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The aim of the study is to evaluate the minimum number of renal scans required to follow pediatric patients postpyeloplasty. We prospectively reviewed the renal scans of 145 children with unilateral pelvi-ureteric junction obstruction who underwent dismembered pyeloplasty. Patients were then divided into four groups based on preoperative split renal function. All patients were followed with renal scan and ultrasound for minimum of 4 years. Renal scan and ultrasound were done after stent removal at 3, 6, and 12 months and then yearly after surgery. Drainage pattern (T1/2) was seen in all groups, except in patients where there was no comment on drainage pattern. Statistical analysis was performed using the Friedman ANOVA and Wilcoxon signed-ranks test as a post hoc test with Bonferroni correction and Kruskal–Wallis test with Mann–Whitney U-test as a post hoc test with Bonferroni correction. On comparison of the pattern of drainage with time in Groups 1–4, it was found that there was no significant difference with time in Group 1. Then, further, using Wilcoxon signed-rank test as post hoc test for Friedman ANOVA, Group 2 showed statistically significant difference in drainage pattern in scans between 6 months and 1 year, Group 3 showed statistically significant difference in drainage pattern in scans between 3 months and 1 year, and Group 4 showed statistically significant difference in drainage pattern in scans done between 3 and 6 months (P < 0.05). Minimum of three renal scans were required for paediatric patients post pyeloplasty at 3 months, 6 months and 1 year in the follow up period. [ABSTRACT FROM AUTHOR]

Background and Study Aim: Standard endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) procedures involve use of no-suction or suction aspiration techniques. A new aspiration method, the stylet slow-pull technique, involves slow withdrawal of the needle stylet to create minimum negative pressure. The aim of this study was to compare the sensitivity of EUS-FNA using stylet slow-pull or suction techniques for malignant solid pancreatic lesions using a standard 22-gauge needle.Patients and Methods: Consecutive patients presenting for EUS-FNA of pancreatic mass lesions were randomized to the stylet slow-pull or suction techniques using a 22-gauge needle. Both techniques were standardized for each pass until an adequate specimen was obtained, as determined by rapid on-site cytology examination. Patients were crossed over to the alternative technique after four nondiagnostic passes.Results: Of 147 patients screened, 121 (mean age 64 ± 13.8 years) met inclusion criteria and were randomized to the stylet slow-pull technique (n = 61) or the suction technique (n = 60). Technical success rates were 96.7 % and 98.3 % in the slow-pull and suction groups, respectively (P > 0.99). The sensitivity for malignancy of EUS-FNA was 82 % in the slow-pull group and 69 % in the suction group (P = 0.10). The first-pass diagnostic rate (42.6 % vs. 38.3 %; P = 0.71), acquisition of core tissue (60.6 % vs. 46.7 %; P = 0.14), and the median (range) number of passes to diagnosis (2 1 2 3 vs. 1 1 2; P = 0.71) were similar in the slow-pull and suction groups, respectively.Conclusions: The stylet slow-pull and suction techniques both offered high and comparable diagnostic sensitivity with a mean of 2 passes required for diagnosis of solid pancreatic lesions. The endosonographer may choose either technique during FNA. [ABSTRACT FROM AUTHOR]

Background: Endoscopic therapy is considered first line for management of benign biliary strictures (BBSs). Placement of plastic stents has been effective but limited by their short-term patency and need for repeated procedures. Fully covered self-expandable metallic stents (FCSEMSs) offer longer-lasting biliary drainage without the need for frequent exchanges.Aims: The aim of this study was to assess the efficacy and safety of FCSEMS in patients with BBS.Methods: A retrospective review of all patients who underwent ERCP and FCSEMS placement at five tertiary referral US hospitals was performed. Stricture resolution and adverse events related to ERCP and/or stenting were recorded.Results: A total of 123 patients underwent FCSEMS placement for BBS and 112 underwent a subsequent follow-up ERCP. The mean age was 62 years (±15.6), and 57% were males. Stricture resolution occurred in 81% of patients after a mean of 1.2 stenting procedures (mean stent dwell time 24.4 ± 2.3 weeks), with a mean follow-up of 18.5 months. Stricture recurrence occurred in 5 patients, and 3 patients required surgery for treatment of refractory strictures. Stent migration (9.7%) was the most common complication, followed by stent occlusion (4.9%), cholangitis (4.1%), and pancreatitis (3.3%). There was one case of stent fracture during removal, and one stent could not be removed. There was one death due to cholangitis.Conclusions: Majority of BBS can be successfully managed with 1-2 consecutive FCSEMS with stent dwell time of 6 months. [ABSTRACT FROM AUTHOR]

The role of preoperative biliary drainage ( PBD) in patients with distal or proximal biliary obstruction secondary to resectable tumors has been a matter for debate. A review of the literature using Medline, Embase and Cochrane databases was undertaken for studies evaluating routes of drainage (endoscopic or percutaneous) and stent types (plastic or metal) in patients with resectable disease. Preoperative biliary drainage is indicated for relief of symptomatic jaundice, cholangitis, patients undergoing neoadjuvant therapy or those patients where surgery may be delayed. Endoscopic methods are preferred over percutaneous methods because of lower complication rates. In patients with proximal biliary obstruction, PBD should be guided by imaging studies to aid in selective biliary cannulation for unilateral drainage in order to reduce the risk of cholangitis in undrained liver segments. [ABSTRACT FROM AUTHOR]

