Search

Since inception in 1968, biliary endoscopic retrograde cholangiopancreatography (ERCP) has transformed into a highly effective, minimally invasive modality for the identification and treatment of a variety of biliary pathologies including benign, malignant, and iatrogenic diseases. The diagnostic role of ERCP has been largely replaced by high-quality imaging modalities including endoscopic ultrasound and magnetic resonance cholangiopancreatography. However, there continues to be significant demand for therapeutic procedures. This article reviews the general principles of ERCP, as well as common indications, contraindications, and potential adverse events with which endoscopists and referring physicians should be familiar., Competing Interests: Disclosure J.P. AbiMansour and J A. Martin has none., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Consumer facing wearable devices capture significant amounts of biometric data. The primary aim of this study is to determine the accuracy of consumer-facing wearable technology for continuous monitoring compared to standard anesthesia monitoring during endoscopic procedures. Secondary aims were to assess patient and provider perceptions of these devices in clinical settings., Methods: Patients undergoing endoscopy with anesthesia support from June 2021 to June 2022 were provided a smartwatch (Apple Watch Series 7, Apple Inc., Cupertino, CA) and accessories including continuous ECG monitor and pulse oximeter (Qardio Inc., San Francisco, CA) for the duration of their procedure. Vital sign data from the wearable devices was compared to in-room anesthesia monitors. Concordance with anesthesia monitoring was assessed with interclass correlation coefficients (ICC). Surveys were then distributed to patients and clinicians to assess patient and provider preferences regarding the use of the wearable devices during procedures., Results: 292 unique procedures were enrolled with a median anesthesia duration of 34 min (IQR 25-47). High fidelity readings were successfully recorded with wearable devices for heart rate in 279 (95.5%) cases, oxygen in 203 (69.5%), and respiratory rate in 154 (52.7%). ICCs for watch and accessories were 0.54 (95% CI 0.46-0.62) for tachycardia, 0.03 (95% CI 0-0.14) for bradycardia, and 0.33 (0.22-0.43) for oxygen desaturation. Patients generally felt the devices were more accurate (56.3% vs. 20.0% agree, p  < 0.001) and more permissible (53.9% vs. 33.3% agree, p  < 0.001) to wear during a procedure than providers., Conclusion: Smartwatches perform poorly for continuous data collection compared to gold standard anesthesia monitoring. Refinement in software development is required if these devices are to be used for continuous, intensive vital sign monitoring., Competing Interests: VC is a consultant for Covidien LP and Boston Scientific, receives research funding from Micro-tech Endoscopy and is a shareholder at Nevakar Corporation. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 AbiMansour, Kaur, Velaga, Vatsavayi, Vogt and Chandrasekhara.)

Competing Interests: Dr Law is a consultant for Olympus, Boston Scientific, ConMed, and Boston Scientific. He receives research support from Olympus and Boston Scientific. He also receives royalties from UpToDate. All other authors disclosed no financial relationships relevant to this publication.

Background and Aims: Coaxial double-pigtail plastic stent (DPPS) placement is often performed within lumen-apposing metal stents (LAMSs) for drainage of pancreatic fluid collections (PFCs) to prevent adverse events (AEs) such as stent occlusion and bleeding. This study compares the safety and outcomes of LAMSs alone versus LAMSs with coaxial DPPSs for PFC management., Methods: Patients undergoing drainage of a PFC with LAMSs were retrospectively identified and categorized as LAMS or LAMS/DPPS based on initial drainage strategy. The AE rate, AE type, and clinical success were extracted by chart review., Results: One hundred eighty-five individuals (83 LAMS, 102 LAMS/DPPS) were identified. No significant differences were found in rates of clinical success (75.9% LAMS vs 69.6% LAMS/DDPS, P = .34) or overall AEs (15.7% LAMS vs 15.7% LAMS/DPPS, P = .825)., Conclusions: In this comparative single-center study, placement of a coaxial DPPS for drainage of PFCs with LAMSs did not affect rates of AEs or clinical success., Competing Interests: Disclosure The following authors disclosed financial relationships: R. Law: Consultant for ConMed and Medtronic; royalties from UpToDate. A. C. Storm: Consultant for Apollo Endosurgery; research support from Apollo Endosurgery and Boston Scientific. B. T. Petersen: Consultant for Olympus America; investigator for Boston Scientific and Ambu. B. K. Abu Dayyeh: Consultant for Endogenex, Endo-TAGSS, Metamodix, BFKW, USGI, Apollo Endosurgery, Medtronic, Spatz Medical, EndoGastric Solutions, Aspire Bariatrics, and Boston Scientific; research support from Cairn Diagnostics, USGI, Apollo Endosurgery, Medtronic, Spatz Medical, EndoGastric Solutions, Aspire Bariatrics, and Boston Scientific; speaker for Olympus and Johnson & Johnson. V. Chandrasekhara: Consultant for Covidien LP and Boston Scientific; shareholder in Nevakar Corporation. