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Motorized Spiral Enteroscopy (MSE) reduces procedure time and increases insertion depth into the small bowel; however, there is scarce evidence on factors affecting MSE efficacy.To evaluate diagnostic yield and adverse events of MSE including patients with prior major abdominal surgery.A prospective observational study was conducted on patients undergoing MSE from June 2019 to December 2021. Demographic characteristics, procedure time, depth of maximum insertion (DMI), technical success, diagnostic yield, and adverse events were collected.Seventy-four anterograde (54.4%) and 62 retrograde (45.6%) enteroscopies were performed in 117 patients (64 males, median age 67 years). Fifty patients (42.7%) had prior major abdominal surgery. Technical success was 91.9% for anterograde and 90.3% for retrograde route. Diagnostic yield was 71.6% and 61.3%, respectively. The median DMI was 415 cm (264-585) for anterograde and 120 cm (37-225) for retrograde enteroscopy. In patients with prior major abdominal surgery, MSE showed significantly longer small bowel insertion time (38 vs 29 min, p = 0.004), with similar diagnostic yield (61 vs 71.4%, p = 0.201) and DMI (315 vs 204 cm, p = 0.226). The overall adverse event rate was 10.3% (SAE 1.5%), with no differences related to prior abdominal surgery (p = 0.598). Patients with prior surgeries directly involving the gastrointestinal tract showed lower DMI (189 vs 374 cm, p = 0.019) with equal exploration time (37.5 vs 38 min, p = 0.642) compared to those with other abdominal surgeries.MSE is effective and safe in patients with major abdominal surgery, although longer procedure times were observed. A lower depth of insertion was detected in patients with gastrointestinal surgery.

Three percent of patients with pancreatic ductal adenocarcinoma (PDAC) present a germline pathogenic variant (GPV) associated with an increased risk of this tumor, CDKN2A being one of the genes associated with the highest risk. There is no clear consensus on the recommendations for surveillance in CDKN2A GPV carriers, although the latest guidelines from the International Cancer of the Pancreas Screening Consortium recommend annual endoscopic ultrasound (EUS) or magnetic resonance imaging (MRI) regardless of family history. Our aim is to describe the findings of the PDAC surveillance program in a cohort of healthy CDKN2A GPV heterozygotes. This is an observational analysis of prospectively collected data from all CDKN2A carriers who underwent screening for PDAC at the high-risk digestive cancer clinic of the “Hospital Clínic de Barcelona” between 2013 and 2021. A total of 78 subjects were included. EUS or MRI was performed annually with a median follow-up of 66 months. Up to 17 pancreatic findings were described in 16 (20.5%) individuals under surveillance, although most of them were benign. No significant precursor lesions were identified, but an early PDAC was detected and treated. While better preventive strategies are developed, we believe that annual surveillance with EUS and/or MRI in CDKN2A GPV heterozygotes may be beneficial.

Background It is unknown whether there is an advantage to using the wet-suction or slow-pull technique during endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) with new-generation needles. We aimed to compare the performance of each technique in EUS-FNB. Methods This was a multicenter, randomized, single-blind, crossover trial including patients with solid lesions of ≥ 1 cm. Four needle passes with 22 G fork-tip or Franseen-type needles were performed, alternating the wet-suction and slow-pull techniques in a randomized order. The primary outcome was the histological yield (samples containing an intact piece of tissue of at least 550 μm). Secondary end points were sample quality (tissue integrity and blood contamination), diagnostic accuracy, and adequate tumor fraction. Results Overall, 210 patients with 146 pancreatic and 64 nonpancreatic lesions were analyzed. A tissue core was retrieved in 150 (71.4 %) and 129 (61.4 %) cases using the wet-suction and the slow-pull techniques, respectively (P = 0.03). The mean tissue integrity score was higher using wet suction (P = 0.02), as was the blood contamination of samples (P Conclusion Overall, the wet-suction technique in EUS-FNB resulted in a higher tissue core procurement rate compared with the slow-pull method. Diagnostic accuracy and the rate of samples with adequate tumor fraction were similar between the two techniques.

