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Introduction: Stent placement in the distal duodenum can be difficult. We describe a case report of a 94-year-old man with metastatic pancreatic head cancer compressing the third and fourth portions of the duodenum, treated by endoscopic stent placement using a colonoscope. Areas Covered: A literature review highlighted two possible procedures for stent placement in the distal duodenum, namely forward-viewing and side-viewing endoscopies. Gastroscopes, duodenoscopes, enteroscopes, and colonoscopes have all been suggested for the purpose. For distal lesions, especially when the duodenal wall is stiffened due to compression or infiltration by neoplastic lesions, a conventional upper endoscope can be too short to reach the narrowed site in “push mode,” necessitating the use of a longer endoscope. Expert Commentary: A colonoscope can be safely and effectively used to accomplish distal duodenal stent placement.

Endoscopes are flexible instruments that combine fiber-optics and charge-coupled devices to facilitate illumination and visualization of otherwise inaccessible sites, such as the lumen of hollow organs. An endoscope consists of a tip, an insertion tube and a control section. Newer endoscopes are capable of providing high-definition, high-resolution images that can be magnified to examine the mucosa in greater detail. Image-enhancing modalities can be used to selectively highlight vascular structures or enhance the appearance of the mucosa. The most commonly used endoscopes are gastroscopes and colonoscopes, which are used for examination of the upper gastrointestinal tract and colon, respectively. Therapeutic endoscopes with larger channel diameters that allow passage of complex and sophisticated accessories are also available for advanced interventional procedures. Specialized endoscopes can be used to inspect the small bowel (enteroscopes, capsule endoscopes), biliary and pancreatic ductal systems (duodenoscopes, choledochoscopes), as well as the extra-luminal anatomy (echoendoscopes). These devices are used for a wide array of applications including assessment of the mucosa of the gastrointestinal tract, visualization and resection of polyps, management of gastrointestinal bleeding, obtaining tissue samples of extra-luminal organs, and screening for pre-malignant conditions. This chapter describes the design and types of endoscopes, its image-processing capabilities, and the various accessories now being used in clinical practice.

BACKGROUND Conventionally, the low luminous intensity, low image resolution, and difficulty in operation have been reported with the ultrathin endoscope. However, it has markedly advanced recently. The improvement of the diagnostic ability is expected. AIM To compare the early gastric cancer diagnostic ability of an ultrathin endoscope loaded with a laser light source and that of the conventional endoscope. METHODS The target subjects were 375 consecutive patients who underwent endoscopy at our hospital for post-endoscopic submucosal dissection follow-up of gastric cancer from January to August 2018. During endoscopy, the ultrathin endoscope was used in 140 patients (37.3%), and the conventional endoscope was used in 235 patients (62.7%). Patient background was adjusted using the propensity score matching method, and gastric cancer detection ability was evaluated in the two groups. RESULTS The gastric cancer detection rate was 7.8% in the ultrathin endoscope group and 7.0% in the conventional endoscope group, and the mean intragastric observation time was 4.1 ± 1.7 min in the ultrathin endoscope group and 4.1 ± 1.9 min in the conventional endoscope group, showing no significant differences between the groups. Moreover, the biopsy implementation rate was 31.8% in the ultrathin endoscope group and 41.1% in the conventional endoscope group, and the biopsy prediction rate was 17.9% and 13.2%, respectively, showing no significant differences between the groups. CONCLUSION The gastric cancer diagnostic ability of the ultrathin endoscope loaded with a laser light source was comparable to that of the conventional endoscope. The observation time was also comparable. Thus, endoscopy using the ultrathin endoscope loaded with the laser light source would be the first option in screening examinations of gastric cancer due to its low invasion.

