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Although asthma is a common chronic airway disease that responds well to anti-inflammatory agents, some patients with asthma are unresponsive to conventional treatment. Mesenchymal stem cells (MSCs) have therapeutic potential for the treatment of inflammatory diseases owing to their immunomodulatory properties. However, the target cells of MSCs are not yet clearly known. This study aimed to determine the effect of human umbilical cord-derived MSCs (hUC-MSCs) on asthmatic lungs by modulating innate immune cells and effector T cells using a murine asthmatic model. Intravenously administered hUC-MSCs reduced airway resistance, mucus production, and inflammation in the murine asthma model. hUC-MSCs attenuated not only T helper (Th) 2 cells and Th17 cells but also augmented regulatory T cells (Tregs). As for innate lymphoid cells (ILC), hUC-MSCs effectively suppressed ILC2s by downregulating master regulators of ILC2s, such as

OBJECTIVES Although lumen-apposing metal stents (LAMS) are being increasingly used in lieu of plastic stents, the clinical approach to endoscopic management of pancreatic fluid collections (PFCs) is poorly standardized. We compared outcomes of approaches over two time intervals, initially using plastic stents and later integrating LAMS. METHODS This was a retrospective, observational, before-after study of prospectively collected data on consecutive patients with symptomatic PFCs managed over two time periods. In the initial period (January 2010-January 2015) endoscopic treatment was undertaken with plastic stents and in the later period (February 2015-August 2020) by integration of LAMS with selective use of plastic stents. The treatment strategy in both periods were tailored to size, extent, type of PFC and stepwise response to intervention. The main outcome was treatment success, defined as resolution of PFC and presenting symptoms at 6-month follow-up. RESULTS A total of 160 patients were treated with plastic stents and 227 patients were treated using an integrated LAMS approach. Treatment success was significantly higher for the integrated approach compared to using only plastic stents (95.6 vs. 89.4%; P = 0.018), which was confirmed to be predictive of treatment success on multivariable logistic regression analysis (odds ratio 2.7, 95% confidence interval 1.1-6.4; P = 0.028). CONCLUSIONS A structured approach integrating LAMS with selective use of plastic stents improved treatment success in patients with PFCs compared to an approach using only plastic stents.

Objective While single-use and detachable-tip duodenoscopes have been recently developed to overcome risks of infection transmission, there are no reliable tools to objectively assess their technical performance. We evaluated the reliability and validity of a newly developed tool to assess the technical performance of reusable duodenoscopes. Methods An assessment tool was developed to measure duodenoscope performance based on three distinct criteria: maneuverability, mechanical/imaging characteristics and ability to perform requisite interventions. The assessment tool was tested prospectively on duodenoscopes used in endoscopic retrograde cholangiopancreatography (ERCP) procedures at nine academic medical centers over a 6-month period. The main outcome was reliability of the duodenoscope assessment tool, which was estimated using Cronbach's coefficient alpha (α). The secondary outcome was validity of the assessment tool. Results The assessment tool evaluated technical performance of reusable duodenoscopes in 1080 ERCP procedures. Indications were biliary in 92.8% and pancreatic in 7.2% procedures. The overall Cronbach's coefficient α for maneuverability was 0.81, assessment of mechanical/imaging characteristics was 0.92, and ability to perform requisite interventions was 0.87. On multiple linear regression analysis, prolonged procedure duration, older patient age and pancreatic interventions were significantly positively associated with higher (worse) scores. Conclusions The newly developed assessment tool appears reliable and valid for evaluating the technical performance of duodenoscopes. Registration: ClinicalTrials.gov Identifier: NCT04004533.

OBJECTIVES Exposure to ionizing radiation remains a hazard for patients and healthcare providers. We evaluated the utility of an artificial intelligence (AI)-enabled fluoroscopy system to minimize radiation exposure during image-guided endoscopic procedures. METHODS We conducted a prospective study of 100 consecutive patients who underwent fluoroscopy-guided endoscopic procedures. Patients underwent interventions using either conventional or AI-equipped fluoroscopy system that uses ultrafast collimation to limit radiation exposure to the region of interest. The main outcome measure was to compare radiation exposure with patients, which was measured by dose area product. Secondary outcome was radiation scatter to endoscopy personnel measured using dosimeter. RESULTS Of 100 patients who underwent procedures using traditional (n = 50) or AI-enabled (n = 50) fluoroscopy systems, there was no significant difference in demographics, body mass index, procedural type, and procedural or fluoroscopy time between the conventional and the AI-enabled fluoroscopy systems. Radiation exposure to patients was lower (median dose area product 2,178 vs 5,708 mGym, P = 0.001) and scatter effect to endoscopy personnel was less (total deep dose equivalent 0.28 vs 0.69 mSv; difference of 59.4%) for AI-enabled fluoroscopy as compared to conventional system. On multivariate linear regression analysis, after adjusting for patient characteristics, procedural/fluoroscopy duration, and type of fluoroscopy system, only AI-equipped fluoroscopy system (coefficient 3,331.9 [95% confidence interval: 1,926.8-4,737.1, P < 0.001) and fluoroscopy duration (coefficient 813.2 [95% confidence interval: 640.5-985.9], P < 0.001) were associated with radiation exposure. DISCUSSION The AI-enabled fluoroscopy system significantly reduces radiation exposure to patients and scatter effect to endoscopy personnel (see Graphical abstract, Supplementary Digital Content, http://links.lww.com/AJG/B461).

