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We reviewed the literature in order to determine the best system to develop a training program for third space endoscopic procedures in the West. There has been a steady growth in the number and type of advanced endoscopic procedures over the past several decades, including the expansion of “third-space” or submucosal endoscopy. Most of our knowledge on training in third-space endoscopy stems from the East, with a lack of consensus regarding the optimal training model for Western endoscopists. We review the current literature and provide insight into a potential training algorithm that can be adopted in the West. A multipronged, stepwise training approach, involving self-directed learning, exposure courses, hands-on explant models, observation of experts, followed by performing cases with gradually increasing difficulty preferably under direct supervision, is the foundation for third-space endoscopy training in the West. Learning and performing third-space endoscopy in the West will continue to be facilitated by the ongoing development of dedicated devices and accessories and the establishment of training benchmarks.

Flexible endoscopic cricopharyngeal myotomy and septotomy offer a minimally invasive transluminal option for the treatment of symptomatic Zenker's diverticulum (ZD). There is currently no consensus regarding postoperative follow-up imaging. We suggest a standardized computed tomography (CT) esophagram protocol for radiographic evaluation of postoperative findings.Single center retrospective analysis of patients with symptomatic ZD who underwent flexible endoscopic diverticulotomy and postoperative imaging with CT esophagram from January 2015 to March 2020. An experienced radiologist blinded to the initial imaging reports prospectively interpreted all CT esophagram findings, in order to minimize bias.Twenty-one patients underwent CT esophagram following flexible endoscopic diverticulotomy for ZD. Diverticulotomy was technically successful in all patients. Most common findings on imaging included: atelectasis (13/21; 62%), persistent esophageal diverticulum (7/21; 33%), pneumomediastinum (3/21; 14%), aspiration (2/21; 10%), and extraluminal air and contrast extravasation consistent with focal esophageal perforation (1/21; 5%).We describe a standardized, simple, and accessible CT esophagram protocol for postoperative imaging of patients with post-flexible endoscopic cricopharyngeal myotomy and septotomy for ZD. CT esophagram facilitates a definitive exclusion of focal esophageal perforation as a postoperative complication of flexible endoscopic diverticulotomy by ruling out extraluminal air and contrast extravasation.

Inpatient endoscopy delay (IED) negatively impacts the delivery of high-quality care. We aimed to identify factors associated with IED and evaluate its effect on hospital length-of-stay (LOS) and readmission.This was a retrospective analysis of all inpatient endoscopies performed between November 2017 and November 2019 at a tertiary care center. IED was defined as the number of days elapsed between anticipated versus actual procedure day. Data were extracted from the endoscopy documentation software and via electronic chart review. Multivariate logistic regressions were modeled to determine variables associated with IED and hospital readmission.A total of 4239 inpatients (mean age, 58.3 years; 50.3% women) underwent endoscopic procedures during the study period of which 819 patients (19.3%) experienced a delay. IED resulted in a median prolonged LOS of 2 days (interquartile range, 1-2 days). Patients with IED were less likely to have an etiology identified on endoscopy (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.63-0.86; P.001). The 2 most common causes for delays were poor bowel preparation (n = 218; 27%) and lack of endoscopy personnel/unit availability (n = 197; 24.4%). Independent predictors of IED included: older age (OR, 1.1; 95% CI, 1.01-1.03; P = .03), female sex (OR, 1.20; 95% CI, 1.03-1.40; P = .02), use of antithrombotics (OR, 1.30; 95% CI, 1.08-1.57; P = .006), opioids (OR, 1.23; 95% CI, 1.04-1.44; P = .012), being on contact isolation (OR, 1.38; 95% CI, 1.09-1.75; P = .008), and colonoscopy (OR, 1.50; 95% CI, 1.27-1.77; P.001). Conversely, inpatients admitted to a dedicated GI medicine service were less likely to have IED (OR, 0.79; 95% CI, 0.65-0.96; P = .02). IED was the only independent predictor of 30-day readmission (OR, 1.22; 95% CI, 1.02-1.47; P = .03).IED occurred frequently, unfavorably prolonged LOS, and was an independent risk factor for 30-day readmission. We provide a comprehensive analysis of actionable variables associated with IED that can be targeted to improve inpatient endoscopy delivery.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with Roux-en-Y gastric bypass (RYGB) anatomy, which is increasing in frequency given the rise of obesity. Laparoscopy-assisted ERCP (LA-ERCP) and enteroscopy-assisted ERCP (EA-ERCP) are distinct approaches with their respective strengths and weaknesses. We conducted a meta-analysis comparing the procedural time, rates of success and adverse events of each method. Patients and methods A search of PubMed, EMBASE and the Cochrane library was performed from inception to October 2018 for studies reporting outcomes of LA or EA-ERCP in patients with RYGB anatomy. Studies using single, double, ‘short’ double-balloon or spiral enteroscopy were included in the EA-ERCP arm. Outcomes of interest included procedural time, papilla identification, papilla cannulation, therapeutic success and adverse events. Therapeutic success was defined as successful completion of the originally intended diagnostic or therapeutic indication for ERCP. Results A total of 3859 studies were initially identified using our search strategy, of which 26 studies met the inclusion criteria. The pooled rate of therapeutic success was significantly higher in LA-ERCP (97.9 %; 95 % CI: 96.7–98.7 %) with little heterogeneity (I2 = 0.0 %) when compared to EA-ERCP (73.2 %; 95 % CI: 62.5–82.6 %) with significant heterogeneity (I2: 80.2 %). Conversely, the pooled rate of adverse events was significantly higher in LA-ERCP (19.0 %; 95 % CI: 12.6–26.4 %) when compared to EA-ERCP (6.5 %; 95% CI: 3.9–9.6 %). The pooled mean procedure time for LA-ERCP was 158.4 minutes (SD ± 20) which was also higher than the mean pooled procedure time for EA-ERCP at 100.5 minutes (SD ± 19.2). Conclusions LA-ERCP is significantly more effective than EA-ERCP in patients with RYGB but is associated with a higher rate of adverse events and longer procedural time.

