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Background and study aims Weight loss is a feature of untreated achalasia. While weight gain after achalasia treatment is expected, little data exist about the extent of it, particularly after peroral endoscopic myotomy (POEM). We aimed to describe the changes in weight after POEM. Patients and methods A retrospective analysis was performed of patients from March 2016 to March 2020 undergoing POEM by an experienced operator at an academic referral center in Kingston, Ontario, Canada. Data examined included pre- and post-POEM body mass index (BMI), procedural characteristics, and Eckardt scores. Results Ninety-two patients underwent POEM during the study period, for 77 of whom follow-up data were available including BMI. Prior to POEM, the median BMI was 26. Six patients (7.8%) were considered to be underweight, 24 (31.2%) were normal, 26 (33.8%) were pre-obese, and 21 (27.2%) were obese. At a median follow-up of 15 months, the clinical success rate was 95%. Patients in the normal weight and pre-obesity categories had a significant increase in weight post-POEM. Of the underweight patients, two (33.3%) moved up to a normal weight category and two (33.3%) became pre-obese. In the normal BMI category, eight (37.5%) became pre-obese and one patient (4.2%) became obese. Ten of the 26 pre-obese patients (38.4%) were obese post-POEM. Seven of the obese patients (33.3%) reached Class III (morbid) obesity at follow-up. Conclusions Patients may experience a marked increase in BMI following POEM, with over one-third of patients becoming pre-obese, obese or morbidly obese at follow-up in our study in a North American population. Further study is required to analyze weight gain patterns post-POEM.Copyright © 2021 Georg Thieme Verlag. All rights reserved.

Background and Aims: Necrotizing pancreatitis is a severe complication seen in 15-20% of patients who present with acute interstitial pancreatitis and is associated with significant morbidity and mortality. The management of necrotic collections in patients with necrotizing pancreatitis has been revolutionized by minimally invasive techniques, such as endoscopic ultrasound (EUS)-guided drainage. The timing of endoscopic intervention for these collections remains contentious. The primary aim of this audit was to compare the outcomes and characteristics of patients who required early endoscopic drainage (<4 weeks) versus those who needed late drainage (>4 weeks) of these collections and to assess whether necrosectomy is commonly required in this cohort. Method(s): We performed a retrospective analysis of prospectively collected data from 2012 to 2021 of consecutive patients in a single tertiary center who had EUS-guided cystogastrostomy for symptomatic pancreatic necrotic collections. Necrosis had been confirmed by a specialist radiologist on computed tomography scan. The decision regarding the timing for endoscopic intervention (early vs late) for these patients was based on clinical assessment, review of imaging, pathology test results, and a multidisciplinary discussion with radiologists, surgeons, and gastroenterologists. Patients were excluded if follow-up data were missing. The included patients' medical records, pathology results, imaging findings, and procedural reports were retrospectively reviewed. Cystogastrostomies were performed for patients if the pancreatic necrotic collections were causing sepsis or outlet obstruction. All endoscopic drainage procedures were performed by trained interventional endoscopists (either one of two gastroenterologists or a hepatobiliary surgeon) in a single tertiary center. Two different types of stents were used for endoscopic drainage: plastic double pigtail stents and lumen-apposing metal stents (LAMS), or both, without fl

Background and Aim: Endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for drainage in malignant biliary obstruction. However, ERCP is not always successful, due to difficulties with selective biliary cannulation or gastroduodenal obstruction preventing access to the ampulla of Vater. Although percutaneous transhepatic biliary drainage has traditionally been the preferred approach in these circumstances, endoscopic ultrasound-guided biliary drainage (EUS-BD), using a novel lumen-apposing metal stent (LAMS) with an electrocautery-enhanced delivery system, has shown a technical success rate of 95% in overseas studies. This multicenter study aimed to evaluate the efficacy and safety of EUS-BD using LAMS (Hot AXIOS; Boston Scientific) in an Australian cohort. Method(s): Patients in whom a LAMS was used for biliary drainage across 11 tertiary Australian hospitals from October 2016 to June 2020 were retrospectively identified. Patient and procedural data were collected from the electronic medical records of each hospital. The primary outcome measure was technical success, defined as successful EUS-BD. Secondary outcomes included adverse events and 30-day mortality. Result(s): A total of 41 patients (median age, 72 years [range, 45-94]; 22 [54%] male) had attempted EUS-BD across the 11 hospitals. Etiology of biliary obstruction included pancreatic adenocarcinoma (n = 30), ampullary carcinoma (n = 3), cholangiocarcinoma (n = 1), duodenal cancer (n = 1), and metastatic disease (n = 6). Initial ERCP drainage failed due to inability to access the papilla as a result of malignant duodenal obstruction (n = 8), inability to locate the papilla due to tumor infiltration (n = 11), and failed cannulation (n = 22). The median common bile duct (CBD) diameter was 18 mm (IQR, 16-19.5), with access obtained through the duodenum in all but two procedures (95%), in which the stent was inserted through the gastric antrum. Fluoroscopic guidance was used in two-thi