BACKGROUND AND AIM Infected necrotizing pancreatitis is a highly morbid disease managed by minimally invasive surgical (MIS) or endoscopy-based interventions. This meta-analysis compared the clinical outcomes of patients treated using either approach. METHODS MEDLINE and EMBASE databases were searched to identify all randomized trials that compared MIS and endoscopy-based interventions for treatment of infected necrotizing pancreatitis. Main outcome measure was to compare rates of complications or death during 6-month follow-up. RESULTS Three studies involving 184 patients met inclusion criteria. While there was no significant difference in mortality (14.5% vs. 16.1%, risk ratio [RR] = 1.02, P = 0.963), new onset multiple organ failure (5.2% vs. 19.7%, RR = 0.34, P = 0.045), enterocutaneous fistula/perforation (3.6% vs. 17.9%, RR = 0.34, P = 0.034) and pancreatic fistula (4.2% vs. 38.2%, RR = 0.13, P

During regenerative endodontic procedures, the microenvironment of the canal is formed by the degree of disinfection and release of ions from the applied materials onto the top surface. This study aimed to characterize the effects of amnion-chorion membrane and collagen membrane on pulp-dentin regeneration compared to calcium silicate cements (CSCs), focusing on cell migration, mineralization potential, anti-inflammation, and angiogenesis.Two CSCs and 2 membranes were used: ProRoot MTA (Dentsply, Tulsa, OK, USA), RetroMTA (BioMTA, Seoul, Korea), Collagen Membrane (Genoss, Suwon, Korea), and BioXclude (amnion-chorion membrane; Snoasis Medical, Colorado, USA). Transwell and scratch assays were used to evaluate cell migration and wound healing. Mineralization potential was evaluated using alkaline phosphatase activity, Alizarin red S staining, and quantitative real-time polymerase chain reaction for the expression of marker genes. Quantitative real-time polymerase chain reaction was used to measure the levels of angiogenic genes and inflammatory mediators. An endothelial tube formation assay was used to assess angiogenesis.The membranes showed superior migration and wound healing compared with CSCs. Except for RetroMTA, ProRoot MTA and the 2 membranes showed high alkaline phosphatase activity and mineralization nodule formation and upregulated mRNA expression of markers for mineralization. Membranes upregulated the mRNA of angiogenesis genes and increased the capillary tube formation of endothelial cells compared to CSCs. Furthermore, the membrane matrix decreased the expression of inflammatory genes.Collagen membrane and Amnion-chorion membrane showed prominent cell migration, angiogenesis, and healing effects against inflammation, as well as comparable mineralization potential compared to CSCs, recommending the use of membrane as a matrix.

Mesenchymal stem cells (MSCs) are attractive alternatives to conventional anti-asthmatic drugs for severe asthma. Mechanisms underlying the anti-asthmatic effects of MSCs have not yet been elucidated. This study evaluated the anti-asthmatic effects of intravenously administered MSCs, focusing on macrophages and monocytes. Seven-week-old transgenic (Tg) mice with lung-specific overexpression of IL-13 were used to simulate chronic asthma. MSCs were intravenously administered four days before sampling. We examined changes in immune cell subpopulations, gene expression, and histological phenotypes. IL-13 Tg mice exhibited diverse features of chronic asthma, including severe type 2 inflammation, airway fibrosis, and mucus metaplasia. Intravenous administration of MSCs attenuated these asthmatic features just four days after a single treatment. MSC treatment significantly reduced SiglecF

Although liver biopsies (LBs) are being increasingly performed under endoscopic ultrasound (EUS) guidance, there are limited data comparing outcomes with current standard-of-care, transabdominal ultrasound (US)-guided percutaneous (PC) methods. In a randomised trial, we observed that the PC, US-guided method yielded significantly more optimal specimens, defined as specimen length of 25 mm or greater and presence of at least 11 complete portal tracts, compared with the EUS-guided method (57.9% vs 23.8%, p=0.028). Also, the PC method resulted in worse initial postprocedural pain but was less costly (US$1824 vs US$3240, p

