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Background and study aims: Endoscopist techniques affect biliary cannulation success and the risk of adverse events during ERCP. This survey study aims to understand the current practice of biliary cannulation techniques among endoscopists. Methods: Practicing endoscopists were sent an anonymous 28- question electronic survey on biliary cannulation techniques and intraprocedural pancreatitis prophylactic strategies. Results: The survey was completed by 692 endoscopists (6.2% females). A wire-guided cannulation technique (WGT) was the preferred initial biliary cannulation approach (95%). The preferred secondary approaches were a double-wire (DWT) (65.8%), precut needle-knife technique (NKT) (25.7%), transpancreatic sphincterotomy (5.9%) or other (2.6%). Overall, 18.1% of respondents were not comfortable with NKTs. In the setting of pancreatic duct (PD) access, 81.9% and 97% reported a threshold of three or more wire passes or contrast injections into the PD respectively before changing strategy, 34% reported placement of a prophylactic PD stent 200 ERCPs per year) were associated with comfort with precut needle knife techniques and likelihood of prophylactic PD stent (p

BACKGROUND Several studies have examined the efficacy of gastric peroral endoscopic myotomy (G-POEM) for gastroparesis. AIM To evaluate the mid-term efficacy of G-POEM by meta-analysis of studies with a minimum 1 year of follow-up. METHODS We reviewed several databases from inception to 10 June 2021 to identify studies that evaluated the efficacy of G-POEM in refractory gastroparesis, and had at least 1 year of follow-up. Our outcomes of interest were clinical success at 1 year, adverse events, difference in mean pre- and 1 year post-procedure Gastroparesis Cardinal Symptom Index (GCSI) score, and difference in mean pre- and post-procedure EndoFLIP measurements. We analysed data using a random-effects model and assessed heterogeneity by I2 statistic. RESULTS We included 10 studies comprising 482 patients. Pooled rates (95% CI) of clinical success at 1 year and adverse events were 61% (49%, 71%) and 8% (6%, 11%), respectively. Mean GCSI at 1 year post-procedure was significantly lower than pre-procedure; mean difference (MD) (95% CI) -1.4 (-1.9, -0.9). Mean post-procedure distensibility index was significantly higher than pre-procedure in the clinical success group at 40 and 50 mL volume distension; standardised mean difference (95% CI) 0.82 (0.07, 1.64) and 0.91 (0.32, 1.49), respectively. In the clinical failure group, there was no significant difference between mean pre- and post-procedure EndoFLIP measurements. CONCLUSIONS G-POEM is associated with modest clinical success at 1 year. Additional studies with longer follow-up are required to evaluate its longer-term efficacy.

Rapid On-Site-Evaluation (ROSE) with an in-room pathologist (ROSE-P) has been shown to improve the diagnostic yield of specimens obtained from patients undergoing Endoscopic Ultrasound fine needle aspiration or biopsy (EUS-FNAB) of pancreatic lesions. Recently, there has been an increased interest and utilization of Telecytology (ROSE-T) to optimize clinical workflows, and to address social distancing mandates created during the COVID-19 pandemic. The purpose of this study is to compare diagnostic outcomes of ROSE-P and ROSE-T.A single center cohort study of patients who underwent EUS-FNAB of solid pancreatic lesions with ROSE was conducted. The primary outcome was overall diagnostic yield of cancer. All patients who underwent EUS-FNA were entered into a prospectively maintained database. Statistical analyses were performed using descriptive statistics and univariate analysis.There were 165 patients in each arm. There was no difference in diagnostic yield between ROSE-P and ROSE-T (96.4% vs 94.5%, p=.428). ROSE-T was associated with increased use of 22-gauge needles (p=.006) and more needle passes (p.001). There was no significant difference in age, gender, lesion size, needle type, procedure times, or adverse events between the two groups (p.05 for all). There were more pancreatic tail lesions sampled in the ROSE-P group (p.001).Rapid on-site evaluation using Telecytology was not associated with any difference in final histologic diagnosis for EUS-FNAB of solid pancreatic masses. This has important implications for optimizing clinical workflows.