Background/Aim: There are currently no data on the relative retention rates of the Instinct clip, Resolution clip, and QuickClip2Long. Also, it is unknown whether retention rate differs when clips are applied to ulcerated rather than normal mucosa. The aim of this study is to compare the retention rates of three commonly used endoscopic clips. Materials and Methods: Six pigs underwent upper endoscopy with placement of one of each of the three types of clips on normal mucosa in the gastric body. Three mucosal resections were also performed to create “ulcers.” Each ulcer was closed with placement of one of the three different clips. Repeat endoscopy was performed weekly for up to 4 weeks. Results: Only the Instinct and Resolution clips remained attached for the duration of the study (4 weeks). At each time point, a greater proportion of Instinct clips were retained on normal mucosa, followed by Resolution clips. QuickClip2Long had the lowest retention rate on normal mucosa. Similar retention rates of Instinct clips and Resolution clips were seen on simulated ulcers, although both were superior to QuickClip2Long. However, the difference did not reach statistical significance. All QuickClip2Long clips were dislodged at 4 weeks in both the groups.Conclusions: The Resolution and Instinct clips have comparable retention rates and both appeared to be better than the QuickClip2Long on normal mucosa‑simulated ulcers; however this did not reach statistical significance. Both the Resolution clip and the Instinct clip may be preferred in clinical situations when long‑term clip attachment is required, including marking of tumors for radiotherapy and anchoring feeding tubes or stents. Either of the currently available clips may be suitable for closure of iatrogenic mucosal defects without features of chronicity. [ABSTRACT FROM AUTHOR]

Aim This study evaluated patient satisfaction and clinical effectiveness of intracoronal bleach in traumatized anterior discolored intact teeth. Assessment of awareness and knowledge of the patient regarding treatment modalities for such cases was also performed. Material and method Forty-one patients were included in the study. Walking bleach was performed using sodium perborate (tetrahydrate) after root canal treatment and proper cervical seal. Patient was recalled after 1 week for evaluation. The bleaching procedure was repeated again till the patient agreed for it. On each recall visit, shade evaluation was performed using the Vita Classic shade guide. On completion of treatment, the patients were questioned as to their satisfaction level. Statistical analysis was carried out using anova. Results 87.8% of the subjects were highly satisfied with the results obtained; 7.32% were satisfied, while 4.9% were not satisfied. Average number of appointments needed for highly satisfied group was 2.75, and average shade change obtained was 11.97. Significantly more number of appointments were needed for the older patients ( P < 0.01) or patients with older trauma ( P < 0.05)/discoloration ( P < 0.05). Severity of discoloration did not affect the number of appointments ( P > 0.05). Most of the participants (97.6%) were not aware of bleaching procedure. The aspect of this treatment, which satisfied them the most, was improvement of the tooth coloration followed by conservation of tooth structure while the most perplexing thing was the unpredictability of final shade achieved and lack of color stability. Conclusions High level of patient satisfaction after non-vital tooth bleach treatment strongly supports this treatment modality to be a conservative treatment alternative for traumatized discolored anterior tooth. [ABSTRACT FROM AUTHOR]

Background and study aims: Endoscopic submucosal dissection (ESD) is a technically challenging procedure. A novel gel can facilitate ESD due to its submucosal dissecting properties. This prospective porcine survival study evaluated clinical and histologic parameters of hybrid ESD using the gel. Patients and methods: Gastric submucosal lesions were created in six pigs and hybrid ESD was performed. Healing was assessed weekly until necropsy at Day 28. Results: En bloc resection was achieved in all lesions (mean size 40.7 mm). The mean total procedure time was 13.5 minutes and the mean resection time was 5.5 minutes. The mean total histologic injury score was 4. At necropsy, four ulcers had healed completely and two were <6 mm in size. Conclusion: Hybrid ESD of large gastric lesions in a porcine model can be facilitated by the novel gel, dramatically reducing procedure and resection times by eliminating the need for time-consuming submucosal dissection. The novel gel is safe and easy to use, and has the potential to simplify ESD. Further prospective human studies are needed to validate these findings. [ABSTRACT FROM AUTHOR]