Gastroesophageal reflux disease (GERD) is a chronic disease characterized by symptoms of heartburn and acid regurgitation. Uncontrolled GERD can significantly impact quality of life, can lead to complications, and increases the risk of esophageal cancer. Over the past few decades, there has been an increasing prevalence of GERD among adults in Western populations. The use of proton pump inhibitors (PPI) in conjunction with lifestyle modifications remains the mainstay therapy. However, the efficacy of this intervention is often hampered by adherence, costs, and the risks of long-term PPI use. Anti-reflux surgery is an option for patients with refractory symptoms or in those in whom medical therapy is contraindicated or not desirable. While conventional surgery has an acceptable safety profile, there has been an increasing interest in alternate treatments that may potentially offer similar results and be associated with a faster recovery. Recent advances in interventional endoluminal techniques have introduced novel incisionless anti-reflux procedures. While the current data are promising, further larger prospective studies are needed in order to assess the long-term efficacy of endoluminal therapies and its place among the treatment options for GERD.

Background Adherence to quality indicators and surveillance guidelines in the management of Barrett’s esophagus (BE) promotes high-quality, cost-effective care. The aims of this study were (1) to evaluate adherence to standardized classification (Prague Criteria) and systematic (four-quadrant) biopsy protocol, (2) to identify predictors of practice patterns, and (3) to assess adherence to surveillance guidelines for non-dysplastic BE (NDBE). Methods This was a single-center retrospective study of esophagogastroduodenoscopy (EGD) performed for BE (June 2008 to December 2015). Patient demographics, procedure characteristics, and histology results were obtained from the procedure report-generating database and chart review. Adherence to Prague Criteria and systematic biopsies was based on operative report documentation. Multiple logistic regression analysis was performed to identify predictors of practice patterns. Guideline adherent surveillance EGD was defined as those performed within 6 months of the recommended 3- to 5-year interval. Results In total, 397 patients (66.5 % male; mean age 60.1 ± 12.5 years) had an index EGD during the study period. Adherence to Prague Criteria and systematic biopsies was 27.4 % and 24.1 %, respectively. Endoscopists who performed therapeutic interventions for BE were more likely to use the Prague Criteria (OR: 3.16; 95 %CI: 1.47 – 6.82; P Conclusion Adherence to quality indicators and surveillance guidelines in BE is low. Operator characteristics, including experience with endoscopic therapy for BE and time in practice predicted practice pattern. Future efforts are needed to reduce variability in practice and promote high-value care.