Background During a study designed to assess endoscope reprocessing effectiveness, a borescope was used to examine lumens and ports. Cloudy, white, viscous fluid was observed inside fully reprocessed gastroscopes and colonoscopes. This fluid resembled simethicone, which is commonly administered to reduce foam and bubbles that impede visualization during gastrointestinal endoscopy. This article describes methods used to determine whether the observed fluid contained simethicone. Methods Photographs of residual fluid were taken using a borescope. Sterile cotton-tipped swabs were used to collect samples of fluid observed in 3 endoscope ports. Samples were evaluated using Fourier transform infrared spectroscopy (FTIR)–attenuated total reflection analysis. Results Residual fluid was observed inside 19 of 20 endoscopes. Fluid photographed in 8 endoscopes resembled simethicone solutions. FTIR analysis confirmed the presence of simethicone in 2 endoscopes. Conclusions Fluid containing simethicone remained inside endoscopes despite reprocessing. Simethicone is an inert, hydrophobic substance that may reduce reprocessing effectiveness. Simethicone solutions commonly contain sugars and thickeners, which may contribute to microbial growth and biofilm development. Studies are needed to assess the prevalence of residual moisture and simethicone in endoscopes and determine the impact on reprocessing effectiveness. We recommend minimizing the use of simethicone pending further research into its safety.

BACKGROUND The clinical utility of performing esophagogastroduodenoscopy (EGD) before linear endoscopic ultrasonography (L-EUS) to evaluate the luminal upper gastrointestinal (GI) tract is not well established. GOALS The study was aimed to determine the prevalence of clinically meaningful luminal abnormalities (any luminal finding requiring further evaluation with mucosal biopsy or initiation of treatment) in patients undergoing L-EUS. The study also sought to compare the ability of the gastroscope and the linear echoendoscope in identifying these lesions. STUDY A prospective, multicenter cohort study enrolled patients undergoing L-EUS for nonluminal indications. All patients underwent EGD followed by L-EUS by 2 different endoscopists. The second endoscopist was blinded to the results of the initial EGD. The identification of clinically meaningful luminal lesions and quality of endoscopic visualization of the upper GI tract were measured. RESULTS In the cohort of 175 patients, 52 (29.7%) patients had clinically meaningful luminal findings seen in the upper GI tract. There was no significant difference in the number of clinically meaningful lesions identified on EGD and L-EUS (25.1% vs. 22.9%, P=0.39). No significant difference was found in the miss rate of clinically meaningful lesions between the 2 modalities (EGD: 4.5% vs. EUS: 6.9%, P=0.39). CONCLUSIONS A substantial minority of patients undergoing L-EUS for nonluminal indications will have clinically meaningful luminal findings. The endoscopic evaluation of the luminal upper GI tract can be adequately achieved using the linear echoendoscope.

Experts have recommended microbiologic surveillance by external reference laboratories for certain flexible endoscopes. There is currently insufficient evidence on the feasibility and utility of cultures. Researchers evaluated a preassembled toolkit for collecting and processing samples from endoscopes.A pilot study was performed in a large academic medical center. A toolkit was used to aseptically sample biopsy ports and suction/biopsy channels of 5 gastroscopes, 5 colonoscopes, and 5 bronchoscopes after full reprocessing. Blinded specimens were packaged and transported on icepacks to a reference laboratory that used standard methodologies for microbial cultures.The laboratory detected bacteria in samples from 60% of patient-ready endoscopes, including gram-positive and gram-negative species. Viable microbes (10 CFU) were recovered from 2 gastroscopes, 3 colonoscopes, and 4 bronchoscopes. Stenotrophomonas maltophilia and Delftia acidovorans were recovered from all 3 endoscope types. Subsequent environmental testing detected S maltophilia in the reprocessing rinse water.A preassembled toolkit facilitated the aseptic collection of samples for culturing by a reference laboratory that detected viable microbes on fully reprocessed endoscopes. Speciation allowed identification of potential pathogens and a possible common contamination source, demonstrating that microbial cultures may have value even when colony counts are low.