Background/Aims The management of walled-off necrosis (WON) has undergone a paradigm shift from surgical to nonsurgical modalities. Real-world data on the management of symptomatic WON are scarce. Methods Prospectively collected data of symptomatic WON cases were retrospectively evaluated. The treatment modalities used were medical management alone, percutaneous catheter drainage (PCD) or endoscopic drainage (ED), or a combination of PCD and ED. We compared clinical outcome among these modalities. Results A total of 264 patients were evaluated. The most common indications for drainage were pain and fever. Of the patients, 28% was treated with medical therapy alone, 31% with ED, 37% with PCD, and 4% with a combined approach. Technical success and clinical success were achieved in 93% and 91% of patients in the endoscopic arm and in 90% and 81% patients in the PCD arm, respectively (p=0.0004 for clinical success). Lower rates of complications (7% vs. 22%, p=0.005), readmission (20% vs. 34%, p=0.04), and mortality (4% vs. 19%, p=0.0012), and shorter hospital stay (13 days vs. 19 days, p=0.0018) were observed in the endoscopic group than in the PCD group. Conclusions ED of WON is better than PCD and is associated with lower mortality, fewer complications, and shorter hospitalization.

Although lung macrophages are directly exposed to external stimuli, their exact immunologic roles in asthma are still largely unknown. The aim of this study was to investigate the anti-asthmatic effect of Acinetobacter lwoffii in terms of lung macrophage modulation.Six-week-old female BALB/c mice were sensitized and challenged with ovalbumin (OVA) with or without intranasal administration of A. lwoffii during the sensitization period. Airway hyperresponsiveness and inflammation were evaluated. Using flow cytometry, macrophages were subclassified according to their activation status. In the in vitro study, a murine alveolar macrophage cell line (MH-S) treated with or without A. lwoffii before IL-13 stimulation were analysed by quantitative RT-PCR.In a murine asthma model, the number of inflammatory cells, including macrophages and eosinophils, decreased in mice treated with A. lwoffii (A. lwoffii/OVA group) compared with untreated mice (OVA group). The enhanced expression of MHCII in macrophages in the OVA group was decreased by A. lwoffii treatment. M2 macrophage subtypes were significantly altered. A. lwoffii treatment decreased CD11bIntranasal A. lwoffii exposure suppresses asthma development by suppressing the type 2 response via modulating lung macrophage activation, shifting M2a and M2c macrophages to M2b macrophages.

Presently, following endoscopic ultrasound (EUS)-guided biopsy, an endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stenting is performed for palliation of malignant distal biliary obstruction (MDBO). However, technical failure and postprocedure pancreatitis are limitations to ERCP. Endoscopic ultrasonography-guided biliary drainage (EUS-BD) after a failed ERCP has a 90% technical success rate and has been shown to be superior when compared to percutaneous methods, making EUS an increasingly recognized option for biliary drainage. Supporting this approach, findings from recently concluded randomized trials suggest that the safety profile and technical outcomes for EUS-BD are comparable or even superior to that of ERCP for primary biliary decompression in patients with MDBO. Also, EUS-BD is increasingly being utilized in patients with altered surgical anatomy in lieu of percutaneous techniques and balloon-assisted enteroscopy. A growing body of evidence supports the notion that, in the future, EUS may become the primary modality by which biliary decompression is undertaken in the majority of patients with MDBO. The roadmap to this eventuality may require further optimization of procedural techniques, technological innovations, and cost reduction.

Lumen-apposing metal stents (LAMS) integrated in a single-step delivery platform are ideally suited for the endoscopic ultrasound-guided drainage of pancreatic fluid collections. Given their unique ability to approximate the capsule of the fluid collection to the adjoining gastric or duodenal wall, the potential for leak or perforation is minimal. Additionally, the wide stent lumen not only facilitates faster drainage of cyst contents but also enables other therapeutic interventions such as endoscopic debridement in patients with infected necrotizing pancreatitis. A keen awareness of the technical design of LAMS and its clinical effectiveness is important to minimize adverse events and maximize treatment outcomes. This review outlines the technical approach and clinical outcomes when LAMS are used for the endoscopic drainage of pancreatic fluid collections.

Lumen-apposing metal stents (LAMS) are integrated in a single-step delivery platform and can be deployed under endoscopic ultrasound-guidance for the drainage of intra-abdominal fluid collections, decompression of obstructed ductal systems, establishment of anastomosis or creation of fistulous tracts between organs that can facilitate further endoscopic interventions if required. A unique feature of LAMS is their ability to approximate the adjoining structures, thereby minimizing the potential for leak and perforation. Consequently, the innovation has advanced our ability to carry out complex therapeutic interventions and obviate the need for high-risk surgical procedures, particularly in morbid patients. However, a keen awareness of the technical design of LAMS and its implication on treatment effect is important to minimize adverse events and to improve clinical outcomes. This review outlines the technical approach to placement of LAMS, procedural challenges, adverse events, current clinical indications and emerging applications.