Background Biliary sphincter disorders after liver transplantation (LT) are poorly described. We aim to describe the presence and outcome of patients with papillary stenosis (PS) and functional biliary sphincter disorders (FBSDs) after LT according to the updated Rome IV criteria. Methods We reviewed all endoscopic retrograde cholangiopancreatographies (ERCPs) performed in LT recipients between January 2003 and December 2019. Information on clinical and endoscopic findings was obtained from electronic health records and endoscopy databases. Laboratory and clinical findings were collected at the time of ERCP and 1 month after ERCP. Results Among the 1,307 LT recipients, 336 underwent 849 ERCPs. Thirteen (1.0%) patients met the updated Rome IV criteria for PS [former sphincter of Oddi dysfunction (SOD) type I] and 14 patients (1.0%) met the Rome IV criteria for FBSD (former SOD type II). Biliary sphincterotomy was performed in 13 PS and 10 FBSD cases. One month after sphincterotomy, bilirubin, gamma-glutamyl transferase and alkaline phosphatase levels decreased in 85%, 61%, and 92% of those in the PS group (P = 0.019, 0.087, and 0.003, respectively) and in 50%, 70%, and 80% of those in the FBSD group (P = 0.721, 0.013, and 0.093, respectively). All the 14 patients initially suspected of having a FBSD turned out to have a different diagnosis during the follow-up. Conclusions PS after LT is uncommon and occurs in only 1% of LT recipients. Our data do not support the presence of an FBSD after LT. Sphincterotomy is a safe and effective procedure in LT recipients with PS.

Resumen Introduccion En un estudio previo demostramos que un pequeno programa de formacion mejoraba los indicadores de calidad de la esofagogastroduodenoscopia (EGD) que llegaban a los estandares recomendados. Sin embargo, desconocemos el efecto de esta formacion a largo plazo. El objetivo de este estudio fue valorar la calidad de las EGD despues de 3 anos de haber realizado un programa de mejora. Material y metodos Estudio comparativo de 2 cohortes: EGD posteriores a un programa de formacion realizado en 2016 (grupo A) y EGD en enero-marzo de 2019 (grupo B). El grupo B se dividio en 2 subgrupos: endoscopistas que habian participado en el programa de formacion previo (B1) y los que no (B2). Se utilizaron los indicadores de calidad intraprocedimiento recomendados por la ASGE-ACG. Resultados Se analizaron un total de 1.236 EGD, 600 en el grupo A y 636 en el B (439 subgrupo B1 y 197 subgrupo B2). El numero de exploraciones completas fue inferior en el grupo B (566 [94,3%] vs. 551 [86,6%]; p Conclusiones La mejora observada en 2016 tras un programa de formacion no perdura a los 3 anos. Es necesario hacer programas de formacion continuados para mantener la calidad de la EGD por encima de los estandares recomendados.

Resumen Objetivo Evaluar la eficacia y seguridad de la terapia de vacio endoscopica (TVE) en perforaciones y dehiscencias del tracto digestivo superior. Pacientes y metodos Estudio retrospectivo observacional donde se incluyeron todos los pacientes que presentaron algun defecto del tracto gastrointestinal superior y que fueron sometidos a TVE en el periodo comprendido entre abril de 2017 y febrero de 2019 en 3 centros espanoles. Para ello se utilizo el unico sistema de terapia de vacio aprobado para uso endoscopico hasta la fecha (Eso-SPONGEr; B. Braun Melsungen AG, Melsungen, Alemania). Resultados Un total de 11 pacientes fueron sometidos a TVE como tratamiento de una dehiscencia de sutura anastomotica tras esofaguectomia (n = 7), gastrectomia (n = 2), como tratamiento de una perforacion esofagica tras septomiotomia endoscopica de Zenker (n = 1) y tras una perforacion esofagica espontanea o sindrome de Boerhaave (n = 1). La mediana del tamano de la cavidad fue de 8 × 3 cm. De mediana, la TVE se inicio a los 7 dias de la cirugia inicial. La mediana de duracion de la TVE fue de 28 dias. La mediana de esponjas colocadas fue de 7 y el intervalo de recambio de las esponjas, de 3,7 dias. En 10 casos (91%) se consiguio el cierre del defecto y en 9 casos (82%) la resolucion clinica del cuadro infeccioso asociado. Cinco pacientes presentaron algun evento adverso: 3 estenosis anastomoticas, un episodio de dolor retrofaringeo y un caso de neumonia de nueva aparicion. La mediana de estancia hospitalaria desde el inicio de la TVE fue de 45 dias. Un paciente fallecio debido a complicaciones septicas secundarias a la dehiscencia de sutura. Conclusion La TVE tiene una eficacia superior al 90% en las perforaciones y fugas anastomoticas del tracto digestivo superior. Adicionalmente es una terapia segura, siendo los eventos adversos leves.