Background and study aims: The increasing demand for endoscopic procedures poses new contamination challenges, given developing antimicrobial resistance worldwide and potential viral or prion diseases in populations at risk. We examined working channels from reusable luminal endoscopes used in recent years. Methods: Very sensitive fluorescence epimicroscopy was used to examine working channels from 6 decommissioned and 6 factory-new channels, as received, or following spiking and washing in the laboratory. Results: After a single contamination and wash test cycle, new channels retained approximately 75 pg/mm 2 of proteins; through 7 subsequent cycles residual proteins fluctuated between 25 and 75 pg/mm 2 . Decommissioned channels harbored 1 – 4 µg of proteins each, except in one gastroscope (33 µg), including up to 2 % amyloid proteins except in one gastroscope and one sigmoidoscope (with over 80 %); lumens showed wearing with established abraded biofilms in 3 cases. After spiking with scrapie-infected blood components and washing, residual protein levels in new channels varied following standard (17.23 pg/mm 2 ), duplicated (2.39 pg/mm 2 ) or extended (11.3 pg/mm 2 ) washing; no changes were measured among the long-established contamination in old channels. Conclusions: Our observations suggest that wear effects in endoscope lumens may contribute to the adsorption of proteins, thus facilitating retention and survival of bacteria. As demonstrated by recent outbreaks worldwide despite recommended reprocessing, the development of antimicrobial-resistant bacterial strains, and the estimated prevalence of variant Creutzfeldt-Jakob disease (vCJD) in the UK particularly, combined with increasing demand for endoscopic procedures, call for sustained precautions and improved methods for the reprocessing of nonautoclavable, reusable surgical instruments.

To evaluate the feasibility and safety of Roux-en-Y gastrojejunal bypass procedure using a hybrid NOTES-12 mm trocar technique in a survival porcine model.The procedure was carried out on ten pigs. Two gastroscopes were introduced through the mouth and through a 12 mm trocar, respectively. A mechanical circular gastro-jejunal anastomosis was created by introducing a stapler after the trocar incision was enlarged. A 21 mm EEA OrVil circular stapler was utilized in the first six pigs and a 25 mm one was used in the other four. All pigs were fed beginning 24 hours after the procedure and were euthanized three weeks later.The procedure was successfully completed in all ten animals. The mean length of the skin incision was 2.5 cm. All pigs survived without complications. Endoscopic inspection detected anastomotic strictures in 5/6 of the 21 mm-stapler and in 0/4 of the 25 mm-stapler anastomoses (p0.05).Roux-en-Y gastrojejunal bypass using a hybrid NOTES-single 12 mm trocar access technique is a simple and safe procedure in a survival porcine model. Functional results need to be evaluated by further studies.

Complete surgical resection with negative margins without lymphadenectomy is the treatment of choice for nonmetastatic Gastrointestinal Stromal Tumors (GISTs). Laparoscopic resection of gastric GISTs5 cm is an acceptable and oncologically feasible, safe, and effective treatment. We present our experience of an endoscopically assisted minimally invasive transumbilical single-incision laparoscopic (SILS) technique for gastric GISTs resection.Four patients with small gastric GISTs ≤5 cm located on the greater curvature or the anterior wall were resected with SILS by using a lesion-lifting technique under the guidance of flexible gastroscopy.The technique was feasible and safe and offered significant advantages in locating the tumor and controlling the resection margins. There were no major intraoperative or postoperative complications, conversions, or tumor ruptures. Pathology showed low-risk GISTs resected with disease-free margins without tumor rupture. No recurrences have been observed.The endoscopically assisted SILS wedge gastrectomy is a feasible, safe, and advantageous technique for the treatment of the greater curvature or anterior wall gastric GISTs.