Despite numerous previous studies, the full action mechanism of the pathogenesis of asthma remains undiscovered, and the need for further investigation is increasing in order to identify more effective target molecules. Recent attempts to develop more efficacious treatments for asthma have incorporated mesenchymal stem cell (MSC)-based cell therapies. This study aimed to evaluate the anti-asthmatic effects of MSCs primed with Liproxstatin-1, a potent ferroptosis inhibitor. In addition, we sought to examine the changes within macrophage populations and their characteristics in asthmatic conditions. Seven-week-old transgenic mice, constitutively overexpressing lung-specific interleukin (IL)-13, were used to simulate chronic asthma. Human umbilical cord-derived MSCs (hUC-MSCs) primed with Liproxstatin-1 were intratracheally administered four days prior to sampling. IL-13 transgenic mice demonstrated phenotypes of chronic asthma, including severe inflammation, goblet cell hyperplasia, and subepithelial fibrosis. Ly6C+M2 macrophages, found within the pro-inflammatory CD11c+CD11b+ macrophages, were upregulated and showed a strong correlation with lung eosinophil counts. Liproxstatin-1-primed hUC-MSCs showed enhanced ability to downregulate the activation of T helper type 2 cells compared to naïve MSCs in vitro and reduced airway inflammation, particularly Ly6C+M2 macrophages population, and fibrosis in vivo. In conclusion, intratracheal administration is an effective method of MSC delivery, and macrophages hold great potential as an additional therapeutic target for asthma.

Infection control and prevention seem to be buzzwords at the dawn of 2021 as the world slowly adapts to the reality of a global COVID-19 pandemic. The Hippocratic principle for hygiene, every disease has its own nature and arises from external causes, holds value even for the discipline of endoscopy where despite best practices in reprocessing techniques there persists substantial risks for infection transmission, particularly for duodenoscopes. Outbreaks of duodenoscope-related infection (DRI) have been reported with pathogenic organisms that include Klebsiella pneumoniae, Pseudomonas aeruginosa and more recently carbapenem-resistant Enterobacteriaceae (CRE) [1,2]. These adverse events involving multidrug resistant organisms have raised serious concerns regarding current standards-of-care. While professional societies have revised existing guidelines for duodenoscope reprocessing techniques, significant limitations persist [3,4]. The Food and Drug Administration (FDA) has published numerous safety communications on this topic and recently mandated that endoscope manufacturers transition away from fixed endcap duodenoscopes to those with features that significantly improve cleaning and disinfection or eliminate the need for reprocessing altogether [5]. Consequently, with objective of eliminating infection transmission associated with use of contaminated reusable duodenoscopes, endoscope manufacturers have moved to develop single-use platforms. This opinion will review the current status and future prospects of this new technology. Open in a separate window Box 1 No caption available

While there is consensus that the COVID-19 pandemic has negatively impacted delivery of routine clinical care and has put enormous stress on the financial status of healthcare systems, definitive data on the effect of this ongoing pandemic on individual subspecialties, such as interventional endoscopy, are lacking. In an audit, we projected a 7.3% decline in the annual procedural volume, 15.2% increase in anticipated procedure-related reimbursement and 22.6% loss in downstream revenue to the health system, per Medicare fee structure calculations. While lack of patient enrolment delayed conclusion of clinical trials, educational activities transitioned from inperson to online attendance with greater outreach and more delegate participation. Some changes, particularly pertaining to patient referrals and education, are likely permanent. The healthcare system has not experienced a pandemic crisis in several generations. When healthcare delivery is severely disrupted, screening and diagnostic evaluations can often be delayed without adversely affecting long-term health. However, for interventional endoscopy centres, where referrals are often for diagnosis of suspected malignancies or for minimally invasive treatment such as resection of early cancer, delay in medical care carries consequences. While an estimated 18 million GI endoscopic procedures are performed each year, before and after undergoing procedures, patients often require additional work-up that includes hospitalisations, diagnostic investigations and oncological or surgical treatment. These evaluations and interventions generate both direct and indirect downstream revenue for health systems.1 While it is widely believed that healthcare institutions face unprecedented clinical workflow and financial pressures due to COVID-19,2 its impact on the discipline of interventional endoscopy is unclear. Our objective was to examine the clinical, financial and academic implications of COVID-19 on a tertiary-level interventional endoscopy centre in the USA. The Center for Interventional Endoscopy, instituted in the AdventHealth Orlando hospital in April 2013, is staffed by 5 full-time endoscopists and 62 support personnel …

