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Background and Aims Digital single-operator cholangioscopy (DSOC) allows direct visualization of the biliary tree for evaluation of biliary strictures. Our objective was to assess the interobserver agreement (IOA) of DSOC interpretation for indeterminate biliary strictures using newly refined criteria. Methods Fourteen endoscopists were asked to review an atlas of reference clips and images of 5 criteria derived from expert consensus. They then proceeded to score 50 deidentified DSOC video clips based on the visualization of the following: (1) tortuous and dilated vessels, (2) irregular nodulations, (3) raised intraductal lesion, (4) irregular surface with or without ulcerations, and (5) friability. The endoscopists then diagnosed the clips as neoplastic or non-neoplastic. Intraclass correlation (ICC) analysis was done to evaluate interrater agreement for both criteria sets and final diagnosis. Results Clips of 41 malignant lesions and 9 benign lesions were scored. Three out of 5 revised criteria had almost perfect agreement. ICC was almost perfect for presence of tortuous and dilated vessels (0.86), raised intraductal lesions (0.90), and presence of friability (0.83); substantial agreement for presence of irregular nodulations (0.71); and moderate agreement for presence of irregular surface with or without ulcerations (0.44). The diagnostic ICC was almost perfect for neoplastic diagnosis (0.90) and non-neoplastic (0.90). The overall diagnostic accuracy using revised criteria was 77%, ranging from 64% to 88%. Conclusion The IOA and accuracy rate of DSOC using the new Mendoza criteria shows a significant increase of 16% and 20% compared with previous criteria. The reference atlas helps with formal training and may improve diagnostic accuracy.

We describe a case of a gastric neuroendocrine tumor (NET) in a patient with a history of long- term proton pump inhibitor (PPI) use. A 29- year- old man using PPI for the last 10 years due to gastroesophageal reflux disease developed progressive bouts of heartburn. Upper gastrointestinal endoscopy localized an elevated lesion with central depression in the greater curvature of gastric body. Lesion biopsies revealed a well- differentiated neuroendocrine tumor. Despite PPIs have a well- established safety profile, concerns have been raised about a potential relationship between PPI- induced hypergastrinemia and the development of neuroendocrine tumors.

EUS-guided biliary drainage (EUS-BD) offers minimally invasive decompression when conventional endoscopic retrograde cholangiopancreatography fails. Stents can be placed from the intrahepatic ducts into the stomach (hepaticogastrostomy [HG]) or from the extrahepatic bile duct into the small intestine (choledochoduodenostomy [CCD]). Long-term patency of these stents is unknown. In this study, we aim to compare long-term patency of CCD versus HG.Consecutive patients from 12 centers were included in a registry over 14 years. Demographics, procedure info, adverse events, and follow-up data were collected. Student's t-test, Chi-square, and logistic regression analyses were conducted. Only patients with at least 6-month follow-up or who died within 6-month postprocedure were included.One-hundred and eighty-two patients were included (93% male; mean age: 70; HG n = 95, CCD n = 87). No significant difference in indication, diagnosis, dissection instrument, or stent type was seen between the two groups. Technical success was 92% in both groups. Clinical success was achieved in 75/87 (86%) in the HG group and 80/80 (100%) in the CCD group. A trend toward higher adverse events was seen in the CCD group. A total of 25 patients out of 87 needed stent revision in the HG group (success rate 71%), while eight out of 80 were revised in the CCD group (success rate 90%). Chi square shows CCD success higher than HG (90% vs. 71%, P = 0.010). After adjusting for diagnosis, jaundice or cholangitis presentation, instrument used for dissection, and gender, CCD was 4.5 times more likely than HG to achieve longer stent patency or manage obstruction (odds ratio 4.5; 95% 1.1548-17.6500, P = 0.0302).CCD is associated with superior long-term patency than HG but with a trend toward higher adverse events. This is particularly important in patients with increased survival. Additional studies are required before recommending a change in practice.

Endoscopic ultrasound training has a learning curve greater than the other endoscopic therapeutic techniques. One of the preclinical teaching methods is the use of ex vivo porcine models.To describe five ex vivo porcine models for training in therapeutic echoendoscopic procedures.Using porcine digestive tract containing esophagus, stomach, duodenum, spleen, liver and gallbladder, five models for therapeutic echoendoscopy training were described. With other segments of the porcine pieces (such as the bladder, spleen segment and omentum segment) and with easily accessible materials (such as grape and ultrasound gel), lesions were simulated to be treated. These models were applied in the Hands on course at the IRCAD (Institut de recherche contre les cancers de l'appareil digestif) Barretos of 2017. Endoscopic equipment and instruments are the same as those used in clinical practice.The models are easily reproducible and do not require exchange during the hands on course period. Endoscopic and echographic imaging and tactile sensitivity are similar to the real one.The models described in this study demonstrated to be realistic, easy to reproduce and allow repetition during the same session. However, comparative studies are necessary to verify the real impact on teaching.