Background and Aim: Peroral endoscopic myotomy (POEM) is performed globally for the treatment of achalasia. A newly available endoscopic knife, the triangle tip-jet (TTJ) (Olympus Triangle TipKnife-J, KD-645L), has the capability of knife dissection along with submucosal injection. We aim to present our experience with the TTJ knife in comparison to the conventional TT knife in POEM, with a focus on procedural characteristics including time, efficiency, and the number of instrument exchanges. Method(s): All patients with achalasia who underwent POEM between March 2016 and March 2020 at a single tertiary academic center were included in the retrospective cohort. Demographic, procedural, and outcomes data were compared. Result(s): Ninety-two procedures, 48 using the TT knife, and 44 with the TTJ knife were analyzed. Demographic data were similar. Procedure time was reduced using the TTJ knife (87 vs 61 min, P = <0.001) despite similar myotomy lengths (16.5 vs 15.2 cm, P = 0.09). Efficiency was increased in the TTJ group (5.5 vs 4.3 min/cm of procedure, P = 0.005). The number of instrument exchanges (16.7-1.7, P = <0.001) and usage of coagulation forceps decreased (1.7-0.5, P = <0.001). There was no difference in the procedural difficulty (POEM difficulty score [PDS] 2.2 vs 2.4, P = 0.4). Patients with higher procedural difficulty saw a greater improvement in procedural outcomes. Procedural success was high in both groups (96% vs 100%, P = 0.2). No serious adverse events were reported. Conclusion(s): The use of the TTJ knife increases efficiency during POEM for Achalasia. The total procedure time is decreased by 28-41%, and procedural efficiency is increased by 22-34%.Copyright © 2021 The Authors. JGH Open published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

Background and Aim: Percutaneous cholecystostomy tube (PC) drainage of the gall bladder (GB) has long been the preferred alternative to laparoscopic cholecystectomy in patients who are deemed too high risk or not appropriate for surgical intervention. Although PC has proven effective in resolving acute sepsis, reintervention for tube dysfunction is required in up to 28% of cases. Recently, endoscopic ultrasound (EUS)-guided transluminal drainage using a novel lumen-apposing metal stent (LAMS) with an electrocautery-enhanced delivery system has gained favor as another means of providing GB drainage. A meta-analysis of the overseas literature demonstrated a technical success rate of 95.2% and a procedure mortality rate of 0.02%. This multicenter study aimed to evaluate the efficacy and safety of EUS-guided GB drainage using LAMS (Hot AXIOS; Boston Scientific) in an Australian cohort. Method(s): Patients in whom a LAMS was used for GB drainage across eight tertiary Australian hospitals from October 2016 to June 2020 were retrospectively identified. Patient and procedural data were collected from the electronic medical records of each respective hospital. Primary outcome measures were technical success, defined as successful initial deployment of the LAMS, and clinical success, defined as resolution of symptoms at 72 h after the procedure. Secondary outcomes included adverse events and 30-day mortality. Result(s): A total of 37 patients (median age, 76 years [range, 39-94]; 26 [70%] male) across the eight hospitals had attempted EUS-guided GB drainage. Indications for proceeding to cholecystostomy drainage, as opposed to surgical management, included advanced age and comorbidities (n = 18), incurable malignancy (n = 13), poor functional state (n = 4), and clinically significant portal hypertension (n = 2). Visible GB calculi were seen in 24 patients (65%), with the remaining patients having acalculous cholecystitis, largely due to malignant obstruction. Most patients (9

Caffeine is a widely used psychostimulant that is associated with increased acetylcholine levels in mammalian brain and acetycholinesterase antagonism. Acetylcholine, a neuromodulator, plays an important role in the processing of visual information. One key example in human vision, thought to at least partly involve cholinergic neuromodulation, is perceptual surround suppression of contrast, whereby the perceived contrast of a pattern is altered by the presence of a neighbouring pattern. Perceptual surround suppression is weaker with pharmacological administration of donepezil (a centrally-acting acetylcholine enzyme inhibitor) in healthy human observers. Here, we test whether temporarily manipulating caffeine levels (from complete washout to a controlled dose of caffeine) has a similar effect on perceptual surround suppression in 21 healthy young adults (aged 20-24 years, 11 females). Neither ingestion of a caffeine pill nor placebo altered contrast judgments when the target pattern was presented on a uniform grey background ( p=0.54). With caffeine ingestion, perceptual surround suppression strength was reduced relative to baseline (prior to pill ingestion, p=0.003) and placebo ( p=0.029), irrespective of whether the surround was oriented parallel or orthogonal to the central target. While daily habitual caffeine consumption of low-to-moderate doses (<400 mg/day, estimated from a written questionnaire) is not predictive of performance, our study indicates that acute consumption of caffeine on the day of testing influences perceptual surround suppression strength. Perceptual surround suppression is predominantly attributed to inhibitory processes involving the major cortical inhibitory neurotransmitter, gamma-aminobutyric acid. Our results point to the involvement of other neuromodulators, possibly cholinergic, in perceptual surround suppression.