Background: Recent attempts to develop more efficacious treatments for asthma, a TH2-dominant disease, have incorporated mesenchymal stem cell (MSC)-based cell therapies. Despite numerous previous studies, the full action mechanism of the pathogenesis of asthma remains undiscovered, and the need for further investigation is increasing in order to identify more effective target molecules. Objective: This study aimed to evaluate the anti-asthmatic effects of intratracheally administered MSCs primed with Liproxstatin-1, a potent ferroptosis inhibitor. In addition, we sought to examine the changes within macrophage populations and their characteristics in asthmatic conditions to explain the pathogenesis of asthma. Methods: Seven-week-old transgenic (TG) mice, constitutively overexpressing lung-specific interleukin (IL)-13, were used to simulate chronic asthma. Human umbilical cord-derived MSCs (hUC-MSCs) primed with Liproxstatin-1 were intratracheally administered four days prior to sampling. Bronchoalveolar lavage fluid and lung tissues were then evaluated. Results: IL-13 TG mice demonstrated phenotypes of chronic asthma, including severe inflammation in the respiratory organs, goblet cell hyperplasia, and subepithelial fibrosis. The ratio of Ly6C+M2 macrophages, found within the pro-inflammatory CD11c+CD11b+ macrophages, was also upregulated, and showed a strong correlation with lung eosinophil counts. Upon intratracheal administration of Liproxstatin-1-primed hUC-MSCs, which showed enhanced ability to downregulate the activation of TH2 cells compared to naive MSCs in vitro, the IL-13 TG mice showed reduced airway inflammation and fibrosis, in addition to a decreased ratio of Ly6C+M2 macrophages. Conclusions: Intratracheal administration is an effective method of MSC delivery, and macrophages hold great potential as an additional therapeutic target for asthma.

Background and aim Despite the increasing number of procedures being performed, there is no consensus on the optimal approach to performing direct endoscopic necrosectomy (DEN), which is a labor-intensive, nonstandardized intervention. We prospectively validated the usefulness of a predefined, structured, stepwise approach to DEN with the objective of improving procedural efficiency and resource use. Materials and methods A prospective study of patients with necrotizing pancreatitis who after endoscopic transluminal drainage did not have clinical improvement and required DEN. The study was undertaken in 2 phases. Phase I was a retrospective analysis of interventions performed using an unstructured, conventional approach. Median of 3 necrosectomy sessions (range, 2 to 3) were required to achieve 80% treatment success in 20 patients. On the basis of these observations, a structured approach that included 3 steps (debridement, necrosis extraction, and irrigation) was developed and validated prospectively in phase II in 39 patients. The main outcome was to compare procedural efficiency defined as a number of necrosectomy sessions to achieve treatment success. Results Although there was no significant difference in treatment success (phase I=80.0 vs. phase II=94.9%, P=0.17), the procedure was more efficient in phase II [median session, 2 (interquartile range=1 to 3) vs. 3 (interquartile range=2 to 3); P=0.003]. Multiple logistic regression analysis revealed that a structured, stepwise approach was associated with fewer necrosectomy sessions to achieve treatment success (odds ratio=4.7; 95% confidence interval=1.5-15.0; P=0.008) when adjusted for patient demographics, lab parameters, and disease characteristics. Conclusions By decreasing the number of necrosectomy sessions, a structured, stepwise approach to endoscopic necrosectomy seems to improve procedural efficiency.

ObjectiveSingle-use duodenoscopes have been recently developed to eliminate risk of infection transmission from contaminated reusable duodenoscopes. We compared performances of single-use and reusable duodenoscopes in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).DesignPatients with native papilla requiring ERCP were randomised to single-use or reusable duodenoscope. Primary outcome was comparing number of attempts to achieve successful cannulation of desired duct. Secondary outcomes were technical performance that measured duodenoscope manoeuvrability, mechanical-imaging characteristics and ability to perform therapeutic interventions, need for advanced cannulation techniques or cross-over to alternate duodenoscope group to achieve ductal access and adverse events.Results98 patients were treated using single-use (n=48) or reusable (n=50) duodenoscopes with >80% graded as low-complexity procedures. While median number of attempts to achieve successful cannulation was significantly lower for single-use cohort (2 vs 5, p=0.013), ease of passage into stomach (p=0.047), image quality (pConclusionGiven the overall safety profile and similar technical performance, single-use duodenoscopes represent an alternative to reusable duodenoscopes for performing low-complexity ERCP procedures in experienced hands.Trial registration numberClinicaltrials.gov number: NCT04143698

Background & Aims Indwelling plastic endoprosthesis in patients with disconnected pancreatic duct syndrome (DPDS) reduces the risk of pancreatic fluid collection (PFC) recurrence. Although lumen-apposing metal stents (LAMS) are used with increasing frequency for PFC drainage, they require timely removal and little is known about their effects in patients with DPDS and recurrence of PFC. Methods We performed a prospective study of patients who underwent endoscopic ultrasound-guided drainage of PFC using LAMS and were found to have DPDS. After resolution of PFC, LAMS were replaced with double-pigtail plastic stents. The primary outcome was to compare PFC recurrence between patients with DPDS who did vs did not receive replacements with plastic stents after removal of the LAMS. Results Of 188 PFC patients treated with LAMS, 94 had DPDS, 71 had intact pancreatic ducts, and duct patency was unknown in 23. In patients with DPDS, replacement of LAMS with plastic stents was successful in 70 patients (74.5%) and technically unsuccessful in 24 patients (25.5%). At a median follow up of 183 days (interquartile range, 179–188 days), although none of the patients with an intact duct had a recurrence of PFC, 7 of the 94 patients with DPDS had recurrence of PFC (7.4%) (P = .020). PFC recurred in 1 of 70 patients with DPDS in whom replacement of LAMS with plastic stent was successful (1.4%) and in 6 of 24 patients with unsuccessful stent replacement (25.0%) (P = .001). Conclusions In treatment of PFCs with LAMS in patients with DPDS, it is important to replace the LAMS with indwelling plastic stents to minimize PFC recurrence and reduce morbidity. Clinicaltrials.gov no: NCT02422095