Background and Aim Endoscopic submucosal dissection ( ESD) is a complex procedure and is associated with significant risks. The aims of this pilot study were to study feasibility and procedural times of gastric ESD using a novel gel and endoscopic scissors in a porcine model. Methods Simulated 3-cm gastric submucosal lesions were created in a porcine model. Subsequently, viscous gel was injected into the created bleb. A needle knife was used to create an initial incision when needed. Endoscopic scissors were then used for circumferential incision around the simulated submucosal lesions. The inserted coil (i.e. submucosal lesion) was then removed. The submucosal surface was carefully examined for signs of injury. Procedural times were recorded. Results ESD was carried out in four consecutive pigs using the 'Scissorhands' technique. A small submucosal incision was created a using needle knife in the first pig and electrocauterywas not used in the remaining three pigs. Circumferential incision using the scissors was done successfully in all pigs. Submucosal dissection was not required in any case. 'Auto-dissection' of created lesions by the gel was noted to be complete in all cases. Inserted coils were noted in the submucosal space during all experiments and were removed. All lesions were successfully resected en bloc. The mean procedure time was 19 min (range 13-22 min). Conclusion The combined technique of endoscopic scissors for circumferential incision and viscous gel for submucosal dissection permitted easy, safe and efficient gastric ESD. Electrocautery may be avoided and its consequent adverse events (e.g. perforation). [ABSTRACT FROM AUTHOR]

Aim The resin ionomer Geristore, originally designed for restorative procedures, has been used extensively in treating subgingival defects (such as root resorption and perforations) and as a retrofilling material. The purpose of this study was to evaluate the cell adhesion as well as in vitro biocompatibility of human periodontal fibroblast cells with resin ionomer Geristore in comparison with mineral trioxide aggregate ( MTA) and glass ionomer cement ( GIC). Material and method Adhesion, growth, and morphology of human periodontal fibroblasts over test materials were evaluated by scanning electron microscopy ( SEM). Biocompatibility was assessed by 3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide salt ( MTT) assay. Results Compared to glass coverslips, cells grew and spread qualitatively better over the surface of Geristore in comparison with the other test materials. In vitro interpretation indicates that Geristore is significantly less cytotoxic to human periodontal ligament cells. Results of statistical analysis revealed that material extracts had significant effect on cell proliferation at both 24 h ( F = 547.62, P < 0.05) and at 48 h ( F = 6048.18, P < 0.05). Conclusion Our study supports that Geristore has enhanced biologic behavior to human periodontal ligament cells and superior biocompatibility in comparison with MTA and GIC, so it can be suggested as a material of choice in root resorption, perforations, and root-end filling. [ABSTRACT FROM AUTHOR]

The use of biological agents in inflammatory bowel diseases across the Asia-Pacific region is increasing. As new molecules and targets are identified, knowledge regarding the indications, utility, optimization and adverse effects of biological agents grows. Careful patient selection, attention to communication and patient education will maximize the benefit of these drugs. Tertiary referral centers with specific interest in inflammatory bowel diseases and experience play an important role in their use. There is enormous opportunity for patients to benefit from biological agents in the therapy of Crohn's disease and ulcerative colitis. Use of these agents has been studied across a variety of indications and populations, and at different stages in the disease course. Failure to respond or loss of response can result from different causes, and can be medically managed in many cases. More research on the pleiotropic effects, safety of biological agents and biomarkers in the prediction of response will provide a sounder basis for individually directing therapy. Adverse events such as opportunistic infection and malignancy can occur, and screening prior to therapy and discussion on risk-benefit of the various management options are important. Cost of these medications especially with maintenance therapy remains an important issue in many Asia-Pacific countries. New and more specific agents will better target therapy and minimize adverse events. [ABSTRACT FROM AUTHOR]

Aim: In vitro experiments were carried out to evaluate the potential of propolis, a natural resin known for its wide therapeutic window, as storage medium to preserve the viability of cultured human periodontal ligament (PDL) cells. Materials and Methods: Primary cultures of human PDL cells were subjected to either independent exposure of propolis (2.5%, 5.0%, 10.0%, and 20.0%), Hank's balanced salt solution (HBSS), milk (0.5%), artificial saliva, Dulbecco's modified Eagle's medium (DMEM) or combination of propolis 10% + DMEM, propolis 20% + DMEM for 30 min to 24 h at 37°C. Cell viability was assessed using standard endpoints i.e., tetrazolium bromide salt (MTT), neutral red uptake, and trypan blue dye exclusion assay. Results: In general, combinations of propolis 10% + DMEM, propolis 20% + DMEM, and DMEM alone were found to be better than other media used in this study. The difference in the potentials of these media to maintain the cell viability reached to the statistically significant levels by 24 h, when compared with other media used viz., propolis 2.5% ( P < 0.01), propolis 5.0% ( P < 0.05), propolis 10.0% ( P < 0.05), propolis 20.0% ( P < 0.001), HBSS ( P < 0.001), and milk ( P < 0.01). Trypan blue dye exclusion assay could be recorded the most sensitive among all the assays selected to study the cell viability of PDL cells. Conclusions: Study indicates that combinations of propolis 10% + DMEM, propolis 20% + DMEM, and DMEM alone are equally good as storage media of choice to keep PDL cells viable during extra-alveolar period up to 24 h. Other more readily available medium such as milk may serve as appropriate alternative storage medium for shorter time periods i.e., up to 12 h. [ABSTRACT FROM AUTHOR]

The authors reflects on the use of self-expandable metallic stents (SEMS) for esophageal variceal hemorrhage. They state that traditionally SEMS were used for a variety of malignant and benign esophageal disorders. The authors further claim that while endoscopic band litigation is the treatment of choice for most patients, SEMS appear to be more effective, easier to insert and have lower risks of complications.