ERCP is the first line of treatment for malignant biliary obstruction and EUS-guided biliary drainage (EUS-BD) is usually used for patients who have failed ERCP. EUS-guided gallbladder drainage (EUS-GBD) has been suggested as a rescue treatment for patients who fail EUS-BD and ERCP. In this meta-analysis, we have evaluated the efficacy and safety of EUS-GBD as a rescue treatment of malignant biliary obstruction after failed ERCP and EUS-BD. We reviewed several databases from inception to August 27, 2021, to identify studies that evaluated the efficacy and/or safety of EUS-GBD as a rescue treatment in the management of malignant biliary obstruction after failed ERCP and EUS-BD. Our outcomes of interest were clinical success, adverse events, technical success, stent dysfunction requiring intervention, and difference in mean pre- and postprocedure bilirubin. We calculated pooled rates with 95% confidence intervals (CI) for categorical variables and standardized mean difference (SMD) with 95% CI for continuous variables. We analyzed data using a random-effects model. We included five studies with 104 patients. Pooled rates (95% CI) of clinical success and adverse events were 85% (76%, 91%) and 13% (7%, 21%). Pooled rate (95% CI) for stent dysfunction requiring intervention was 9% (4%, 21%). The postprocedure mean bilirubin was significantly lower compared to preprocedure bilirubin, SMD (95% CI): -1.12 (-1.62--0.61). EUS-GBD is a safe and effective option to achieve biliary drainage after unsuccessful ERCP and EUS-BD in patients with malignant biliary obstruction.

Argon plasma coagulation (APC) is a standard modality for the treatment of gastrointestinal bleeding. However, there are no metrics to assess technical proficiency. We aimed to determine if a Quick APC Training Test (QAPCTT) can improve performance and assess proficiency with this modality.Endoscopy trainees at various levels of training were asked to perform the QAPCTT with an in vivo model before and after an APC curriculum with didactic lectures and additional hands-on experience. As trainees performed the test, endoscopic supervisors recorded the time required to complete each task as well as the number of inadvertent mucosal touchdowns. Each partipant was assigned a technical proficiency score by supervising endoscopists.Fourteen adult gastroenterology fellows participated in the course. 100% of fellows were comfortable with generator settings and APC equipment after the course compared to only 21% (p 0.001) on the pre-test questionnaire. Those deemed technically proficient on the post-course QAPCTT required significantly less time for the task of making a square (100 s vs. 215 s; p = 0.006) and had significantly fewer inadvertent mucosal touchdowns (5 vs. 19; p = 0.0017).Dedicated APC training is required to achieve competence with this modality. A structured curriculum improves knowledge about the technique and hands-on training is important for achieving technical proficiency. The QAPCTT appears improve APC technique and may readily identify trainees in need of additional APC experience to gain proficiency.

Author(s): Thiruvengadam, Nikhil R; Miranda, Janille; Kim, Christopher; Behr, Spencer; Corvera, Carlos; Dai, Sun-Chuan; Kirkwood, Kimberly; Harris, Hobart W; Hirose, Kenzo; Nakakura, Eric; Ostroff, James W; Kochman, Michael L; Arain, Mustafa A | Abstract: IntroductionA step-up endoscopic or percutaneous approach improves outcomes in necrotizing pancreatitis (NP). However, these require multiple radiographic studies and fluoroscopic procedures, which use low-dose ionizing radiation. The cumulative radiation exposure for treatment of NP has not been well defined.MethodsWe conducted a retrospective study of consecutive patients with NP admitted to University of California San Francisco Medical Center from January 2011 to June 2019. We calculated effective doses for fluoroscopic procedures using the dose area product and used the National Cancer Institute tool for computed tomography studies. The primary outcome was the cumulative effective dose (CED). Multivariable logistic regression was used to evaluate risk factors of high exposure (CED g 500 mSv).ResultsOne hundred seventy-one patients with NP (mean follow-up 40 ± 18 months) underwent a median of 7 (interquartile range [IQR] 5-11) computed tomography scans and 7 (IQR 5-12) fluoroscopic procedures. The median CED was 274 mSv (IQR 177-245) and 30% (51) of patients received high exposure. Risk factors of high exposure include multiorgan failure (aOR 3.47, 95%-CI: 1.53-9.88, P = 0.003), infected necrosis (adjusted odds ratio [aOR] 3.89 95%-CI:1.53-9.88, P = 0.005), and step-up endoscopic approach (aOR 1.86, 95%-CI: 1.41-1.84, P = 0.001) when compared with step-up percutaneous approach.DiscussionPatients with NP were exposed to a substantial amount of ionizing radiation (257 mSv) as a part of their treatment, and 30% received more than 500 mSv, which corresponds with a 5% increase in lifetime cancer risk. Severity of NP and a step-up endoscopic approach were associated with CED g 500 mSv. Further studies are needed to help develop low-radiation treatment protocols for NP, particularly in patients receiving endoscopic therapy.

