastructure costs (2005 to present); he is currently the unpaid chair of the UK capsule endoscopy users’ group. G. Rahmi is giving training courses provided by Medtronic on the small-bowel capsule (2017 to 2018). C. Spada receives a consultancy fee from Medtronic. J. van Hooft’s department is currently receiving research grants from Cook Medical, Boston Scientific, Olympus, and Medtronic. D. Domagk, C. Hassan, M. Pennazio, M.E. Riccioni, and E. Rondonotti have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Dr. Despott has received research and education grants from Fujifilm, Aquilant Medical, Pentax, and Olympus.

Competing Interests: Competing interests: None

Backgrounds and Aim: Technically 'difficult' (TD) colonoscopy is associated with incomplete colonoscopy, discomfort and longer procedures. Double-balloon colonoscopy (DBC) may facilitate TD colonoscopy. The primary outcome was to compare the time taken to achieve caecal intubation during conventional colonoscopy (CC) and DBC in patient with a TD colon., Methods: We performed a prospective, randomised study comparing DBC and CC for TD colonoscopy. Patients were screened for parameters predictive of TD colonoscopy using an original scoring system and randomised to DBC or CC. Pain, sedation dose, colonoscopy completeness, time taken for cecal intubation, procedure completion, recovery time and patient satisfaction were recorded., Results: Forty-four patients were recruited (DBC=22; CC=22). DBC facilitated total colonoscopy in 22 cases whereas 9 CC procedures were incomplete (P=0.019). Median pre-procedure difficulty scores were equal for both groups (4.0 vs. 4.0). Mean patient discomfort, pain scores and recovery time were significantly lower for the DBC group (2.3 vs. 5.5, P=0.001; 2.0 vs. 5.9, P=0.005; 5 vs. 20min, P=0.014 respectively). Mean time taken for cecal intubation was similar (17.5 vs. 14min, P=0.18); CONCLUSION: DBC facilitates colonoscopy completion and may be a more comfortable alternative to CC for TD cases although the time taken to achieve caecal intubation was similar., (Copyright © 2017 Editrice Gastroenterologica Italiana S.r.l. All rights reserved.)

Over the last 16 years, the disruptive technologies of small bowel capsule endoscopy and device-assisted enteroscopy have revolutionised endoluminal imaging and minimally invasive therapy of the small bowel. Further technological developments continue to expand their indications and use. This brief review highlights the state-of-the-art in this arena and aims to summarise the current and potential future role of these technologies in clinical practice., Competing Interests: Competing interests: EJD: Research, education and travel grants received from Aquilant Endoscopy (UK), Fujifilm, Keymed-Olympus and Boston Scientific. Speaker honoraria received from Fujifilm and Keymed-Olympus.

Background: Spiral enteroscopy is a recently introduced technology alternative to balloon-assisted enteroscopy for examination of the small bowel., Aim: To compare small bowel insertion depths and procedure duration by spiral enteroscopy and double-balloon enteroscopy performed in the same cohort of patients, in immediate succession, using the same method of insertion depth estimation., Methods: A prospective, back-to-back comparative study was performed in 15 patients. Spiral enteroscopy procedures were performed first and a tattoo was placed to mark the most distal point., Results: Double-balloon enteroscopy passed the tattoo placed at spiral enteroscopy in 14/15 cases (93%). Median insertion depths for double-balloon enteroscopy and spiral enteroscopy were 265cm and 175cm, respectively (P=0.004). Median time to achieve maximal depth of insertion was significantly shorter for spiral enteroscopy compared with double-balloon enteroscopy (24min vs. 45min, respectively; P=0.0005). However, in 14 patients no differences were found in median time to reach the same insertion depth (P=0.28)., Conclusion: Double-balloon enteroscopy achieved significantly greater small bowel insertion depth than spiral enteroscopy. Although overall double-balloon enteroscopy procedure duration was longer, the time taken to reach the same small bowel insertion depth by both spiral enteroscopy and double-balloon enteroscopy was similar., (Copyright © 2015 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). The Guideline was also reviewed and endorsed by the British Society of Gastroenterology (BSG). It addresses the roles of small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders. Main recommendations 1 ESGE recommends small-bowel video capsule endoscopy as the first-line investigation in patients with obscure gastrointestinal bleeding (strong recommendation, moderate quality evidence). 2 In patients with overt obscure gastrointestinal bleeding, ESGE recommends performing small-bowel capsule endoscopy as soon as possible after the bleeding episode, optimally within 14 days, in order to maximize the diagnostic yield (strong recommendation, moderate quality evidence). 3 ESGE does not recommend the routine performance of second-look endoscopy prior to small-bowel capsule endoscopy; however whether to perform second-look endoscopy before capsule endoscopy in patients with obscure gastrointestinal bleeding or iron-deficiency anaemia should be decided on a case-by-case basis (strong recommendation, low quality evidence). 4 In patients with positive findings at small-bowel capsule endoscopy, ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by capsule endoscopy (strong recommendation, high quality evidence). 5 ESGE recommends ileocolonoscopy as the first endoscopic examination for investigating patients with suspected Crohn's disease (strong recommendation, high quality evidence). In patients with suspected Crohn's disease and negative ileocolonoscopy findings, ESGE recommends small-bowel capsule endoscopy as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known stenosis (strong recommendation, moderate quality evidence).ESGE does not recommend routine small-bowel imaging or the use of the PillCam patency capsule prior to capsule endoscopy in these patients (strong recommendation, low quality evidence). In the presence of obstructive symptoms or known stenosis, ESGE recommends that dedicated small bowel cross-sectional imaging modalities such as magnetic resonance enterography/enteroclysis or computed tomography enterography/enteroclysis should be used first (strong recommendation, low quality evidence). 6 In patients with established Crohn's disease, based on ileocolonoscopy findings, ESGE recommends dedicated cross-sectional imaging for small-bowel evaluation since this has the potential to assess extent and location of any Crohn's disease lesions, to identify strictures, and to assess for extraluminal disease (strong recommendation, low quality evidence). In patients with unremarkable or nondiagnostic findings from such cross-sectional imaging of the small bowel, ESGE recommends small-bowel capsule endoscopy as a subsequent investigation, if deemed to influence patient management (strong recommendation, low quality evidence). When capsule endoscopy is indicated, ESGE recommends use of the PillCam patency capsule to confirm functional patency of the small bowel (strong recommendation, low quality evidence). 7 ESGE strongly recommends against the use of small-bowel capsule endoscopy for suspected coeliac disease but suggests that capsule endoscopy could be used in patients unwilling or unable to undergo conventional endoscopy (strong recommendation, low quality evidence)., (© Georg Thieme Verlag KG Stuttgart · New York.)

