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Background and Aims EUS-directed transgastric ERCP (the EDGE procedure) is a simplified method of performing ERCP in Roux-en-Y gastric bypass patients. The EDGE procedure involves placement of a lumen-apposing metal stent (LAMS) into the excluded stomach to serve as a conduit for passage of the duodenoscope for pancreatobiliary intervention. Originally a multistep process, urgent indications for ERCP have led to the development of single-session EDGE (SS-EDGE) with LAMS placement and ERCP performed in the same session. The goal of this study was to identify predictive factors of intraprocedural LAMS migration in SS-EDGE. Methods We conducted a multicenter retrospective review that included 9 tertiary medical centers across the United States. Data were collected and analyzed from 128 SS-EDGE procedures. The primary outcome was intraprocedural LAMS migration. Secondary outcomes were other procedural adverse events such as bleeding and perforation. Results Eleven LAMS migrations were observed in 128 procedures (8.6%). Univariate analysis of clinically relevant variables was performed, as was a binary logistic regression analysis of stent diameter and stent dilation. This revealed that use of a smaller (15 mm) diameter LAMS was an independent predictor of intraprocedural stent migration (odds ratio, 5.36; 95% confidence interval, 1.29-22.24; P = .021). Adverse events included 3 patients who required surgery and 2 who experienced intraprocedural bleeding. Conclusions Use of a larger-diameter LAMS is a predictive factor for a nonmigrated stent and improved procedural success in SS-EDGE. Although larger patient cohorts are needed to adequately assess these findings, performance of LAMS dilation and fixation may also decrease risk of intraprocedural LAMS migration and improve procedural success.

Background This systematic review aims to assess the accuracy of hydrogen breath testing as a predictor of bowel preparation. Methods Studies were identified from MEDLINE, Embase, Web of Science, Cochrane Library and clinicaltrials.gov. Two investigators evaluated abstracts for inclusion criteria - report of correlation between hydrogen breath levels and bowel preparation quality, prospective design and non-emergent colonoscopy in adults. Included studies underwent duplicate data extraction using a standardized approach. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool assessed quality of the studies. Results One hundred fifty-nine publications were identified, and six unique studies met inclusion criteria. The number of patients analyzed ranged from 61 to 127. Three studies were performed in the USA, one in Japan and two in Italy. Three studies used a prebiotic in addition to a purgative, with the intention of enhancing the discriminating ability of hydrogen breath levels. Three studies assessed baseline hydrogen levels. In five of the six studies, hydrogen breath levels were predictive of inadequate bowel preparation. Suggested absolute hydrogen levels to distinguish adequate from inadequate bowel preparation ranged from 3 to 10 parts per million. Depending on the cutoff value, sensitivity ranged from 71% to 100% and specificity from 87% to 100%. There was significant heterogeneity among studies in breath testing protocol and breath analyzer used. Full-text studies had low risk of bias in most assessed domains. Conclusion Hydrogen breath levels predict bowel preparation adequacy but existing studies have significant limitations. Further studies should use standardized methods and consider the real-world practicality of self-administered home breath testing.

Background: Inadequate bowel preparation before colonoscopy is common, resulting in clinical and economic harms. The US Multi-Society Taskforce advocates use of both written and oral instructions for patients before colonoscopy. However, little is known about the most effective method of patient education. This systematic review aims to assess the effectiveness of patient-oriented educational interventions in improving the quality of bowel preparation. Methods: Studies were identified from MEDLINE, EMBASE, Cochrane, CINAHL, and Web of Science. Two investigators evaluated each abstract for the following inclusion criteria: evaluation of a patient-oriented educational intervention, prospective design, and measurement of bowel preparation quality with a validated scale. Included studies underwent duplicate data extraction by 2 investigators using a standardized approach. Extracted data included the method of intervention, timing of intervention, staffing of intervention, purgative used, bowel preparation scale used, and bowel preparation quality. Methodological quality of studies was assessed using amodified Downs and Black instrument. Due to significant heterogeneity in assessment of outcomes, meta-analysis was not performed. Results: 1080 unique published studies were identified, and 7 of these studies met inclusion criteria. Five studies were randomized controlled trials, and 2 were quasi-experimental. The number of patients analyzed ranged from 99 to 969. 3 studies were performed in the US, 2 in Taiwan, 1 in China, and 1 in Korea. 3 interventions used paper-based tools (1 cartoon, 2 illustrated brochures), 2 interventions used videos, 1 intervention used face-to-face education, and 1 used telephone calls. In 6 of the 7 studies, the educational intervention was effective in improving bowel preparation quality, with an absolute increase in bowel preparation adequacy ranging from 2% to 32%. No study accounted for all significant confounders of bowel preparation quality (i.e. constipation, diabetes, opiates, socioeconomic status, literacy rate, age, gender, BMI). Validity scores ranged from 12-23, with a median value of 18, indicating fair methodological quality. Conclusions: Patient-oriented educational interventions significantly improve bowel preparation quality, but existing studies are of variable quality and may have limited generalizability. Gastroenterologists should work internally and with referring practices to ensure that patients receive evidence-based preparation education. Future studies should focus on comparative effectiveness and cost-effectiveness of educational interventions