Although rare in occurrence, adverse events such as delayed bleeding and buried stent syndrome have been reported after lumen-apposing metal stents (LAMS) placement in patients undergoing endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs). In a prospective study, we observed delayed adverse events in 6.4% of 188 patients which occurred when the PFCs were 7 cm or smaller in size and the removal of LAMS was delayed beyond 4 weeks. LAMS are being increasingly preferred over double pigtail plastic stents for patients undergoing EUS-guided PFC drainage because their deployment is technically easy and the wide lumen facilitates quick drainage of cyst contents. However, delayed adverse events such as bleeding and buried stent syndrome have been reported after LAMS placement.1–3 In this study, we attempted to identify predictors of adverse events by examining data that were collected prospectively in all patients undergoing EUS-guided PFC drainage using LAMS. By institutional protocol, after LAMS placement, the endoprostheses were removed at outpatient follow-up in 3–4 weeks and all patients were contacted by telephone call to obtain follow-up at 6 months. The data collected included 292 demographic, laboratory, radiological, technical, clinical and treatment outcome variables, with a minimum follow-up duration of 6 months (NCT02422095). Patient details, PFC characteristics, disease severity and clinical outcomes were summarised as means with SD and medians with IQR for continuous variables and as frequencies and proportions for categorical variables. In order to identify the factors associated with …

Colonic laterally spreading lesions (LSL) are increasingly managed using endoscopic methods that comprise two main techniques: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). In this review, we aimed to review the most recent literature on selection of the best endoscopic technique in the management of colonic LSL. EMR and ESD are complimentary techniques in the management of patients with colonic LSL. EMR is safe and effective in most patients with LSL, except for cancers with submucosal invasion in whom R0 resection is favored.

ObjectiveAlthough lumen-apposing metal stents (LAMS) are increasingly used for drainage of walled-off necrosis (WON), their advantage over plastic stents is unclear. We compared efficacy of LAMS and plastic stents for WON drainage.DesignPatients with WON were randomised to endoscopic ultrasound-guided drainage using LAMS or plastic stents. Primary outcome was comparing total number of procedures to achieve treatment success defined as symptom relief in conjunction with WON resolution on CT at 6 months. Secondary outcomes were treatment success, procedure duration, clinical/stent-related adverse events, readmissions, length of hospital stay (LOS) and costs.Results60 patients underwent LAMS (n=31) or plastic stent (n=29) placement. There was no significant difference in total number of procedures performed (median 2 (range 2–7) LAMS vs 3 (range 2–7) plastic, p=0.192), treatment success, clinical adverse events, readmissions, LOS and overall treatment costs between cohorts. Although procedure duration was shorter (15 vs 40 min, pConclusionExcept for procedure duration, there was no significant difference in treatment outcomes between LAMS and plastic stents. To minimise adverse events with LAMS, patients should undergo follow-up imaging and stent removal at 3 weeks if WON has resolved.Trial registration numberNCT02685865.

Lumen-apposing metal stents are integrated in a single-step delivery system for draining intra-abdominal fluid collections. The theoretic advantage of lumen-apposing stents is the ability to approximate the wall of the drained cavity or organ to the gastrointestinal tract lumen. The use of lumen-apposing stents now includes drainage of organs adjacent to the stomach/duodenum and creation of anastomosis between the stomach and jejunum. The lumen-apposing stents may also serve as a conduit for accessing the remnant stomach for performing biliary tract interventions. This article outlines the approach to placement of lumen-apposing metal stents, technical challenges, and measures to counter adverse events.

Determining an accurate diagnosis in indeterminate biliary strictures is challenging with historically low sensitivity of 50-60% as all presently available diagnostic modalities possess some degree of inherent limitations.1-3 However, the development of the second-generation single-operator cholangioscopy system (SpyGlassDS, Boston Scientific Corp.) has resulted in a significant improvement in the diagnostic sensitivity to 75-85%, and we have recently shown in a randomized trial that an accurate diagnosis can be established in 90% of patients with indeterminate biliary strictures.4,5.