Resumen Objetivo Conocer el estado actual de la ultrasonografia endoscopica (USE) en Espana. Metodos Analisis descriptivo a partir de una encuesta nacional con 11 preguntas: 10 relativas a la tecnica y una a la formacion y experiencia de los ecoendoscopistas. Resultados Contestaron 60 endoscopistas correspondientes a 48 de los 97 (49,5%) hospitales que realizan USE en Espana. Se contabilizaron en un ano 28.678 exploraciones (20.311 diagnosticas, 7.446 con puncion y 921 terapeuticas). Un 64% de los hospitales realiza entre 300 y 999 pruebas por ano. Todos los centros disponen de ecoendoscopio radial y sectorial, con una mediana de 2 por hospital (2-8). La aguja de citologia que mas se usa es la de 22 gauges (98%) y de histologia la Procore (72%). El estudio del pancreas y la via biliar es la indicacion mas frecuente de USE diagnostica (60%), seguido de la estadificacion de neoplasias del tubo digestivo (20%). El 72% de los hospitales dispone de un citopatologo en la sala y la sedacion es administrada a partes iguales por los endoscopistas y anestesistas. En cuanto a la experiencia, el 45% de los ecoendoscopistas realizan menos de 300 exploraciones anuales y la mediana de tiempo de formacion es de 6 meses (0,5-36). Conclusiones La USE esta adecuadamente implementada en Espana y se dispone de buen equipamiento. Sin embargo, es necesario establecer un programa estandarizado de formacion en USE, ya que la de muchos ecoendoscopistas podria ser insuficiente segun los estandares establecidos por las Sociedades Cientificas.

Aim To understand the current state of endoscopic ultrasonography (EUS) in Spain. Methods Descriptive analysis from a national survey with 11 questions: 10 related to technique and 1 to the training and experience of the endoscopists. Results Sixty endoscopists from 48 of the 97 (49.5%) hospitals that perform EUS in Spain responded to the survey. A total of 28,678 procedures (20,311 diagnostic, 7446 with puncture and 921 therapeutic) were recorded over the course of one year. Approximately 64% of the hospitals perform between 300 and 999 tests per year. All have radial and sectorial echoendoscopes, with a median of 2 (2–8) scopes. For cytological diagnosis, the 22-gauge needle is the most commonly used (98%) and, for histological diagnosis, the Procore (72%). The study of the pancreas and bile duct is the most common indication for diagnostic EUS (60%), followed by the staging of digestive tract neoplasms (20%). Approximately 72% of the hospitals perform on-site cytopathology evaluations and sedation is administered in equal parts by both endoscopists and anaesthetists. In terms of experience, 45% of echoendoscopists perform fewer than 300 annual exams and the median training duration is 6 months (0.5–36). Conclusions EUS is adequately implemented in Spain and good equipment is available. However, it is necessary to establish a standardised EUS training programme since the one undertaken by many echoendoscopists could prove insufficient according to the standards established by Scientific Societies.