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aim: Self-expandable metal stents (SEMSs) are widely used for palliation of distal malignant biliary obstruction (dMBO). However, previous studies comparing the outcomes between uncovered SEMSs (UCSEMSs) and fully covered SEMSs (FCSEMSs) report conflicting results. This large cohort study aimed to compare the clinical outcomes between UCSEMSs and FCSEMSs for dMBO., Methods: A retrospective cohort study was performed in patients with dMBO who underwent either UCSEMS or FCSEMS placement between May 2017 and May 2021. Primary outcomes were rates of clinical success, adverse events (AEs), and unplanned endoscopic reintervention. Secondary outcomes were types of AEs, intervention-free stent patency, and management and outcomes of stent occlusion., Results: The cohort included 454 patients (364 in the UCSEMS group and 90 in the FCSEMS group). Median follow-up duration was 9.6 months and was similar between the 2 groups. Use of UCSEMSs and FCSEMSs had comparable clinical success (P = .250). However, use of UCSEMSs had significantly higher rates of AEs (33.5% vs 21.1%; P = .023) and unplanned endoscopic reintervention (27.0% vs 11.1%; P = .002). UCSEMSs had a higher rate of stent occlusion (26.9% vs 8.9%; P < .001) and shorter median time to stent occlusion (4.4 months vs 10.7 months; P = .002). Stent reintervention-free survival was higher in the FCSEMS group. FCSEMSs had a significantly higher rate of stent migration (7.8% vs 1.1%; P < .001), but patients in the FCSEMS group had similar rates of cholecystitis (.3% vs 1.1%; P = .872) and post-ERCP pancreatitis (6.3% vs 6.6%; P = .90). When UCSEMSs did occlude, placement of a coaxial plastic stent had a higher rate of stent reocclusion compared with coaxial SEMS placement (46.7% vs 19.7%; P = .007)., Conclusion: FCSEMSs should be considered for the palliation of dMBO because of lower rates of AEs, longer patency rates, and lower rates of unplanned endoscopic intervention., (Copyright © 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Reports suggest that the rate of adverse events (AEs) post-endoscopic sphincterotomy (ES) to be as high as 10%, with gastrointestinal bleeding being most common after post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis., Objective: The aim of this study was to characterize the incidence of bleeding in patients with thrombocytopenia following ES., Design: Retrospective observational cohort study., Methods: Patients with thrombocytopenia (defined as <150,000 platelets/μL) who underwent ES between May 2017 and December 2020 were identified at a tertiary care medical center. The incidence of immediate (intraprocedural oozing >5 min or requiring intervention) or delayed (clinical bleeding with associated hemoglobin drop within 14 days) post-ES bleeding was determined via manual chart review., Results: A total of 221 patients with a mean platelet count of 108,000 ± 13,000 platelets/μL underwent ERCP with ES. Immediate bleeding occurred in 11 (5%) patients with no significant drop in hemoglobin or transfusion requirement. Two patients (0.9%), both of whom were noted to have immediate bleeding, also developed delayed bleeding. Presence of malignancy was associated with an increased risk of bleeding (36.4% versus 11.4%, p  = 0.037) while platelet count was not., Conclusion: In a cohort of patients with thrombocytopenia, rates of immediate and delayed bleeding are similar to previously reported AE rates of ES in the general patient population. Careful attention should be given to patients with a history of active malignancy as well as those who develop immediate bleeding as they appear to be at increased risk for bleeding complications., Competing Interests: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: ACS is a consultant for Apollo Endosurgery and received research support from Apollo Endosurgery and Boston Scientific. RL is a consultant for ConMed and Medtronic and receives royalties from UpToDate. BP is a consultant for Olympus America and investigator for Boston Scientific and Ambu. BKA reports consultant roles with Endogenex, Endo-TAGSS, Metamodix, and BFKW; consultant and grant or research support from USGI, Cairn Diagnostics, Aspire Bariatrics, and Boston Scientific; speaker roles with Olympus, Johnson and Johnson; speaker and grant or research support from Medtronic, Endogastric Solutions; and research support from Apollo Endosurgery and Spatz Medical. VC is a consultant for Covidien LP, is on the advisory board for Interpace Diagnostics, and is a shareholder in Nevakar, Inc. The remaining authors have no conflicts or funding to disclose., (© The Author(s), 2023.)