Systematically assessing the safety and effectiveness of spraying rhubarb powder solution under gastroscope for the treatment of acute non-varicose upper gastrointestinal bleeding, and confirmation for further clinical research and application.We searched the following databases up till November 2019: PubMed, the Cochrane Library, EMBASE, CNKI, WanFang Data, VIP and SinoMed. Randomized controlled trials (RCTs) were used to compare the curative effect of spraying rhubarb powder solution with other drugs under gastroscope for the treatment of acute non-varicose upper gastrointestinal bleeding.Out of 171 articles, 14 RCTs involving 1493 patients were included. All control groups included in the RCTs were treated with norepinephrine solution. The hemostatic effect of spraying rhubarb powder solution under gastroscope was examined for 24 h at high concentration (0.1 g/mL). The hemostatic effect at higher conc. (0.1 g/mL) found far more better than low conc.(RR = 1.48;95 %CI:1.25,1.75;P﹤0.00001) (0.03 g/mL)as homeostatic effect at low conc.is same that of norepinephrine solution (RR = 1.02;95 %CI:0.94,1.10;P = 0.62). Moreover within 48 h, rhubarb powder solution with 0.1 g/mL or 0.15 g/mL conc. have of significantly higher hemostatic effects than norepinephrine solution (RR = 1.18;95 % CI: 1.08, 1.30;P = 0.0003). Occurrence of rebleeding event within 48 h after successful hemostasis (RR = 0.42;95 %CI:0.24,0.74;P = 0.003) reduced exceptionally. After that the hemostatic effect of rhubarb powder solution with 0.1 g/mL conc.examined within 72 h again exhibited significant improvement than norepinephrine solution (RR = 1.19;95 %CI:1.12,1.26;P 0.00001). On par with immediate hemostasis time, rhubarb powder solution took unprecedented less time than norepinephrine solution;(MD=-5.56S;95 %CI:-6.16, -4.95;P﹤0.00001). Additionally, the adverse reaction produced by rhubarb powder solution is much lower than norepinephrine solution (RR = 0.22;95 %CI:0.11,0.42;P 0.00001).According to meta-analysis, Spraying rhubarb powder solution under gastroscope in the treatment of acute non-varicose upper gastrointestinal bleeding is superior to norepinephrine solution in improving hemostasis effect. Shortening immediate hemostasis time and reducing rebleeding,and is safe to use. Based on the results of this study, physicians can treat patients with acute non-varicose upper gastrointestinal bleeding by spraying rhubarb powder solution under gastroscope according to the patients' condition.However, the sample size included in this study is small and of substandard quality qu, and a large sample size clinical trial with strict design and normative report is needed to verify the safety and efficacy of rhubarb powder solution under gastroscope for acute non-varicose upper gastrointestinal bleeding.

Researchers evaluated flexible endoscope damage and contamination levels at baseline and 2 months later. Postcleaning test results exceeded benchmarks for all gastroscopes and no colonoscopes. Microbial growth was found in samples from 47% of fully reprocessed endoscopes at baseline and 60% at follow-up. Borescope examinations identified scratches, discoloration, debris, and fluid inside endoscopes. Irregularities changed over time. Study evaluations allowed damaged and contaminated endoscopes to be identified and re-reprocessed or sent for repairs.

Background & Aims: The aim of this study is to present the experience of our center over the last 8 years in a series of patients with Zenker’s diverticulum (ZD), treated using an endoscopic, minimally invasive procedure. Methods: We retrospectively included 31 patients with a previously established diagnosis of ZD based on endoscopic and oral contrast examinations. Patients’ age, comorbidities, size of the diverticulum or previous endoscopic treatment were not considered exclusion criteria. A soft, flexible diverticuloscope to expose the septum and a dual knife for “cutting” the diverticular septum were used. We analyzed the short term efficacy based on symptomatic relief and occurrence of side effects, and long term efficiency at 6 and 12 months by clinical assessment, upper gastrointestinal endoscopy and oral contrast media passage. Results: Patients had a mean age of 67 years (range 42-86); 55% of them were male. All patients reported symptom relief after the procedure. A decrease of more than 70% from the initial size of the diverticulum was noted. There were 3 cases (9.67%) of intraprocedural hemorrhage, endoscopically managed. No serious post-procedural complications and no mortality were reported. The mean procedural time was 21.87 minutes (range 15-25 minutes). Average hospitalization was 2.5 days. Five patients developed recurrence and needed a second session of endoscopic treatment for achieving complete myotomy. Conclusions: Endoscopic management for ZD was efficient and safe in our series of patients. A short hospitalization period was required.