Background and Aims: The benefit of rapid on-site evaluation (ROSE) on the diagnostic accuracy of endoscopic ultrasound–guided fine-needle biopsy (EUS-FNB) has never been evaluated in a randomized study. This trial aimed to test the hypothesis that in solid pancreatic lesions (SPLs), diagnostic accuracy of EUS-FNB without ROSE was not inferior to that of EUS-FNB with ROSE. Methods: A noninferiority study (noninferiority margin, 5%) was conducted at 14 centers in 8 countries. Patients with SPLs requiring tissue sampling were randomly assigned (1:1) to undergo EUS-FNB with or without ROSE using new-generation FNB needles. The touch-imprint cytology technique was used to perform ROSE. The primary endpoint was diagnostic accuracy, and secondary endpoints were safety, tissue core procurement, specimen quality, and sampling procedural time. Results: Eight hundred patients were randomized over an 18-month period, and 771 were analyzed (385 with ROSE and 386 without). Comparable diagnostic accuracies were obtained in both arms (96.4% with ROSE and 97.4% without ROSE, P = .396). Noninferiority of EUS-FNB without ROSE was confirmed with an absolute risk difference of 1.0% (1-sided 90% confidence interval, –1.1% to 3.1%; noninferiority P < .001). Safety and sample quality of histologic specimens were similar in both groups. A significantly higher tissue core rate was obtained by EUS-FNB without ROSE (70.7% vs. 78.0%, P = .021), with a significantly shorter mean sampling procedural time (17.9 ± 8.8 vs 11.7 ± 6.0 minutes, P < .0001). Conclusions: EUS-FNB demonstrated high diagnostic accuracy in evaluating SPLs independently on execution of ROSE. When new-generation FNB needles are used, ROSE should not be routinely recommended. (ClinicalTrial.gov number NCT03322592.)

Resumen Introduccion El registro y la medicion de los indicadores de calidad suponen una oportunidad de mejora. Sin embargo, no existen experiencias previas en nuestro medio sobre su cumplimiento en la esofagogastroduodenoscopia (EGD). Objetivo Analizar el cumplimiento de los criterios de calidad de las EGD y evaluar la mejora tras la realizacion de un programa de formacion. Pacientes y metodos Estudio comparativo de 2 cohortes: una, retrospectiva (grupo control) y otra, prospectiva (grupo intervencion), antes y despues de un programa de formacion que consistio en una sesion informativa y la mejora del programa de elaboracion de informes. Se utilizaron los indicadores de calidad propuestos por la American Society for Gastrointestinal Endoscopy y el American College of Gastroenterology. Resultados Se incluyeron un total de 1.200 EGD de forma secuencial (600 en cada grupo). Tras el programa de formacion se observo una mejoria significativa en los siguientes indicadores: indicacion documentada (93 vs. 99,8%; p Conclusion Un programa de formacion muy sencillo mejora los indicadores de calidad de la EGD, alcanzando la mayoria los estandares recomendados por la American Society for Gastrointestinal Endoscopy y el American College of Gastroenterology.

Resumen Introduccion Los polipos gastricos son lesiones habitualmente asintomaticas y constituyen un hallazgo durante la realizacion de una endoscopia. Objetivo Estudiar la frecuencia de los diferentes tipos de polipos gastricos en nuestro medio y su posible asociacion con otros factores. Pacientes y metodos Estudio retrospectivo de las gastroscopias realizadas durante 10 anos en un hospital de tercer nivel. Se recogieron datos demograficos, antecedentes patologicos, indicacion de la gastroscopia y caracteristicas morfologicas e histologicas de los polipos. Resultados Se incluyeron 41.253 gastroscopias, identificandose 827 (2%) con polipos gastricos correspondientes a 709 pacientes. La edad media fue 65,6 anos y un 62% fueron mujeres. El 53,9% tenian multiples polipos. La localizacion mas frecuente fue fundus y la mayoria fueron menores de 1 cm (83,3%). Se obtuvo muestra para anatomia patologica en 607 pacientes, siendo los mas frecuentes los polipos hiperplasicos (42,8%), seguidos de los polipos de glandula fundica (37,7%). Los factores que se asociaron de forma independiente a los polipos hiperplasicos fueron la edad y el ser polipo unico, de tamano ≥ 6 mm y localizacion no fundica. Contrariamente, los de glandula fundica se asociaron a la indicacion por reflujo y el ser multiples, Conclusiones Los polipos de glandula fundica e hiperplasicos son los mas frecuentes en nuestro medio, y tienen rasgos contrarios que pueden orientar al diagnostico histologico. En el caso de polipos unicos es recomendable la toma de biopsias para descartar el diagnostico de adenoma.