Abnormalities in liver function tests, including transient and self-limiting hypertransaminasemia, cholestatic disease and hepatitis, can develop during treatment with anti-tumour-necrosis-factor (TNF) therapy. The optimal management of liver injury related to anti-TNF therapy is still a matter of debate. Although some authors recommend discontinuing treatment in case of both a rise of alanine aminotransferase more than 5 times the upper limit of normal, or the occurrence of jaundice, there are no standard guidelines for the management of anti-TNF-related liver injury. Bibliographical searches were performed in PubMed, using the following key words: inflammatory bowel disease (IBD); TNF inhibitors; hypertransaminasemia; drug-related liver injury; infliximab. According to published data, elevation of transaminases in patients with IBD treated with anti-TNF is a common finding, but resolution appears to be the usual outcome. Anti-TNF agents seem to be safe with a low risk of causing severe drug-related liver injury. According to our centre experience, we found that hypertransaminasemia was a common, mainly self-limiting finding in our IBD cohort and was not correlated to infliximab treatment on both univariate and multivariate analyses. An algorithm for the management of liver impairment occurring during anti-TNF treatment is also proposed and this highlights the need of a multidisciplinary approach and suggests liver biopsy as a key-point in the management decision in case of severe rise of transaminases. However, hepatic injury is generally self-limiting and drug withdrawal seems to be an exception.