Background and Aims The American Society for Gastrointestinal Endoscopy recommends prophylactic pancreatic duct stent placement (PPS) and rectal nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk individuals and suggests that rectal indomethacin may decrease the risk and severity of PEP in average-risk individuals. The European Society for Gastrointestinal Endoscopy recommends rectal indomethacin for all patients undergoing ERCP. Previous surveys of European endoscopists revealed low adoption of PPS or rectal NSAIDs to prevent PEP. We sought to capture current practice in the prevention of PEP among endoscopists in the United States involved in advanced endoscopy fellowship programs. Methods An anonymous online 16-item survey was e-mailed to 233 advanced endoscopists involved in advanced endoscopy fellowship programs. Results Of the 233 endoscopists who were invited to participate, 62 responded (26.7%). Most respondents reported working in tertiary referral centers (57; 95.0%) and performing ERCP for greater than 5 years (44; 74.6%). All respondents (60; 100.0%) reported working with fellows. Most PPS users (41; 72.0%) reported use of PPS in high-risk patients only and using PPS for PEP in ≤25% of ERCPs (38; 64.4%). Most respondents reported using rectal NSAIDs for high-risk patients only (34; 59.7%) compared with respondents (23; 40.1%) who reported using rectal NSAIDs for prevention of PEP in average-risk patients undergoing ERCP. Most respondents (49; 83.0%) also reported using rapid intravenous fluids to prevent PEP. Conclusions Among endoscopists involved in advanced endoscopy fellowships in the United States, rectal NSAIDs are used more frequently than PPS in the prevention of PEP. Despite mounting evidence supporting the use of rectal NSAIDs to prevent PEP in average-risk patients, less than half of the respondents in this survey reported such practice.

Bronchogenic cysts belong in the category of foregut duplication cysts, along with esophageal and neuroenteric duplication cysts. They are often found incidentally on cross-sectional imaging. Although they are benign, patients often undergo surgical resection because of diagnostic uncertainties. We report the first case of bronchogenic cyst diagnosed with the microforceps, after previous nondiagnostic fine-needle aspirations, thus allowing the patient to avoid surgery.

Introduction Orthotopic liver transplantation anastomotic biliary strictures (OLT ABS) are managed with endoscopic biliary stent therapy but the recurrence rate is substantial. Our aims were to retrospectively determine the recurrence rates of OLT ABS after initial successful stent therapy, characterize the management of recurrences and identify associated variables. Materials and Methods Clinical data from 943 patients receiving non-living donor OLT at our institution from 2005-2012 were reviewed, and 123 OLT ABS patients receiving stent therapy were identified. Features of their endoscopic stent therapy and other pertinent clinical information were evaluated. Results ABS recurred in 25.5% of patients (24/94) after an initial successful course of stent therapy. Recurrences were received a second course of endoscopic stent therapy and 67% of patients (16/24) achieved long-term remediation of ABS. Six patients underwent a third course of endoscopic stent therapy with 4 patients achieving remediation. Overall remediation rate among ABS recurrences was 83.3% (20/24). A bivariate comparison demonstrated HCV infection, age, median months of maximal stenting and a lower maximum cumulative stent diameter were risk factors for ABS recurrence. Using a Cox regression model, only HCV status proved to be a risk factor for recurrence. Discussion In conclusion repeat stent therapy achieved high stricture remediation rates. Recurrence after the first or even second course of stenting should not imply failure of endoscopic therapy. A positive HCV status may be associated with higher stricture recurrence rates and this association should be further investigated.