Background Endoscopic examination and therapy carry a potential risk of cross-infection, and the traditional reprocessing method is time-consuming. Here we reported a novel disposable sheathed gastroscope system and evaluated its efficacy in endoscopic therapy. Methods The disposable sheathed gastroscope system used in this study consisted of a disposable sheath and a common video gastroscope, which were both provided by Shenda Endoscope Co., Ltd., Shenyang, China. The sterilised disposable sheath covered the outer surface of the gastroendoscope. An outlaid disposable air-water pipe (still covered by the sheath) and a miniature pump instead of the gastroscopic air-water channel were used for sending air and water. A flexible pipe, with one end tightly connected to the distal tip of covering film, was inserted into the gastroscopic suction-biopsy channel and joined to a three-way cap. This pipe was used as the disposable suction-biopsy channel. After examination and therapy, the contaminated sheath, including pipes and valves, was taken off and a new sheath was put on. Using this sheathed gastroscope system, 78 patients with gastric hyperplastic polyps underwent endoscopic mucosal resection in Beijing Military General Hospital. As a control, 76 patients with similar polyps underwent endoscopic resection with a conventional gastroscope. The time duration of the endoscopic procedure and reprocessing were measured. Results All 154 procedures were completed by using each gastroscope system. No complications were seen during or after the procedures. The endoscopists who performed the procedures felt the sheath did not affect the operation at all, and all endoscopists had no preference for sheathed versus conventional gastroscopes in endoscopic procedures. The mean procedural time was slightly longer in the Sheathed Group than in the Conventional Group (8.9±2.2 vs. 8.1±1.5 mins, p=0.000). However, the duration of endoscopic reprocessing was much shorter (4.9±0.2 vs. 35±0.2 mins, p=0.000). No microbial contamination was detected in each gastroscope after procedures. Conclusions The novel disposable sheathed gastroscope should be suitable for endoscopic therapy.

Background and Aims Visual inspection of the instrument channel has been proposed as a quality assurance step during endoscope reprocessing. However, the nature and severity of findings in a broad array of endoscopes (gastroscopes, colonoscopes, duodenoscopes, and echoendoscopes) after systemic implementation of an inspection protocol remain unknown. In addition, a study using borescope inspection in upper endoscopes and colonoscopes raised concerns about persistent simethicone residue despite full reprocessing. Methods A pilot inspection study using a prototype borescope (SteriCam Inspection Scope; SteriView Inc, San Rafael, Calif) was performed on routinely used endoscopes after high-level disinfection, manual forced-air dry of the instrument channel, and overnight vertical storage. Video recordings 1.5 to 2 minutes in duration were reviewed for visible moisture, debris, discoloration, scratches, channel shredding (scratches that result in strips or filaments of the channel lining protruding into the lumen), and visible evidence of biofilm or simethicone residue. Results A total of 97 inspections of 59 endoscopes were reviewed. The most common finding was scratches, seen in 51 devices (86%). Channel shredding was found in 35 devices (59%). Intrachannel debris was identified in 22 (23%) of the 97 inspections. No moisture was seen (0%) in the 74 inspections performed after forced-air dry and overnight vertical storage compared with moisture in 5 of 18 inspections (28%) performed after storage alone. No visual evidence of biofilm or simethicone residue was discovered despite its frequent use in our unit. Conclusion Internal defects of the instrument channel appear to occur frequently. Manual forced-air drying of the channel appears to be highly effective in eliminating moisture compared with overnight hang drying alone. Video inspection of the endoscope channel may be useful to audit reprocessing performance and to identify damaged endoscopes.

With the development of a sub-specialty focused on pediatric gastrointestinal disorders, new technologies such as pediatric endoscopy were developed for diagnostic and therapeutic aims. Current endoscopic technology permits safe visualization, tissue sampling, and therapeutic procedures. Outer tip and working channel diameters have the greatest importance in the selection of an endoscope for the smaller children. The use of a smaller endoscope could represent the limiting element for the use of accessories, which are needed primarily for therapeutic purposes. Gastroscopes with outer diameters ranging from 4.9 to 12.8 mm are at present available, and colonoscopes range from 9.8 to 13.3 mm. Working channel diameters range from 1.5 mm of the slimmest instruments up to 4.2 mm of the largest adult therapeutic endoscopes. In 2017, the European Society of Gastrointestinal Endoscopy (ESGE) and European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) published the executive summary of the Guideline on pediatric gastrointestinal endoscopy that refers to infants, children, and adolescents aged 0–18 years.

Purpose Endoscopic placement of self-expandable metal stents (SEMSs) to relieve malignant colorectal obstruction has been widely accepted in clinical practice. Despite increasing experience, early and late complications occur with an incidence ranging from 4% to 20%. Materials and methods We have adopted a modification in the technique. A pediatric nasogastroscope (4.8 mm in diameter) has been used to pass the obstruction. It is possible to have a direct vision of the anatomy and pathology, and to pass the guidewire above the obstruction, through the nasogastroscope, under direct vision. Fluoroscopy was also used to follow the course of the guidewire and deployment of the stent. Results Early and late complications have been reduced with the new technique. Conclusions In the most recent experience of 64 patients, early and late complications have been reduced significantly. This new technique reduces radiation exposure by 70% for the patients and for the operators.