Background: Post-operative pancreatic fluid collections (POPFCs) can be drained using percutaneous or endoscopic approaches. The primary aim of this study was to compare rates of clinical success between endoscopic ultrasound-guided drainage (EUSD) with percutaneous drainage (PTD) in the management of symptomatic POPFCs after distal pancreatectomy. Secondary outcomes included technical success, total number of interventions, time to resolution, rates of adverse events (AEs), and POPFC recurrence., Methods: Adults who underwent distal pancreatectomy from January 2012 to August 2021 and developed symptomatic POPFC in the resection bed were retrospectively identified from a single academic center database. Demographic data, procedural data, and clinical outcomes were abstracted. Clinical success was defined as symptomatic improvement and radiographic resolution without requiring an alternate drainage modality. Quantitative variables were compared using a two-tailed t-test and categorical data were compared using Chi-squared or Fisher's exact tests., Results: Of 1046 patients that underwent distal pancreatectomy, 217 met study inclusion criteria (median age 60 years, 51.2% female), of whom 106 underwent EUSD and 111 PTD. There were no significant differences in baseline pathology and POPFC size. PTD was generally performed earlier after surgery (10 vs. 27 days; p < 0.001) and more commonly in the inpatient setting (82.9% vs. 49.1%; p < 0.001). EUSD was associated with a significantly higher rate of clinical success (92.5% vs. 76.6%; p = 0.001), fewer median number of interventions (2 vs. 4; p < 0.001), and lower rate of POPFC recurrence (7.6% vs. 20.7%; p = 0.007). AEs were similar between EUSD (10.4%) and PTD (6.3%, p = 0.28), with approximately one-third of EUSD AEs due to stent migration., Conclusion: In patients with POPFCs after distal pancreatectomy, delayed drainage with EUSD was associated with higher rates of clinical success, fewer interventions, and lower rates of recurrence than earlier drainage with PTD., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Aims: Percutaneous gallbladder drainage has traditionally been the reference standard treatment for cholecystitis in patients deemed unfit for surgery. Endoscopic transpapillary gallbladder drainage has emerged as a reliable alternative that offers an internal, incisionless option in nonsurgical patients. The aim of this study was to describe techniques for successful selective cystic duct cannulation and gallbladder drainage during ERCP., Methods: A series of endoscopic transpapillary gallbladder procedures is shown, including endoscopic and fluoroscopic video and images. Each case highlights best practices, devices, and techniques to aid with successful completion of challenging cases., Results: Standard cystic duct cannulation and gallbladder access is described using a standard catheter and a 0.035-inch angled guidewire. Challenges to selective cystic duct cannulation are overcome using various approaches, including using a rotatable catheter system, downsizing to a smaller guidewire, occluding the proximal common hepatic duct with an occlusion balloon, and directly intubating the cystic duct using peroral cholangioscopy. Dilation of the cystic duct is performed using standard devices designed for biliary intervention, but smaller, percutaneous angioplasty balloons are used for small ducts and severe strictures. After dilation, a plastic, double-pigtail stent is deployed across the papilla, and access is reobtained in a similar fashion to place a second, parallel stent. To eliminate the need to re-access the gallbladder after initial stent deployment, a cytology brush catheter is repurposed to obtain dual-wire access within the gallbladder before initial stent deployment., Conclusions: When the fundamentals of ERCP and the techniques described here are used, endoscopic transpapillary gallbladder drainage can be performed safely and effectively to treat cholecystitis in patients who are not surgical candidates., (© 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Competing Interests: Competing interests Dr. Storm has received research grant support from Apollo Endosurgery, Boston Scientific, Endogenex, Endo-TAGSS and Enterasense and is a consultant for Apollo Endosurgery, Boston Scientific, ERBE Elektromedizin, GI Dynamics, Intuitive Surgical and Olympus. Dr. Rajan has intellectual property with Medtronic and Ruhoff Corporation and is a consultant for Olympus and Ethicon.