As cytological aspirates from endoscopic-ultrasound-guided fine needle aspiration (EUS-FNA) has limited diagnostic sensitivity and are suboptimal for molecular profiling and morphological characterisation of certain neoplasms, a fine needle biopsy (FNB) with three-pronged (Franseen geometry) cutting edge has been developed to procure histology. In a randomised trial of 46 patients with pancreatic masses, procurement of histological core tissue as evidenced by total tissue and tumour areas was significantly higher for 22G FNB than FNA needle. Also, retention of tissue architecture and presence of desmoplastic fibrosis, which are critical for ancillary testing and molecular profiling, respectively, were significantly higher for FNB. Given the poor outcomes of traditional chemotherapy, there is increased focus on molecular profiling so that pancreatic cancer treatment can be personalised. Pancreatic tissue with architecture containing both tumour cells and desmoplastic stroma is pivotal for molecular analysis. Although EUS-FNA is diagnostically accurate, the cytological aspirate is suboptimal for DNA sequencing.1–3 Therefore, clinical trials evaluating personalised treatment in pancreatic cancer prefer tissue procurement via percutaneous or surgical biopsies over EUS-FNA.4 Recently, a three-plane symmetric needle with Franseen geometry has been developed for performing EUS-guided FNB.5 The large crown-tip with three cutting edges and long insertion length were postulated to facilitate histological tissue procurement (figure 1A). We conducted a randomised trial comparing tissue acquisition between the 22-gauge (G) Franseen biopsy (Acquire, Boston Scientific) and 22G standard bevel FNA (Expect, Boston Scientific) (figure 1B) needles in patients undergoing EUS-guided sampling of pancreatic masses. Figure 1 The 22G Franseen design with a crown-shaped needle tip revealing the three symmetrical planes for histological core tissue acquisition (A). The standard bevel needle used at fine needle aspiration for procurement of cytological aspirates (B). EUS-guided sampling was performed using both needle types, the 22G FNB and 22G FNA needles, with randomisation of the order in which the …

Given the lack of procedure standardization, findings vary from analyses of pancreatic tissues collected by endoscopic ultrasound-guided fine-needle biopsy. It is not clear which needle and technique yield the best specimen for analysis. We compared the specimen quality and accuracy of diagnoses made from samples collected by fine-needle biopsy needles using different collection techniques.Patients found to have pancreatic masses during imaging (n = 129) were assigned randomly to groups from whom pancreatic tissue samples were collected by reverse-bevel, Menghini-tip, franseen, or fork-tip needles. A second randomization determined the technical sequence of biopsies in each patient (suction, no suction, and stylet retraction). Two independent pathologists, blinded to the type of needle and sampling technique, analyzed all the samples. Final diagnoses of malignancy were made based on surgical resection, death from cancer progression, or findings from radiology or clinical follow-up evaluations (reference standard). The primary objective was to compare the cellularity of the samples collected, defined as the proportion of core tissue in the biopsy sample. Secondary objectives were to compare the accuracy of diagnoses made from biopsy samples and identify factors associated with high cellularity.One-hundred and nine patients had a final diagnosis of malignancy (84.5%) and 20 patients had benign disease (15.5%). Samples collected by fork-tip or franseen needles had significantly higher cellularity than samples collected by reverse-bevels or Menghini-tip needles (P.001). Neoplasias were identified with greater than 90% accuracy using samples collected by fork-tip or franseen needles (P.001 compared with other needles). On multivariable regression analysis, use of franseen needles (odds ratio [OR], 4.42; 95% CI, 2.58-7.58; P.001) or fork-tip needles (OR, 3.86; 95% CI, 2.24-6.64; P.001), stylet retraction (OR, 2.13; 95% CI, 1.21-3.72; P = .008), no suction (OR, 2.74; 95% CI, 1.57-4.80; P.001), and pancreatic mass larger than 3 cm (OR, 1.92; 95% CI, 1.21-3.05; P = .005) were associated with high cellularity of the sample.In patients with suspected pancreatic cancer, samples with the highest degree of cellularity in a single biopsy, resulting in a diagnostic accuracy of 90% of higher, were collected by fine-needle biopsy using the franseen or fork-tip needle. Clinicaltrials.gov no: NCT04085055.

Background and Aim Recently, a 22 gauge (G) needle with a Franseen tip design was developed for EUS-guided fine needle biopsy (EUS-FNB). This study evaluated the performance of the Franseen biopsy needle in EUS-guided tissue acquisition. Methods This is a retrospective study of patients who underwent EUS-FNB using the Franseen needle. Lesions were sampled either using only the Franseen needle or after failed diagnostic fine needle aspiration (FNA). After rapid onsite evaluation (ROSE), two dedicated passes were performed for histological assessment using the cell block technique. Main outcomes were (a) rates of diagnostic adequacy for ROSE and histological diagnosis and (b) quality of histology as determined by total tissue area and tumor percentage in tissue. Results 30 patients underwent EUS-FNB of pancreatic or other masses over a 3-month period. 24 lesions were sampled using only the Franseen needle and 6 after failed diagnostic FNA. The final diagnosis was pancreatic cancer in 12, gastrointestinal stromal cell tumor in 5, other tumors in 4 and benign disease in 9. Diagnostic adequacy for ROSE was 96.6% and a histological diagnosis was established in 96.7% of patients. The median tissue area was 2.9mm2 (IQR=0.68-8.71mm2) and the median tumor percentage in tissue was 73.9% (IQR=44-97.6). The rates of technical success and adverse events were 96.7% and 3.3%, respectively. Conclusions Preliminary data suggest that the Franseen needle yields diagnostic material for ROSE and histology in greater than 95% of patients. This article is protected by copyright. All rights reserved.