International audience

Endoscopic full-thickness resection (EFTR) is a "changing-concept" endoscopic resection technique, which safely allows resecting deep submucosal tumors (SMTs) in the gastrointestinal (GI) wall. It's a highly promising endoscopic procedure that allows full-thickness excision of a small piece of the complete GI wall by using only a flexible endoscope. EFTR is a meeting point between surgery and endoscopy and probably the onset of many prospective combined minimally invasive therapeutic techniques that science will explore. In this review, use of the EFTR technique for gastrointestinal SMTs is highlighted, focusing on some technical aspects, indications, contraindications and outcomes.

Background Pathogens have been transmitted via flexible endoscopes that were reportedly reprocessed in accordance with guidelines. Methods Researchers observed reprocessing activities to ensure guideline compliance in a large gastrointestinal endoscopy unit. Contamination was assessed immediately after bedside cleaning, manual cleaning, high-level disinfection, and overnight storage via visual inspection, aerobic cultures, and tests for adenosine triphosphate (ATP), protein, carbohydrate, and hemoglobin. Results All colonoscopes and gastroscopes were reprocessed in accordance with guidelines during the study. Researchers collected and tested samples during 60 encounters with 15 endoscopes. Viable microbes were recovered from bedside-cleaned (92%), manually cleaned (46%), high-level disinfected (64%), and stored (9%) endoscopes. Rapid indicator tests detected contamination (protein, carbohydrate, hemoglobin, or ATP) above benchmarks on bedside-cleaned (100%), manually cleaned (92%), high-level disinfected (73%), and stored (82%) endoscopes. Visible residue was never observed on endoscopes, but it was often seen on materials used to sample endoscopes. Seven endoscopes underwent additional reprocessing in response to positive rapid indicators. Control endoscope channels were free of biologic residue and viable microbes. Conclusion Despite reprocessing in accordance with US guidelines, viable microbes and biologic debris persisted on clinically used gastrointestinal endoscopes, suggesting current reprocessing guidelines are not sufficient to ensure successful decontamination.

Background Insufficient data exist for how long endoscopes can be stored after reprocessing. Concern about possible microbial colonization has led to various recommendations for reprocessing intervals among institutions, with many as short as 5 days. A significant cost savings could be realized if it can be demonstrated that endoscopes may be stored for as long as 21 days without risk of clinically significant contamination. Objective To demonstrate whether flexible endoscopes may be stored for as long as 21 days after reprocessing without colonization by pathogenic microbes. Design Prospective, observational study. Setting Tertiary care center. Endoscopes Four duodenoscopes, 4 colonoscopes, and 2 gastroscopes. Intervention Microbial testing of endoscope channels. Main Outcome Measurements Culture results at days 0, 7, 14, and 21. Results There were 33 positive cultures from 28 of the 96 sites tested (29.2% overall contamination rate). Twenty-nine of 33 isolates were typical skin or environmental contaminants, thus clinically insignificant. Four potential pathogens were cultured, including Enterococcus , Candida parapsilosis , α-hemolytic Streptococcus , and Aureobasidium pullulans ; all were likely clinically insignificant as each was only recovered at 1 time point at 1 site, and all grew in low concentrations. There were no definite pathogenic isolates. Limitations Single center. Conclusion Endoscopes can be stored for as long as 21 days after standard reprocessing with a low risk of pathogenic microbial colonization. Extension of reprocessing protocols to 21 days could effect significant cost savings.