Video 1Use of a novel, on-demand overtube to perform a targeted right colonic enema and improve suboptimal bowel preparation., (© 2022 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Background and study aims  A percutaneous intragastric trocar (PIT) enables intraluminal use of laparoscopic tools and helps overcome traditional limitations of endoscopy. The aim of this study was to determine the efficacy of using a PIT to perform an anti-reflux stapling procedure. Materials and methods  Trocars were placed in four animals and an articulating stapler was used to perform fundoplication under endoscopic guidance. Animals were monitored for 14 days post-procedure. Functional lumen imaging of the esophagogastric junction (EGJ) was performed at baseline, immediately post-intervention, and at 14 days. Results  The procedure was successful in all animals who survived to day 14 without distress or significant adverse events. Baseline EGJ distensibility was 5.0 ± 1.2 mm 2 /mmHg, 2.7 ± 0.7 mm 2 /mmHg post-procedurally, and 3.0 ± 0.8mm 2 /mmHg on day 14. Average change in distensibility pre- and post-procedure was -2.3 ± 1.8 mm 2 /mmHg (95 % confidence interval [CI] -0.5 to 5.1, P  = 0.08) while change in pre- and day 14 distensibility was -2.0 ± 1.4 mm 2 /mmHg (95 % CI -0.1 to 4.2, P  = 0.06). Conclusions  An intragastric trocar allows for use of large-diameter laparoscopic instruments to safely and effectively perform endoluminal fundoplication with anti-reflux properties that persist for at least 14 days., Competing Interests: Competing interests Dr. Abu Dayyeh reports consultant roles with Endogenex, Endo-TAGSS, Metamodix, and BFKW; consultant and grant or research support from USGI, Cairn Diagnostics, Aspire Bariatrics, Boston Scientific; speaker roles with Olympus, Johnson and Johnson; speaker and grant or research support from Medtronic, Endogastric solutions; and research support from Apollo Endosurgery and Spatz Medical. Dr. Storm has received research grant support from Apollo Endosurgery, Boston Scientific, Endogenex, Endo-TAGSS, and Enterasense. He is a consultant for Apollo Endosurgery, ERBE, GI Dynamics, Intuitive Surgical, and Olympus. The remaining authors have no conflicts to disclose., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: Endoscopic ultrasound (EUS)-guided main pancreatic duct (PD) access may be used when conventional endoscopic retrograde cholangiopancreatography (ERCP) techniques fail. The use of a percutaneous transluminal angioplasty balloon (PTAB), originally developed for vascular interventions, can be used to facilitate transmural ( e.g. , transgastric) PD access and to dilate high-grade pancreatic strictures., Aim: To describe the technique, efficacy, and safety of PTABs for EUS-guided PD interventions., Methods: Patients who underwent EUS with use of a PTAB from March 2011 to August 2021 were retrospectively identified from a tertiary care medical center supply database. PTABs included 3-4 French angioplasty catheters with 3-4 mm balloons designed to use over a 0.018-inch guidewire. The primary outcome was technical success. Secondary outcomes included incidence of adverse events (AEs) and need for early reintervention., Results: A total of 23 patients were identified (48% female, mean age 55.8 years). Chronic pancreatitis was the underlying etiology in 13 (56.5%) patients, surgically altered anatomy (SAA) with stricture in 7 (30.4%), and SAA with post-operative leak in 3 (13.0%). Technical success was achieved in 20 (87%) cases. Overall AE rate was 26% ( n = 6). All AEs were mild and included 1 pancreatic duct leak, 2 cases of post-procedure pancreatitis, and 3 admissions for post-procedural pain. No patients required early re-intervention., Conclusion: EUS-guided use of PTABs for PD access and/or stricture management is feasible with an acceptable safety profile and can be considered in patients when conventional ERCP cannulation fails., Competing Interests: Conflict-of-interest statement: Andrew C Storm is a consultant for Apollo Endosurgery; and received research support from Apollo Endosurgery and Boston Scientific. Ryan J Law is a consultant for ConMed and Medtronic and receives royalties from UpToDate. Bret T Petersen is a consultant for Olympus America and investigator for Boston Scientific and Ambu. Barham K Abu Dayyeh reports consultant roles with Endogenex, Endo-TAGSS, Metamodix, and BFKW; consultant and grant or research support from USGI, Cairn Diagnostics, Aspire Bariatrics, Boston Scientific; speaker roles with Olympus, Johnson and Johnson; speaker and grant or research support from Medtronic, Endogastric solutions; and research support from Apollo Endosurgery and Spatz