Background: Deep small bowel insertion during double balloon enteroscopy can be difficult to achieve., Aims: To determine the factors influencing depth of insertion during double balloon enteroscopy., Methods: History of abdomino-pelvic surgery, route of insertion, type of enteroscope, age, sedation or general anaesthesia used and gender were considered as potential influencing factors; procedures were categorised accordingly and maximal depth of insertion calculated., Results: At multivariate analysis, maximal depth of insertion was significantly associated with history of abdominal-pelvic surgery (P<0.001), rectal approach (P=0.011), gender (P=0.02) and use of the therapeutic enteroscope (P=0.047). Mean maximal depth of insertion was 266±12cm, 255±9cm (P=0.50), 197±10cm (P<0.0001), 160±12cm (P<0.01) and 103±33cm (P<0.15) when 0, 1, 2, 3 and 4 influencing factors were present, respectively., Conclusion: Maximal depth of insertion was significantly influenced by history of abdomino-pelvic surgery, insertion route, gender and type of enteroscope used., (Copyright © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: GI bleeding secondary to small-intestine vascular lesions (SIVLs) is associated with rebleeding despite initial hemostasis by endotherapy applied at double-balloon endoscopy (DBE)., Objective: To evaluate the long-term outcomes of DBE endotherapy of SIVL (as described by the Yano-Yamamoto classification). The impact of repeat DBE endotherapy for recurrent bleeding also was assessed., Design: Retrospective cohort study. The mean (± standard deviation [SD]) follow-up period was 4.9 (± 1.7) years (range 2.4-9.1 years)., Setting: Tertiary-care referral center., Patients: A total of 43 patients, who underwent 69 sessions of DBE endotherapy of SIVLs., Intervention: DBE endotherapy., Main Outcome Measurements: Frequency of overt rebleeding after the initial DBE endotherapy., Results: Overt rebleeding occurred in 16 of 43 patients (37%). Patients with multiple SIVLs showed a significantly higher rate of overt rebleeding than did those with a solitary SIVL (12/23 [52%] vs 4/20 [20%]; P = .017). The trend toward frequency of rebleeding after the first DBE hemostasis appeared to be higher for patients with type 1a SIVLs than for those with type 1b or type 2 lesions: type 1a (8/16, 50%) versus type 1b (5/19, 26%) (P = .12) and type 1a (8/16, 50%) versus type 2 (2/7, 29%) (P = .31), respectively. In 12 of 16 patients (75%) who underwent repeat DBE endotherapy at each episode of overt rebleeding (median 3 times, range 2-6), the frequency of rebleeding decreased significantly after the first year of follow-up, as compared with the remaining 4 patients who did not undergo repeat DBE; mean (± SD) 0.12 (± 0.19) versus 0.52 (± 0.33) times per year per patient (P = .006)., Limitations: Single-center, retrospective study., Conclusion: Although the presence of multiple SIVLs was associated with rebleeding, repeat DBE endotherapy resulted in an improved long-term outcome in patients with refractory SIVL bleeding., (Copyright © 2014 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: A nurse practitioner-led dysphagia service was introduced to improve appropriateness of investigations., Objective: To determine the clinical outcomes and efficacy of this service., Design and Patients: A 7-year prospective audit of the first 2000 patients referred for investigation of dysphagia., Setting: Royal Cornwall Hospitals NHS Trust., Intervention: An innovative nurse practitioner-led telephone dysphagia hotline (DHL) assessment service for all patients and consultant review following investigation prior to discharge., Outcomes: Clinical outcomes, service efficiency and cost effectiveness., Results: 2000 patients (median age 70 years, 48% male) were referred in less than 7 years, 1775 being managed fully through the DHL. 67% patients had gastroscopy only, 13% barium swallow only and 8.8% both and 11.2% had no investigation. Reflux was the commonest cause (41.3%), 9% had peptic stricture, 10% malignancy 1.9% pharyngeal pouches and 0.8% achalasia. The did not attend rate was reduced from 3.9% to 1.1% and 151 patients either refused or did not require investigation saving a potential £53 040. Although some patients with pharyngeal pouches had gastroscopy as initial investigation, no complications resulted., Conclusions: The nurse practitioner-led DHL service has improved efficiency and resulted in a safe prompt service to patients.

The last decade has witnessed a revolution in small bowel (SB) endoscopy technologies. Endoscopists are no longer confined to the use of push enteroscopy or the significantly more invasive intra-operative enteroscopy: SB capsule endoscopy (SBCE) and device assisted enteroscopy (DAE) have rapidly enabled endoscopic visualisation of the entire SB without the need for surgery. DAE goes a step further by allowing tissue sampling and the application of endotherapy. These developments have also been parallelled by rapid advances in dedicated radiological SB imaging technologies. Although it is clear that SBCE and DAE may have a significant role in the diagnosis and management of IBD patients, their respective place in relation to other technologies within the clinical paradigm of IBD is as yet unclear. This review outlines the current evidence base relating to these endoscopic technologies and their impact in the diagnosis and management of IBD and highlights current international recommendations., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: To determine the location and use of small bowel endoscopy services in the UK and to analyse training uptake to assess future demand and shape discussions about training and service delivery., Design: Surveys of British Society of Gastroenterology (BSG) members by web-based and personal contact were conducted to ascertain capsule endoscopy practice and numbers of procedures performed. This was compared with expected numbers of procedures calculated using BSG guidelines, hospital episode statistics and published data of capsule endoscopy in routine practice. Analysis of data from two national training courses provided information about training., Results: 45% of UK gastroenterology services offered in-house capsule endoscopy. 91.3% of survey responders referred patients for capsule endoscopy; 67.7% felt that local availability would increase referrals. Suspected small bowel bleeding and Crohn's disease were considered appropriate indications by the majority. Demand is increasing in spite of restricted use in 21.6% of centres. Only two regions performed more than the minimum estimate of need of 45 procedures per 250 000 population. Eight centres perform regular device-assisted enteroscopy; 14 services are in development. 74% of trainees were interested in training and of those training in image interpretation, 67% are doctors and 28% are nurses., Conclusions: Capsule endoscopy is used by the majority of UK gastroenterologists but appears to be underused. Current demand for device-assisted enteroscopy seems likely to be matched if new services become established. Future demand is likely to increase, however, suggesting the need to formalise training and accreditation for both doctors and nurses., Competing Interests: Competing interests: MEM has received support to attend conferences by Given Imaging Ltd. and received honoraria for lectures from Intromedic Ltd.