Background and study aim: Endoscopic retrograde cholangiopancreatography (ERCP) is difficult in patients with altered anatomy following Billroth II gastrectomy. Afferent loop intubation, selective cannulation, and sphincterotomy are the main issues. Experience from a tertiary referral endoscopy center is reported. Patients and methods: A total of 713 patients with Billroth II reconstruction who underwent ERCP between October 1982 and October 2012 were retrospectively identified from a prospectively collected database (mean age 69 ± 27 years; 567 males). The main indications for ERCP were common bile duct stones (51.2 %) and obstructive jaundice (24.8 %). Procedures were always started with a duodenoscope; in cases of failure to reach the papilla the duodenoscope was changed to a gastroscope. Endoscopic sphincterotomy was performed using a long-nose sigmoid inverted sphincterotome. Results: The successful duodenal intubation rate was 86.7 % (618/713 patients). The main reason for intubation failure was a long and angulated afferent loop. Successful cannulation/opacification of the desired biliopancreatic duct was 93.8 % (580/618). Biliary and/or pancreatic sphincterotomy were performed in 490 (84.5 %) and 23 (4.0 %) patients, respectively. The adverse event rate was 4.3 % (45/1050 procedures). Peritoneal perforation occurred in 1.8 % of the cases (19/1050 procedures) and always required immediate surgery. Two patients died after surgery (overall mortality 0.3 %). The other adverse events resolved following conservative management or endoscopic reintervention. Conclusions: In experienced centers, ERCP in Billroth II patients had morbidity and mortality rates that were comparable to patients with normal anatomy. The main reasons for failure were related to the inability to reach the papilla. Peritoneal perforation was the most common adverse event, and required a prompt surgical approach.

In this series of four patients, some modifications of the standard over-the-wire (OTW) technique for stent deployment using the balloon overtube normally used in single-balloon enteroscopy are presented. This modified technique allowed the use of OTW stents in patients where there were difficulties that meant the standard technique was unsuccessful. For each patient, the authors describe different small novel adaptations of this modified technique that enabled self-expanding metal stents (SEMSs) and biodegradable stents to be successfully deployed in different gastrointestinal locations. Moreover, in one patient the stent was placed without fluoroscopic guidance.

Background The present study aimed to assess the efficacy of computer-based endoscope cleaning and disinfection using a hospital management information system (HMIS). Methods A total of 2,674 gastroscopes were eligible for inclusion in this study. For the processes of disinfection management, the gastroscopes were randomly divided into 2 groups: gastroscope disinfection HMIS (GD-HMIS) group and manual group. In the GD-HMIS group, an integrated circuit card (IC card) chip was installed to monitor and record endoscope cleaning and disinfection automatically and in real time, whereas the endoscope cleaning and disinfection in the manual group was recorded manually. The overall disinfection progresses for both groups were recorded, and the total operational time was calculated. Results For the GD-HMIS group, endoscope disinfection HMIS software was successfully developed. The time to complete a single session of cleaning and disinfecting on a gastroscope was 15.6 minutes (range, 14.3-17.2 minutes) for the GD-HMIS group and 21.3 minutes (range, 20.2-23.9 minutes) for the manual group. Failure to record information, such as the identification number of the endoscope, occasionally occurred in the manual group, which affected the accuracy and reliability of manual recording. Conclusions Computer-based gastroscope cleaning and disinfection using a hospital management information system could monitor the process of gastroscope cleaning and disinfection in real time and improve the accuracy and reliability, thereby ensuring the quality of gastroscope cleaning and disinfection.

Obesity is a burgeoning problem in China with potential for significant adverse economic and health consequences if not addressed. Unfortunately, the body mass index (BMI) targets used in the West are not applicable to China as Asians have visceral adiposity and thus develop complications of obesity at a lower BMI. Recent studies suggest using lower BMI targets for defining overweight and obesity and to qualify patients for bariatric surgery. Diet, exercise and pharmacology have been the foundation for treatment in those not meeting criteria for bariatric surgery, despite modest weight loss that is poorly sustained over time. The large majority in China are averse to bariatric surgery and thus endoscopic bariatric therapy is emerging as an illustrious remedy to fill this gap. Of the current procedures available endoscopic sleeve gastroplasty has shown the most promise due to the significant and sustained weight loss it produces coupled with the ease of execution and lower cost. The procedure is performed under general anesthesia using a full-thickness endoscopic suturing device and patients are discharged the same day. The mean procedure time in experienced hands is 60 minutes. Due to the repetitive nature of the procedure, the learning curve is steep. Data thus far demonstrate total body weight loss to be 16-20% at 12 months. The safety profile is excellent with a low morbidity rate seen in the 3 000 procedures performed worldwide. Therefore, widespread dissemination in China is expected with the potential to help millions of obese patients.