Background and Aims Tissue diagnosis, regardless of technique or endoscope used, can be challenging in patients with indeterminate biliary strictures (IDBSs). This exploratory study evaluated the utility and role of rapid onsite evaluation of touch imprint cytology (ROSE-TIC) when single-operator cholangioscopy (SOC)-guided biopsies of IDBSs are performed. Methods Patients with IDBSs were evaluated by intraprocedural ROSE-TIC during SOC-guided biopsy procedures. Final diagnosis was established by long-term patient follow-up in conjunction with off-site findings or surgical histology. The main outcome measure was to evaluate the utility of ROSE-TIC by determination of its operating characteristics and comparison with off-site histologic assessment. Results Of 31 patients with IDBSs, tissue diagnosis was indeterminate at prior ERCP-guided brush and/or biopsy in 14, prior EUS-guided FNA (EUS-FNA) in 6, and a mass could not be identified at EUS in 11. The mean number of biopsies performed was 3.3 (range 1-8), and diagnostic interpretation by ROSE-TIC was diagnostic and/or suspicious for carcinoma in 15, benign in 13, atypical-reactive in 2, and bile duct intraductal papillary mucinous neoplasm in 1. Final diagnosis by surgical histology (n = 4), death by disease (n = 10), and patient follow-up (n = 17) showed that the overall sensitivity of ROSE-TIC for diagnosing malignancy was 100%, specificity 88.9%, positive predictive value 86.7%, negative predictive value 100%, and diagnostic accuracy 93.5%. Conclusions Preliminary data suggest that the diagnostic outcomes of SOC-guided biopsies in IDBSs can be significantly improved by using ROSE-TIC. This technique also may benefit centers that rely mainly on fluoroscopy-guided intraductal biopsies.

Accurate diagnosis and staging of pancreatic neoplasms is essential for surgical planning and identification of locally advanced and metastatic disease that is incurable by surgery. The ability to position the endoscopic ultrasonography (EUS) transducer close to the pancreas combined with the use of fine-needle aspiration enables the accurate diagnosis of pancreatic cysts and solid masses. EUS is also increasingly being used to procure core tissue for molecular analysis that facilitates personalized treatment of pancreatic cancer. Various therapeutic interventions can be undertaken under EUS guidance. This article focuses on the applications of EUS and endoscopic retrograde cholangiopancreatography in pancreatic neoplasms.

Background & Aims Although single-operator cholangioscopy (SOC)-guided lithotripsy and large balloon sphincteroplasty (LBS)-based techniques are effective rescue measures, the ideal approach to management of difficult bile duct stones is unclear. We conducted a randomized trial to compare the effectiveness of SOC-guided lithotripsy and LBS-based approaches for endoscopic management of difficult bile duct stones. Methods Patients with difficult bile duct stones who failed retrieval using balloon or basket were randomly assigned to groups that received SOC-guided laser lithotripsy (SOC-LL, n = 33) or LBS (n = 33), from June 2016 through August 2018. When assigned treatment was unsuccessful, patients underwent mechanical lithotripsy before crossing over to the other group. The main outcome was treatment success, defined as ability to clear the duct in 1 session. Secondary outcomes were adverse events and treatment costs. Results A higher proportion of patients in the SOC-LL group had treatment success (93.9%) than in the LBS group (72.7%; P = .021). On multiple logistic regression analysis, treatment success was significantly associated with use of SOC-LL (odds ratio [OR], 8.7; 95% CI, 1.3–59.3; P = .026), stone to extrahepatic bile duct ratio of 1 or less (OR, 28.8; 95% CI, 1.2–687.6; P = .038), and lack of a tapered bile duct (OR, 26.9; 95% CI, 1.3–558.2; P = .034). There was no significant difference between groups in adverse events (9.1% in the SOC-LL group vs 3.0% in the LBS group, P = .61) or overall treatment cost ($16,684 in the SOC-LL group vs $10,626 in the LBS group; P = .097). Conclusions In a randomized trial of patients with difficult bile stones that cannot be cleared by standard maneuvers, SOC-guided lithotripsy leads to duct clearance in a significantly higher proportion of patients than LBS-particularly when stone size exceeds the diameter of the extrahepatic bile duct. Adjunct lithotripsy might be required in patients with tapered distal bile duct, because LBS alone is less likely to be successful. ClinicalTrials.gov no: NCT00852072.