Background Bile leak after liver transplantation (LT) is commonly treated with endoscopic retrograde cholangiopancreatography (ERCP); however, there are limited data regarding the optimal treatment strategy. Objective We aimed to examine the role of ERCP in LT recipients with bile leaks at two large institutions. Methods We reviewed all ERCPs performed in LT recipients with bile leak and duct-to-duct biliary anastomosis at two high-volume transplant centers. Results Eighty patients were included. Forty-seven (59%) patients underwent ERCP with plastic stent placement (with or without sphincterotomy) and 33 patients (41%) underwent sphincterotomy alone. Complete resolution was obtained in 94% of the stent group vs. 58% of the sphincterotomy group ( p Conclusion ERCP with plastic stent placement is highly successful and more effective than sphincterotomy alone for post-LT bile leak treatment. These results indicate that ERCP and plastic stent placement should be considered the standard of care for the treatment of bile leaks in LT.

Background & Aims Guidelines recommend routine antibiotic prophylaxis for patients undergoing endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of pancreatic cysts, but there is conflicting evidence for its necessity. We investigated whether performing the procedure without antimicrobial prophylaxis increases the incidence of infection. Methods We performed a multicenter, randomized, noninferiority trial to compare prophylaxis with ciprofloxacin vs placebo in patients with a pancreatic cyst requiring EUS-FNA at multiple centers in Spain. From September 2014 to June 2018, patients were randomly assigned to groups that received the prophylaxis with ciprofloxacin (n = 112) or saline solution (n = 114, placebo). We recorded patients' demographic data, lesion characteristics, and procedure data and followed patients for 21 days. A total of 205 patients completed the trial (90.7%), receiving ciprofloxacin or the control, with no statistically significant differences in demographics, baseline data, or procedure characteristics between groups. The primary outcome was FNA-related infection. Secondary outcomes were incidence of fever, procedure complications, and medication-related adverse events. Results The only case of FNA-related infection (0.44%) occurred in a patient in the placebo group (0.87%); this patient developed acute pancreatitis and bacteremia after the procedure. Prevention of infection was not inferior in the control group; the difference between proportions was 0.87% (95% confidence interval, –0.84% to 2.59%). There were no differences between groups in fever (2 patients in each group: 1.78% vs 1.76%; P = 1.00) or other adverse events. Conclusions In a randomized trial of patients undergoing EUS-FNA for pancreatic cyst evaluation, we found the risk of infection to be low. The incidence of infections did not differ significantly with vs without ciprofloxacin prophylaxis. (ClinicalTrials.gov, Number: NCT02261896).

In a previous study we demonstrated that a simple training programme improved quality indicators of Oesophagogastroduodenoscopy (OGD) achieving the recommended benchmarks. However, the long-term effect of this intervention is unknown. The aim of this study was to assess the quality of OGDs performed 3 years after of having completed a training programme.A comparative study of 2 cohorts was designed as follows: Group A included OGDs performed in 2016 promptly after a training programme and Group B with OGDs performed from January to March 2019, this group was also divided into 2 subgroups: subgroup B1 of Endoscopists who had participated in the previous training programme and subgroup B2 of Endoscopists who had not. The intra-procedure quality indicators proposed by ASGE-ACG were used.A total of 1236 OGDs were analysed, 600 from Group A and 636 from Group B (439 subgroup B1 and 197 subgroup B2). The number of complete examinations was lower in Group B (566 [94.3%] vs. 551 [86.6%]; p0.001). A significant decrease was observed in nearly all quality indicators and they did not reach the recommended benchmarks: retroflexion in the stomach (96% vs. 81%; p0.001); Seattle biopsy protocol (86% vs. 50%; p=0.03), description of the upper GI bleeding lesion (100% vs. 62%; p0.01), sufficient intestinal biopsy specimens (at least 4) in suspected coeliac disease (92.5% vs. 18%; p0.001), photo documentation of the lesion (94% vs. 90%; p0.05). Regarding the overall assessment of the procedure (including correct performance and adequate photo documentation), a significant decrease was also observed (90.5% vs. 62%; p0.001). There were no differences between subgroups B1 and B2.The improvement observed in 2016 after a training programme did not prevail after 3 years. In order to keep the quality of OGDs above the recommended benchmarks, it is necessary to implement continuous training programmes.