Benign biliary strictures can be difficult to manage. Untreated biliary strictures can lead to complications, such as chronic cholestasis, jaundice, recurrent sepsis, and secondary biliary cirrhosis, which can have severe ramifications. The management landscape is constantly evolving, with the development of modifiable self-expandable metal stents and biodegradable stents. This review critically appraises current endoscopic treatment strategies, in particular focusing on the shortfalls, such as stent migration and stricture recurrence. It also proposes a treatment algorithm based on aetiologias and the location of the strictures. [ABSTRACT FROM AUTHOR]

The article explores the advanced endoscopic management of strictures, fistulae, and colitis-associated neoplasia. Topics discussed include the use of biologic agents for treating the inflammatory component of strictures related to Crohn's disease and the risk of forming new strictures secondary to rapid mucosal healing or worsening of existing strictures. The possibility of performing endoscopic balloon dilatation in either a retrograde or antegrade manner is mentioned.

A letter to the editor is presented in response to the study by Daram and colleagues on inherent mechanical strengths during closure and after deployment and rotational abilities of three types of through-the-scope endoscopic clips.

A letter to the editor is presented in response to the article "Anesthetic Management of Peroral Endoscopic Myotomy for Esophageal Achalasia: A Retrospective Case Series" by E. Tanaka et al. in a 2014 issue.

Background and Aim Endoscopic retrograde cholangiopancreatography ( ERCP) in patients with roux-en-Y anastomosis ( REYA) is challenging. Use of double balloon enteroscope-assisted ERCP ( DBE- ERCP) has been successful. We aim to determine predictors of successful biliary cannulation with DBE- ERCP in patients with REYA. Methods We retrospectively studied patients with REYA who had DBE- ERCP between 2009 and 2015. Results 86 DBE- ERCP were done on 52 patients. Patients had REYA for liver transplant ( n = 26), gastrojejunostomy ( n = 9), previous bile duct injury ( n = 9), biliary atresia ( n = 2) and other ( n = 6). The biliary-enteric anastomosis was reached in 76% and cholangiogram was successful in 70%. Highest success rates were in patients with previous bile duct injury (94%) or gastrojejunostomy (89%). Post-transplant patients had intermediate success (64%). Patients with redo surgery (46%) and childhood surgery (38%), especially Kasai procedure (20%), had low success. Patients with previous bile duct injury were more likely to succeed (94% vs 63%, P = 0.010). Those more likely to fail were patients with childhood surgery (38% vs 73%, P = 0.037), biliary atresia (20% vs 73%, P = 0.013) and second operation post-transplant (25% vs 70%, P = 0.046). Conclusion Indication for REYA impacts on successful biliary cannulation in patients undergoing DBE- ERCP. The procedure is most successful in non-liver transplant adult surgery and post-transplant patients without a second operation. It is least successful in patients with surgically corrected biliary atresia and post-transplant patients with second operation. Alternative methods of biliary access should be considered in these patients. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 33-year-old woman who was referred for assessment of abnormal liver enzymes and diarrhoea to determine the diagnostic challenges of glycogenic hepatopathy. The physical examinations showed a diffusely tender abdomen while the ultrasound tests found fatty infiltration of the liver and liver enzyme elevation that led to a liver biopsy. The patient had normal liver enzymes and improvement in glycaemic control with HbA1c 9.3% during a 12 month follow-up.

Acute gastrointestinal perforations occur either from spontaneous or iatrogenic causes. However, particular attention should be made in acute iatrogenic perforations as timely diagnosis and endoscopic closure prevent morbidity and mortality. With the increasing use of diagnostic endoscopy and advances in therapeutic endoscopy worldwide, the endoscopist must be able to recognize and manage perforations. Depending on the size and location of the defect, a variety of endoscopic clips, stents, and suturing devices are available. This review aims to prepare and guide the endoscopist to use the right tools and techniques for optimal patient outcomes. [ABSTRACT FROM AUTHOR]

Background and Aim: Cholecystectomy and endoscopic retrograde cholangiopancreatography are the gold standard for managing acute cholecystitis and malignant biliary obstruction, respectively. Recent advances in therapeutic endoscopic ultrasound (EUS) have provided alternatives for managing patients in whom these approaches fail, namely, EUS‐guided gallbladder drainage (EUS‐GB) and EUS‐guided bile duct drainage (EUS‐BD). We aimed to assess the technical and clinical success of these techniques in the largest multicenter cohort published to date. Methods: A retrospective, multicenter, observational study involving 17 centers across Australia and New Zealand was conducted. All patients who had EUS‐GB or EUS‐BD performed in a participating center using a lumen apposing metal stent between 2016 and 2020 were included. Primary outcome was technical success, defined as intra‐procedural successful drainage. Secondary outcomes included clinical success and 30‐day mortality. Results: One hundred and fifteen patients underwent EUS‐GB (n = 49) or EUS‐BD (n = 66). EUS‐GB was technically successful in 47 (95.9%) while EUS‐BD was successful in 60 (90.9%). All failed cases were due to maldeployment of the distal flange outside of the targeted lumen. Clinical success of EUS‐GB was achieved in 39 (79.6%). No patients required subsequent cholecystectomy. Clinical success of EUS‐BD was achieved in 52 (78.8 %). Thirty‐day mortality was 14.3% for EUS‐GB and 12.1% for EUS‐BD. Conclusions: EUS‐guided gallbladder drainage and EUS‐BD are promising alternatives for managing nonsurgical candidates with cholecystitis and malignant biliary obstruction following failed endoscopic retrograde pancreatography. Both techniques delivered high technical success with acceptable clinical success. Further research is needed to investigate the gap between technical and clinical success. [ABSTRACT FROM AUTHOR]