Medical. Vinay Chandrasekhara is a consultant for Covidien LP, is on the advisory board for Interpace Diagnostics, and is a shareholder in Nevakar, Inc. The remaining authors have no conflicts or funding to disclose., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Video 1Narration of case and demonstration of appendiceal foreign body removal using a novel magnetic catheter., (© 2022 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Background and study aims  The aim of this study was to assess long-term clinical outcomes beyond 6 years in patients who underwent per-oral endoscopic myotomy (POEM) for the treatment of achalasia. Patients and methods  Patients with achalasia who underwent POEM between 2010 and 2012 and had follow-up of at least 6 years were retrospectively identified at eight tertiary care centers. The primary outcome evaluated was clinical success defined by an Eckardt symptom score (ESS) ≤ 3 for the duration of the follow-up period. The clinical success cohort was compared to failure (ESS > 3 at any time during follow-up) in order to identify characteristics associated with symptom relapse. The incidence of patient-reported gastroesophageal reflux (GER) was also evaluated. Results  Seventy-three patients with 6-year follow-up data were identified. Sustained clinical remission was noted in 89 % (65/73) at 6-years. Mean ESS decreased from 7.1 ± 2.3 pre-procedure to 1.1 ± 1.1 at 6 years ( P  < 0.001). Symptomatic reflux was reported by 27 of 72 patients (37.5 %). Type I achalasia (OR 10.8, P  = 0.04) was found to be associated with clinical failure on logistic regression analysis. Conclusions  In patients with achalasia, POEM provides high initial clinical success with excellent long-term outcomes. There are high rates of patient-reported gastroesophageal reflux post-procedure which persist at long-term follow-up., Competing Interests: Competing interests Dr. N. Thosani is a consultant for Boston Scientific, Medtronic, Endogastric Solutions, and Pentax of America; a speaker for Abbvie, and receives royalties from UpToDate. Dr. M.A. Khashab is a consultant for Boston Scientific, Medtronic and Olympus. Dr. Alessandro Repici MD -Boston consulting fee, speaker fee, research grant. Fujifilm advisory board speaker fee. ERBE advisory board consulting fee. EndoKey advisory board. EndoStart advisory board. Medtronic research grant, consulting fee, advisory board. Dr. Sachin Wani is a Consultant for Boston Scientific, Medtronic, Cernostics and Interpace. Supported by the University of Colorado Department of Medicine Outstanding Early Scholars Program. All remaining authors declare they have nothing to disclose., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: Peroral endoscopic myotomy (POEM) is considered a primary treatment modality for achalasia. It can be performed using either the anterior or posterior approach. A previous randomized clinical trial (RCT) showed that the posterior approach was noninferior to the anterior approach at 1 year post-POEM in terms of clinical success, rate of adverse event, and risk of gastroesophageal reflux disease (GERD). The aim of this post-RCT study was to compare outcomes at ≥ 2 years post-POEM., Methods: Patients who previously completed the 1-year follow-up were contacted and their Eckardt, dysphagia, and GERD questionnaire (GERDQ) scores and frequency of proton pump inhibitor use were recorded. Clinical success was defined as an Eckardt score < 3., Results: 150 patients were initially randomized and 138 completed the 1-year follow-up. Of the 138, 111 (anterior group 54, posterior group 57) also completed ≥ 2 years of follow-up, with an overall clinical success decrease from 89 % to 82 %. At ≥ 2 years post-POEM, clinical success was achieved in 46/54 (85 %) and 45/57 (79 %) in the anterior and posterior groups, respectively ( P  = 0.43). A similar decrease in clinical success was noted in both groups at ≥ 2 years (anterior: 90 % to 85 %; posterior 89 % to 79 %; P  = 0.47). GERDQ score was 6 (interquartile range 6 - 8; P  = 0.08) in both treatment groups., Conclusions: The anterior and posterior POEM techniques remained equally effective at 2 years and decreases in efficacy were similar between the two approaches over time. GERD outcomes were also similar in both groups during medium-term follow-up., Competing Interests: Professor Khashab is a consultant for Boston Scientific, Olympus, and Medtronic, and a medical advisory board member for Boston Scientific and Olympus. Dr. Pioche has received fees from Norgine, and fees and nonfinancial support from Olympus and Boston Scientific. All other authors declare that they have no conflicts of interest., (Thieme. All rights reserved.)