Throughout the world, hepatocellular carcinoma (HCC) ranks as the third leading cause of cancer-related deaths. This chapter summarizes the etiology and pathogenesis of HCC. There are various risk factors associated with HCC including viral hepatitis, cirrhosis (with any underlying etiology including nonalcoholic fatty liver disease (NAFLD)), and toxin-mediated disease. The two main hepatitis viruses associated with the development of HCC are hepatitis B virus (HBV) and hepatitis C virus (HCV). Virtually all cirrhosis-inducing conditions can increase the risk of HCC. There are other etiological factors that have been proposed to develop into HCC but at a much lower frequency. As we continue to further our understanding of human HCC and the mechanisms involved, the field will gain a solid foundation that can help to refine animal models and truly comprehend the entire range of human disease.

Background and Aims Cold snare polypectomy (CSP) is associated with higher rates of complete resection compared with cold biopsy forceps (CBF) for the removal of small polyps (4-9 mm). This study aimed to evaluate self-reported polypectomy preferences and actual practice patterns among endoscopists at an academic center and to identify factors associated with the use of CSP for small polyps. Methods In phase A, endoscopists completed a survey evaluating preferences for polypectomy techniques. In phase B, we performed a retrospective analysis of all consecutive colonoscopies with polypectomy (January 2016 to September 2018). Uni- and multivariate analysis were performed to identify factors associated with CSP for small polyps. Results Nineteen of 26 (73%) endoscopists completed the survey (phase A); 3 (15.8%) were interventional endoscopists. Most respondents indicated that they use CSP (89.5%) for small polyps and identified no reasons for choosing CBF over CSP (73.7%). In phase B, we identified 1118 colonoscopies with 2625 polypectomies for polyps ≤9 mm. Most diminutive polyps (≤3 mm) were removed with CBF (819 of 912; 90%). CBF (46.2%) was also preferentially used for removal of small polyps (n = 1713), followed by hot snare polypectomy (27.2%), and CSP (26.6%). On multivariate analysis, interventional endoscopists were associated with a higher likelihood of using CSP for small polyps (odds ratio, 1.38; 95% confidence interval, 1.07-1.79; P = .01). Conclusions Significant discrepancy exists between self-reported preferences and actual polypectomy practices. CBF is still preferentially used over CSP for the removal of polyps sized 4-9 mm; further strategies are needed to monitor and implement adequate polypectomy techniques.

Non-islet cell tumor hypoglycemia (NICTH) is a rare and serious paraneoplastic complication of both malignant and benign tumors to consider when evaluating fasting hypoglycemia, especially in the setting of liver diseases. We present a case of NICTH in a 54-year-old male with hepatocellular carcinoma (HCC) who presented with symptomatic intractable hypoglycemia (IH) after bowel preparation and fasting for screening upper endoscopy and colonoscopy.

Introduction: Neck pain is a common musculoskeletal problem that up to 70% of the world population will experience at some point in their lives. Intramedullary spinal cord metastasis is an exceedingly rare complication of malignancy that affects less than 1% of all patients with cancer. Case report: We report a case of a 61-year-old man who presented to primary care clinic with 1-month history of worsening neck pain with associated neurologic deficits. Despite initial conservative management, the patient continued to have progressive worsening of sensory and motor deficits. Magnetic resonance imaging of the cervical spine showed vasogenic edema of the brain and spinal cord and nodularity at the C4-C5 level. A computed tomography of the chest showed a dense lesion in the left lower lobe of the lung; histopathology of the biopsied specimen was consistent with moderately differentiated lung adenocarcinoma. Conclusions: A high index of suspicion is necessary when chronic neck pain acutely worsens, changes in character, or is accompanied by neurologic deficits. These clinical signs warrant further investigation into a secondary cause of neck pain. Intramedullary spinal cord metastases are rare complications of systemic cancer that commonly present with neck pain and upper extremity paraesthesias; early diagnosis and management are necessary to prevent complications such as spinal cord hemisection syndrome or spinal cord transection.

This is a 78 year old male with a past medical history of coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), hypertension (HTN), and gastroesophageal reflux disorder (GERD) who presented to the emergency room with worsening shortness of breath (SOB) and low-grade fevers for one week prior to admission. He was originally diagnosed with healthcare associated pneumonia (HCAP) and an acute on chronic COPD exacerbation and treated with prednisone, inhalers, ipratropium/albuterol, and broad-spectrum antibiotics. His symptoms were slow to respond to therapy and he continued to have end-expiratory wheezes with persistent SOB. A CT of his chest was ordered to rule out a possible pulmonary embolus (PE) and instead showed an obstructing mass in the bronchus. Pulmonology was consulted and performed a bronchoscopy, which revealed a foreign body (bean) causing the obstruction, which was removed, and the patient’s symptoms improved shortly thereafter.