Acute gastrointestinal perforations occur either from spontaneous or iatrogenic causes. However, particular attention should be made in acute iatrogenic perforations as timely diagnosis and endoscopic closure prevent morbidity and mortality. With the increasing use of diagnostic endoscopy and advances in therapeutic endoscopy worldwide, the endoscopist must be able to recognize and manage perforations. Depending on the size and location of the defect, a variety of endoscopic clips, stents, and suturing devices are available. This review aims to prepare and guide the endoscopist to use the right tools and techniques for optimal patient outcomes. [ABSTRACT FROM AUTHOR]

Background and study aims: Peroral endoscopic myotomy (POEM) is technically challenging and time consuming. Repeated injection of dyed saline during tunneling is performed to enhance the demarcation between the submucosal layer and the muscularis propria. This process requires exchanging the knife for a catheter to spray dyed saline and is time consuming. This study aimed to describe a new method of injecting dyed saline through an integrated water jet channel during POEM. Patients and methods: POEM was performed using a triangular tip knife. Repeated jet injection of saline mixed with indigo carmine was performed whenever the submucosal dissection plane became unclear. Results: The study cohort consisted of nine patients (8 achalasia, 1 Jackhammer esophagus). All procedures were technically feasible and successful without any complications and resulted in the patients' Eckhardt's scores returning to normal. The mean submucosal tunnel length was 13.3cm and the mean myotomy length was 9.9cm. The mean procedure time was 127 minutes. Conclusion: The modified POEM technique with use of jet injection of dyed saline is simple and may render POEM easier and more efficient than the standard dissection method. [ABSTRACT FROM AUTHOR]

Background: Peroral endoscopic myotomy (POEM) is increasingly used as primary treatment for esophageal achalasia, in place of the options such as Heller myotomy (HM) and pneumatic dilatation (PD) Objective: These evidence-based guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) intend to support clinicians, patients and others in decisions about the use of POEM for treatment of achalasia. Results: The panel agreed on 4 recommendations for adults and children with achalasia. Conclusions: Strong recommendation for the use of POEM over PD was issued unless the concern of continued postoperative PPI use remains a key decision-making concern to the patient. Conditional recommendations included the option of using either POEM or HM with fundoplication to treat achalasia, and favored POEM over HM for achalasia subtype III. [ABSTRACT FROM AUTHOR]

Introduction. Adenocarcinomas account for approximately 40% of small bowel cancers. They are typically mucosal lesions with distinctive features on endoscopy. We describe a rare case of duodenal adenocarcinoma presenting as a subepithelial lesion which posed a diagnostic challenge. Case. An 85-year-old male patient presented for investigation of iron deficiency anaemia. Initial upper endoscopy found a subepithelial duodenal lesion with central depression but otherwise normal appearing mucosa. Superficial biopsies of the duodenal lesion were unremarkable. Subsequent antegrade single balloon enteroscopy revealed active bleeding from the lesion which was refractory to endoscopic treatment. A complete local excision of the lesion via laparotomy was necessary to achieve haemostasis. Histopathology from the lesion showed a moderately differentiated duodenal adenocarcinoma with invasion into the submucosa but no evidence of lymphovascular spread. Conclusion. Duodenal adenocarcinomas are rare gastrointestinal tumours associated with a poor prognosis. This case report outlines a rare presentation of duodenal adenocarcinoma and highlights the importance of judicious assessment of lesions found on endoscopy. Advances in endoscopic diagnostic modalities could facilitate early diagnosis and improve therapeutic outcomes. [ABSTRACT FROM AUTHOR]

Background Treatment for achalasia has traditionally been Heller myotomy (HM). Despite its excellent efficacy rate, a number of patients remain symptomatic post-procedure. Limited data exist as to the best management for recurrence of symptoms post-HM. We present an international, multicenter experience evaluating the efficacy and safety of post-HM peroral endoscopic myotomy (POEM). Methods Patients who underwent POEM post-HM from 13 centers from January 2012 to January 2017 were included as part of a prospective registry. Technical success was defined as successful completion of the myotomy. Clinical success was defined as an Eckardt score of ≤3 on 12-month follow up. Adverse events (AE) including anesthesia-related, operative, and postoperative complications were recorded. Results Fifty-one patients were included in the study (mean age 54.2, 47% male). Technical success was achieved in 100% of patients. Clinical success on long-term follow up was achieved in 48 patients (94%), with a mean change in Eckardt score of 6.25. Seven patients (13%) had AE: six experienced periprocedural mucosal defect treated endoscopically and two patients developed mediastinitis treated conservatively. Conclusion For patients with persistent symptoms after HM, POEM is a safe salvation technique with good short-term efficacy. As a result of the challenge associated with repeat HM, POEM might become the preferred technique in this patient population. Further studies with longer follow up are needed. [ABSTRACT FROM AUTHOR]