Background A growing number of studies seem to suggest that small intestinal bacterial overgrowth (SIBO) is a common clinical problem. Although various techniques are available to make this diagnosis, tradition has accepted small bowel aspirate ((10 5 cfu/ml) as a gold standard. In this systematic review, the validity of culture and other diagnostic testing for SIBO is evaluated. Methods We performed a systematic review of the literature from 1966 to present using electronic databases (PubMed and OVID). Full paper review of those abstracts that fulfilled preset criteria was carried out to evaluate the validity of various tests in diagnosing SIBO. Finally, all papers were evalu- ated against published standards for studies on diagnostic testing. Results Seventy-one papers met the criteria for detailed review. Studies were very heterogeneous with regards to patient populations, test definitions, sample size, and methods in general. Small bowel colony counts appeared elevated in most gastrointestinal diseases com- pared to controls. The traditional definition of(10 5 cfu/ml was usually indicative of stagnant loop conditions. Although, numerous diagnostic tests were studied, not even culture papers met the quality standards described by Reid et al. Breath testing and other diagnostic testing suffered therefore from the lack of a gold standard against which to validate in addition to the poor quality. Conclusions There is no validated diagnostic test or gold standard for SIBO. In this context, the most practical method to evaluate SIBO in studies at this time would be a test, treat, and outcome technique.

Question: A 28-year-old Vietnamese man without any significant past medical history presented with 6 months of epigastric pain without nausea, vomiting, fevers, weight loss, or other symptoms. Physical examination was normal, as were laboratory tests, including a complete blood count, liver function tests, and chemistry panel. Proton pump inhibitor therapy was administered for 2 months without any improvement in symptoms. Esophagogastroduodenoscopy was subsequently performed and revealed a 3.5 2.5-cm ubmucosal bulge at the gastroesophageal junction (Figure A). Biopsy with cold forceps elicited persistent extravasation of a thin hite fluid (Figure B). Histology was indeterminate, and Gram stain, acid-fast bacilli, and cultures were negative. After endoscopy, omputed tomography of the abdomen/pelvis revealed a 3.6 2.7 2.5-cm enhancing perigastric lesion adjacent to a normalappearing pancreas without lymphadenopathy (Figure C). What is the most likely diagnosis, and what should be the next step in determining the diagnosis? Look on page 1258 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information n submitting your favorite image to Clinical Challenges and Images in GI.

Background and study aims A second examination of the right colon, either as a second forward view (SFV) or as retroflexion (RF) in the cecum, can increase adenoma detection rate (ADR) in the right colon. In this meta-analysis, we have evaluated the role of a second examination of the right colon in improving ADR. Methods We reviewed several databases to identify randomized controlled trials that compared right colon SFV with no SFV, and RCTs that compared SFV with RF in the right colon, and reported data on ADR. Our outcomes of interest were ADR and polyp detection rate (PDR) with SFV vs no SFV, right colon and total withdrawal times, and additional ADR and PDR with SFV vs RF. For categorical variables, we calculated pooled risk ratios (RRs) with 95 % confidence intervals (CIs); for continuous variables, we calculated standardized mean difference (SMD) with 95 % CI. Data were analyzed using random effects model. Results We included six studies with 3901 patients. Comparing SFV with no SFV, right colon ADR and PDR were significantly higher in the SFV group: ADR (RR [95 % CI] 1.39 [1.22,1.58]) and PDR (RR [95 % CI] 1.47 [1.30, 1.65]). We found no significant difference in right colon withdrawal time (SMD [95 % CI] 1.54 [–0.20,3.28]) or total withdrawal time (SMD (95 % CI) 0.37 [–0.39,1.13]) with and without SFV. We found no significant difference in additional ADR between SFV and RF. Conclusions SFV of the right colon significantly increases right-sided and overall ADR.