Introduction: Pancreatic neuroendocrine tumours (PNETs) are a rare form of pancreatic neoplasm. Whilst sharing histological similarities with neuroendocrine tumours at other sites, they have a distinct biology and clinical manifestation. The management of PNETs remains controversial, especially in whether to surveil small lesions and of the role of resection in metastatic non-functioning PNETs. We present data from the largest single centre cohort of PNETs in Australia. Method(s): Data from consecutive patients referred to Monash Health, a quaternary pancreaticobiliary referral centre, from 2011 to 2016 with PNETs, were prospectively collected and analysed. Patient demographics, tumour characteristics and staging were collected. Where applicable, procedural details and complications, length of stay, and overall morbidity and mortality data were collected. Result(s): Forty-three patients with a median age of 64.5 years (range 40.8- 84.1 years) were analysed. All the PNETs analysed were non-functional in nature, and in 27 (62.7%) patients, the suspicion of PNET was raised as an incidental finding on cross-sectional imaging. Thirty-two (74.4%) patients were evaluated with endoscopic ultrasound (EUS). The majority of tumours were localised to the pancreas (83.7%). Eleven (25.6%) patients with tumours of a median size of 13mm and Ki67 proliferation index of 2% were surveilled. None of these patients developed progressive disease at a median follow-up of 16 months. Twenty-one (48.8%) patients had resection of their PNETs, with procedure-related mortality of 0%. Six patients (14%) with metastatic disease proceeded to chemotherapy. Conclusion(s): The modern face of PNETs in Australia is changing: PNETs are being identified early on cross-sectional imaging and EUS, and small, low-grade lesions can be safely surveilled without tumour progression. Surgical resection is a successful outcome in a large number of patients.

Introduction: Necrotising pancreatitis is often complicated by walled-off pancreatic necrosis (WOPN), causing either infection or obstructive symptoms. Minimally invasive necrosectomy, either percutaneously or endoscopically, is the favoured treatment, though this is not without complication and some patients still ultimately require open necrosectomy1. Our experience suggests that endoscopic ultrasound (EUS) guided drainage of necrotic collections via cystogastrostomy is a sufficient enough intervention, without the need for any modality of necrosectomy. Method(s): Data from consecutive patients admitted to Monash Health, a quaternary pancreaticobiliary referral centre, with necrotising pancreatitis that underwent EUS guided cystogastrostomy of WOPN was prospectively collected and analysed. Patient demographics, procedural details and complications, length of stay and morbidity and mortality data were collected. Result(s): Eighteen patients with a median age of 67 (range 31-81 years) were analysed. The predominant aetiology of pancreatitis was gallstone (41.2%). The median bedside index for severity in acute pancreatitis (BISAP) and computer tomography severity index (CTSI) scores were 3 and 7, respectively. Initial EUS guided cystogastrostomy was performed at a median of 31 days post-admission (range 12 to 131 days). The majority of procedures were performed for infected necrotic collections. The median number of EUS procedures was 2 and the length of stay post-initial EUS intervention was 17 days. There was one peritoneal perforation from cystogastrostomy and two deaths, though none related to the EUS procedure. At a median follow-up of 12.1 months, no patients required minimally invasive or open necrosectomy. Conclusion(s): Patients with WOPN, a life-threatening complication of necrotisting pancreatitis, were able to be effectively and safely managed with EUS guided cystogastrostomy, without the need for necrosectomy. A prospective randomised controlled trial is

A 26-year-old female without any medical comorbidities presented with increasing epigastric abdominal pain, 10 days after inadvertently ingesting a toothbrush. In an effort to induce emesis, she had introduced a toothbrush into the pharynx, only for the brush to break at the head. A CT scan demonstrated a 10-cm linear hyperdense object, in the distal stomach extending across the pylorus, into the first and second part of the duodenum. There was no evidence of any perforation or collection. Initial gastroscopy revealed the toothbrush penetrating into the lateral wall of the second part of the duodenum. Due to the complexity, the case was referred to a tertiary interventional endoscopy unit. On repeat gastroscopy under general anaesthetic, after careful inspection and surgical back-up, a 20-mm snare was used to lasso the handle of the toothbrush, allowing it to be extracted by gentle traction and manipulation through the pylorus and removed per orally in one piece. A protective overtube was not required. The residual duodenal perforation (Image 1), which in 10 days had formed a tract, was closed with a single over-the-scope clip (Ovesco 12T, Tubingen, Germany). A decompressive nasogastric tube was placed and intravenous antibiotics were given prophylactically. The patient had an uneventful recovery, progressing to a full diet after no leak was seen on follow-up contrast CT scan of the abdomen 3 days later. Repeat gastroscopy six weeks later showed complete closure of the duodenal wall defect with granulation tissue. No Ovesco clip was found. (Figure presented).