Background Endotherapy techniques are a recent addition to the suite of non-surgical and minimally invasive strategies to manage patients with perforations, leaks and fistulae. The emergency nature of these conditions and the heterogeneity of pathologies encountered create difficulties when trying to select appropriate tools in these complex situations. The purpose of this article is to review experience at a tertiary academic centre, describe the various endoscopic tools available and the situations where they can be considered for use. Methods Single-centre series and review of the published literature. Results Of 64 patients, 57 were successfully treated using endoscopic therapy, with surgery used only to provide drainage and suture fully covered metal stents in place to prevent migration. Discussion Selection of an appropriate endotherapy or stent for a patient with an oesophago-gastric perforation or fistula requires an understanding of the anatomy and physiology underlying the patient's presentation and an understanding of the strengths and weaknesses of the available methods. Standard surgical principles of drainage, avoidance of distal obstruction and nutrition remain central to successful outcomes. A combination of surgical and endoscopic treatments may reduce the number of required treatments and can provide the ability to anchor fully covered stents to prevent them from migrating. [ABSTRACT FROM AUTHOR]

Background and Aims: To facilitate access for interventional EUS, flexible (nitinol) 19-G needles have been introduced to permit needle puncture even when the echoendoscope is in an angulated position, such as in the second part of the duodenum. The aims of the study were to evaluate the performance of a flexible 19-G needle during interventional EUS procedures and compare outcomes when the echoendoscope was in the straight versus angulated position.Methods: A retrospective review was undertaken of 162 consecutive patients that underwent a variety of interventional EUS procedures with a flexible 19-G needle across five centers. Patients were subdivided into categories (straight or angulated) depending on the echoendoscope position used for obtaining access to the area of interest (Fig. 1). Fig. 1 Flexible 19-G needle design. a The needle is able to exit the sheath despite the rotated position. b The needle beveled needle tip RESULTS: In the entire cohort, needle-specific technical success was achieved in 93.2 %, procedural success in 85.2 %, and overall clinical success in 76.5 % of cases at a mean follow-up of 3.1 months. Needle-specific technical success was similar between the straight and angulated cohorts (94.0 vs. 91.2 %, p = 0.74). Procedural success (86.7 vs. 77.2 %, p = 0.05), and rate of clinical success was similar between the cohorts (83.3 vs. 86.4 %, p = 0.79), respectively. Overall adverse events were noted in 14.2 % of patients with no difference between the straight and angulated cohorts (p = 0.48).Conclusions: This study demonstrates equivalent technical success, clinical success and safety of using a flexible 19-G needle in straight and angulated endoscope positions for interventional EUS. Therefore, a flexible needle may be considered where an angulated echoendoscope position is encountered. [ABSTRACT FROM AUTHOR]

Achalasia is a primary esophageal motility disorder. It is the absence of peristalsis in the esophageal body and inability of the lower esophageal sphincter to relax, which characterizes this rare condition. Its features typically include dysphagia, regurgitation, chest pain, and weight loss. The ultimate goal in treating achalasia is to relieve the patient's symptoms, improve esophageal emptying, and prevent further dilatation of the esophagus. Current treatment modalities targeted at achalasia include pharmacological therapy, endoscopic therapy, and surgery. This review focuses on the current therapeutic options and explores the role of peroral endoscopic myotomy in the management armamentarium. [ABSTRACT FROM AUTHOR]

Cellular therapies utilizing T cells expressing chimeric antigen receptors (CARs) have garnered significant interest due to their clinical success in hematological malignancies. Unfortunately, this success has not been replicated in solid tumors, with only a small fraction of patients achieving complete responses. A number of obstacles to effective CAR-T cell therapy in solid tumors have been identified including tumor antigen heterogeneity, poor T cell fitness and persistence, inefficient trafficking and inability to penetrate into the tumor, immune-related adverse events due to on-target/off-tumor toxicity, and the immunosuppressive tumor microenvironment. Many preclinical studies have focused on improvements to CAR design to try to overcome some of these hurdles. However, a growing body of work has also focused on the use of local and/or regional delivery of CAR-T cells as a means to overcome poor T cell trafficking and inefficient T cell penetration into tumors. Most trials that incorporate locoregional delivery of CAR-T cells have targeted tumors of the central nervous system - repurposing an Ommaya/Rickham reservoir for repeated delivery of cells directly to the tumor cavity or ventricles. Hepatic artery infusion is another technique used for locoregional delivery to hepatic tumors. Locoregional delivery theoretically permits increased numbers of CAR-T cells within the tumor while reducing the risk of immune-related systemic toxicity. Studies to date have been almost exclusively phase I. The growing body of evidence indicates that locoregional delivery of CAR-T cells is both safe and feasible. This review focuses specifically on the use of locoregional delivery of CAR-T cells in clinical trials. [Display omitted] [ABSTRACT FROM AUTHOR]