Background and study aims EUS-FNA has suboptimal accuracy in diagnosing gastrointestinal subepithelial tumors (SETs). EUS-guided 22-gauge fine needle biopsy (EUS-FNB) and single-incision with needle knife (SINK) were proposed to increase accuracy of diagnosis. This study aimed to prospectively compare the diagnostic accuracy and safety of EUS-FNB with SINK in patients with upper gastrointestinal SETs. Patients and methods All adult patients referred for EUS evaluation of upper gastrointestinal SETs ≥ 15 mm in size were eligible for inclusion. Patients were randomized to undergo EUS-FNB or SINK. Lesions were sampled with a 22-gauge reverse beveled core needle in the EUS-FNB group and by a conventional needle-knife sphincterotome and biopsy forceps in the SINK group. Patients were blinded to the technique used. The primary outcome was diagnostic accuracy. Secondary outcomes included adverse events, histological yield and procedure duration. Study enrollment was terminated early due to poor recruitment. Results A total of 56 patients (31 male (55.37 %); mean age, 67.41 ± 12.70 years) were randomized to either EUS-FNB (n = 26) or SINK (n = 30). Technical success was 96.15 % and 96.66 %, respectively. The majority of lesions were gastrointestinal stromal tumors (51.78 %). No significant difference was found between EUS-FNB and SINK in terms of diagnostic accuracy for a malignant or benign disease (76 % vs. 89.28 %, respectively; P = 0.278). The rate of adverse events (none severe) was also comparable (7.69 % vs. 10 %, respectively; P = 1.0) including two abdominal pain episodes in the EUS-FNB group compared to two delayed bleeding (one requiring hospitalization and radiologic embolization) and 1 abdominal pain in the SINK group. Conclusion EUS-FNB and SINK are equally effective techniques for upper gastrointestinal SETs sampling. SINK can be associated with mild to moderate delayed bleeding.

Background and aims Precut papillotomy is widely used after failed biliary cannulation. Endoscopic ultrasound (EUS)-guided biliary access techniques are newer methods to facilitate access and therapy in failed cannulation. We evaluated the impact of EUS-guided biliary access on endoscopic retrograde cholangiopancreatography (ERCP) success and compared these techniques to precut papillotomy. Patients and methods We retrospectively compared two ERCP cohorts. One cohort consisted of biliary ERCPs (n = 1053) attempted in patients with native papillae and surgically unaltered anatomy in whom precut papillotomy and/or EUS-guided biliary access were routinely performed immediately after failed cannulation. This cohort was compared with a similar ERCP cohort (n = 1062) in which only precut papillotomy was available for failed cannulation. The following outcomes were compared: conventional cannulation success, rates of attempted advanced access techniques (precut or EUS), precut success, EUS-guided biliary access success, and ERCP failure rates. Results Although conventional cannulation success, rates of attempted advanced access technique (precut or EUS), and precut success were similar, the ERCP failure rate was lower when both EUS-guided biliary access and precut were available (1.0 % [95 % confidence interval (CI) 0.4 – 1.6]), compared with when only precut was possible for failed access (3.6 % [95 %CI 2.5 – 4.7]; P Conclusions EUS-guided biliary access decreases the rate of therapeutic biliary ERCP failure. Our results support the use of EUS-guided biliary access to optimize single-session ERCP success. In experienced hands, these techniques appear as effective, if not more so, than precut papillotomy.

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much in common, including their main indications (biliopancreatic disorders), powerful therapeutic capacities and a steep learning curve. Over the years they have evolved from novel diagnostic procedures to interventional therapeutic techniques, but along different paths (different scopes or devices and endoscopists specializing exclusively in one or the other technique). However, EUS has gradually developed into a therapeutic technique that requires skills in the use of ERCP devices and stents, leading some ERCP specialists to explore the therapeutic potential of EUS. The corresponding literature, which has grown exponentially, includes recent experiments on combining the two techniques, which have gradually come to be used in routine care in a number of centers, with positive technical, clinical and financial outcomes. We review EUS and ERCP as individual or combined procedures for managing biliopancreatic disorders.