Background and Study Aims: Precise identification of the gastroesophageal junction (GEJ) is a challenging prerequisite for adequate length of an esophageal myotomy. Multiple standard methods to identify the GEJ have been described; however, a more objective modality is needed to ensure effective peroral endoscopic myotomy (POEM).Patients and Methods: In the double-endoscope transillumination for extent confirmation technique (DETECT), an ultraslim gastroscope is passed to the most distal aspect of the submucosal tunnel created during POEM. A regular gastroscope is advanced into the stomach, and the visualization of transillumination from the ultraslim gastroscope enables identification of the extent of the submucosal tunnel.Results: A total of 10 patients underwent POEM with DETECT. Initial submucosal tunneling was performed based on a determination of the GEJ location via standard methods. DETECT indicated the tunnel extent to be inadequate in 50% of patients, and the tunnel was extended a further 1 to 2cm. The mean initial tunnel length was 15.4cm, with a mean initial myotomy length of 11.9cm. DETECT was performed in less than 10 minutes without complications.Conclusion: DETECT is an objective method for determining the adequacy of the submucosal tunnel length during POEM. [ABSTRACT FROM AUTHOR]

Background: Iatrogenic pharyngoesophageal perforations are a rare but serious complication of endoscopy. Surgical and non-surgical approaches have been reported but result in a significant morbidity and extended hospital stay. Therefore, an unmet need exists for an alternative management technique. We demonstrate a new endoscopic approach for the management of iatrogenic pharyngoesophageal perforations through the use of esophageal fully covered self-expandable metallic stents (FCSEMS). Patients and methods: Two patients who underwent flexible endoscopy each suffered a large iatrogenic perforation detected intraprocedurally. After emergency intubation, an esophageal FCSEMS was deployed in the hypopharynx and the patient admitted to the intensive care unit. On day 3, the patients underwent an esophagogastroduodenoscopy with stent removal. Results: There was complete closure of the perforations on day 3. The patients were extubated and subsequently tolerated a soft diet. The patients were discharged home on day 4. Conclusions: The placement of a removable FCSEMS in the setting of an acutely diagnosed perforation may be a suitable minimally invasive approach for the management of iatrogenic pharyngoesophageal perforations. [ABSTRACT FROM AUTHOR]

Background and Aim: Endoscopic ultrasound-guided biliary drainage (EGBD) may be a safe, alternative technique to percutaneous transhepatic biliary drainage (PTBD) in patients who fail ERCP. However, it is currently unknown how both techniques compare in terms of efficacy, safety, and cost. The aims of this study were to compare efficacy, safety, and cost of EGBD to that of PTBD. Methods: Jaundiced patients with distal malignant biliary obstruction who underwent EGBD or PTBD after failed ERCP were included. Technical success, clinical success, and adverse events between the two groups were compared. Results: A total of 73 patients with failed ERCP subsequently underwent EGBD ( n = 22) or PTBD ( n = 51). Although technical success was higher in the PTBD group (100 vs. 86.4 %, p = 0.007), clinical success was equivalent (92.2 vs. 86.4 %, p = 0.40). PTBD was associated with higher adverse event rate (index procedure: 39.2 vs. 18.2 %; all procedures including reinterventions: 80.4 vs. 15.7 %). Stent patency and survival were equivalent between both groups. Total charges were more than two times higher in the PTBD group ( p = 0.004) mainly due to significantly higher rate of reinterventions (80.4 vs. 15.7 %, p < 0.001). Conclusion: EGBD and PTBD are comparably effective techniques for treatment of distal malignant biliary obstruction after failed ERCP. However, EGBD is associated with decreased adverse events rate and is significantly less costly due to the need for fewer reinterventions. Our results suggest that EGBD should be the technique of choice for treatment of these patients at institutions with experienced interventional endosonographers. [ABSTRACT FROM AUTHOR]

Background and study aims: A new on-demand enteroscopy (ODE) device has been designed to allow deep enteroscopy using a standard adult colonoscope with the aid of a novel through-the-scope balloon. The aims of the current study were to establish the feasibility, efficacy, and safety of ODE in performing anterograde and retrograde enteroscopy. Patients and methods: A retrospective, single-center study of 28 consecutive deep ODE procedures (11 anterograde and 17 retrograde) was performed. Diagnostic yield, therapeutic yield, technical success, procedure time, depth of maximal insertion (DMI), time to DMI, and adverse events were recorded. Results: The mean diagnostic and therapeutic yields were 45% and 36% for anterograde enteroscopy and 59% and 47% for retrograde enteroscopy, respectively. Technical success was achieved in 100%. For anterograde enteroscopy, the mean total procedure time was 24 minutes, with a mean DMI of 1.2m. For retrograde enteroscopy, the mean total procedure time was 31 minutes, with a mean DMI of 1.1m. No adverse events were recorded. Conclusion: Deep enteroscopy using a novel through-the-scope balloon and standard endoscope appeared to be feasible and safe, with rapid procedures times. [ABSTRACT FROM AUTHOR]

Pancreatic ductal adenocarcinoma (PDAC) is the most frequent pancreatic cancer type, characterized by a dismal prognosis due to late diagnosis, frequent metastases, and limited therapeutic response to standard chemotherapy. Circulating tumor cells (CTCs) are a rare subset of tumor cells found in the blood of cancer patients. CTCs has the potential utility for screening, early and definitive diagnosis, prognostic and predictive assessment, and offers the potential for personalized management. However, a gold-standard CTC detection and enrichment method remains elusive, hindering comprehensive comparisons between studies. In this review, we summarize data regarding the utility of CTCs at different stages of PDAC from early to metastatic disease and discuss the molecular profiling and culture of CTCs. The characterization of CTCs brings us closer to defining the specific CTC subpopulation responsible for metastasis with the potential to uncover new therapies and more effective management options for PDAC. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with a preexisting duodenal stent covering the papilla is particularly challenging. The aim of this study was to describe a multicenter experience of performing ERCP in patients with biliary obstruction in whom the papilla was obscured by a preexisting duodenal stent. A total of 38 patients with preexisting duodenal stents obscuring the papilla underwent ERCP. Endoscopic biliary cannulation was successful in 13 patients (34.2 %). In 12 of these 13 patients (92.3 %), endoscopic therapy was performed during the same procedure and achieved clinical success with relief of jaundice in all cases (100%). The most commonly utilized procedure in patients in whom ERCP failed was EUS-guided biliary drainage (EGBD; n=13/22, 59.1 %), followed by percutaneous transhepatic biliary drainage (n=9/22, 40.9 %). Three patients in whom ERCP failed either did not consent to further intervention or were transferred to other centers. Thus, ERCP was technically challenging in our cohort of patients with preexisting duodenal stents, but was nonetheless successful in about one third of cases. Overall, when performed by experts, endoscopic biliary drainage (via ERCP or EGBD) can be successfully achieved in the majority of patients with indwelling duodenal stents. [ABSTRACT FROM AUTHOR]

Background: Parenchymal-sparing pancreatic surgery is ideal for lesions such as small pancreatic neuroendocrine tumors (PanNET). However, precise localization of these small tumors at surgery can be difficult. The placement of fiducials under endoscopic ultrasound (EUS) guidance (EUS-F) has been used to direct stereotactic radiation therapy for pancreatic adenocarcinoma. This report describes two cases in which placement of fiducials was used to guide surgical resection. This study aimed to assess the feasibility, safety, and efficacy of using EUS-F for intraoperative localization of small PanNETs. Methods: A retrospective study analyzed two consecutive patients with small PanNETs who underwent EUS-F followed by enucleation in a tertiary-care referral hospital. The following features were examined: technical success and complication rates of EUS-F, visibility of the fiducial at the time of surgery, and fiducial migration. Results: In the study, EUS-F was performed for two female patients with a 7-mm and a 9-mm PanNET respectively in the uncinate process and neck of the pancreas. In both patients, EUS-F was feasible with two Visicoil fiducials (Core Oncology, Santa Barbara, CA, USA) placed either within or adjacent to the tumors using a 22-gauge Cook Echotip needle. At surgery, the fiducials were clearly visible on intraoperative ultrasound, and both the tumor and the fiducials were successfully enucleated in both cases. No complications were associated with EUS-F, and no evidence of pancreatitis was shown either clinically or on surgical pathology. This investigation had the limitations of a small single-center study. Conclusions: For patients undergoing enucleation, EUS-F is technically feasible and safe and aids intraoperative localization of small PanNETs. [ABSTRACT FROM AUTHOR]

The plan was to create an endoscopic gastrojejunostomy fistula using a LAMS close to the hepaticojejunostomy to permit subsequent endoscopic management of biliary cast syndrome with conventional ERCP and electrohydraulic lithotripsy (EHL). A plastic biliary stent (7 Fr × 9 cm) was placed into the left intrahepatic duct and a fully covered self-expandable metallic stent (8 mm × 60 mm; WallFlex, Boston Scientific) was placed in the right intrahepatic duct to facilitate passage of the fragmented stones ([1]). [Extracted from the article]

The article presents a case study of a 25-year-old woman under endoscopic retrograde cholangiopancreatography for migrated biliary stent retrieval. The study demonstrates snare-over-scope technique creating second over-the-scope port, which can also be used for stents that migrated into the pancreatic duct.

The article presents a case study of a 72-year-old female with a 6-month history of iron deficiency anemia, abdominal pain, and imaging evidence of ileum's mural thickening. The study used a through-the-scope balloon catheter-assisted retrograde enteroscopy system to investigate the patient's condition.

The article presents a case study of a 30-year-old woman who suffered from a type 1 duodenal perforation and was admitted to the hospital's emergency unit for percutaneous flexible endoscopic necrosectomy. The patient has underwent an daily irrigation with hydrogen peroxide to efficiently manage its retroperitoneal abscess. The article also discusses the feasibility of percutaneous endoscopic necrosectomy (PEN) for treating retroperitoneal abscess.