COVID-19 in the endoscopy unit:How likely is transmission of infection?Results from an international,multicenter study

BACKGROUND Coronavirus disease 2019(COVID-19)significantly affected endoscopy practice,as gastrointestinal endoscopy is considered a risky procedure for transmission of infection to patients and personnel of endoscopy units(PEU).AIM To assess the impact of COVID-19 on endoscopy during the first European lockdown(March-May 2020).METHODS Patients undergoing endoscopy in nine endoscopy units across six European countries during the period of the first European lockdown for COVID-19(March-May 2020)were included.Prior to the endoscopy procedure,participants were stratified as low-or high-risk for potential COVID-19 infection according to the European Society of Gastrointestinal Endoscopy(ESGE)and the European Society of Gastroenterology and Endoscopy Nurses and Associates(ESGENA)joint statement,and contacted 7-14 d later to assess COVID-19 infection status.PEU were questioned regarding COVID-19 symptoms and/or infection via questionnaire,while information regarding hospitalizations,intensive care unitadmissions and COVID-19-related deaths were collected.The number of weekly endoscopies at each center during the lockdown period was also recorded.RESULTS A total of 1267 endoscopies were performed in 1222 individuals across nine European endoscopy departments in six countries.Eighty-seven(7%)were excluded because of initial positive testing.Of the 1135 pre-endoscopy low risk or polymerase chain reaction negative for COVID-19,254(22.4%)were tested post endoscopy and 8 were eventually found positive,resulting in an infection rate of 0.7%[95%CI:0.2-0.12].The majority(6 of the 8 patients,75%)had undergone esophagogastroduodenoscopy.Of the 163 PEU,5[3%;(95%CI:0.4-5.7)]tested positive during the study period.A decrease of 68.7%(95%CI:64.8-72.7)in the number of weekly endoscopies was recorded in all centers after March 2020.All centers implemented appropriate personal protective measures(PPM)from the initial phases of the lockdown.CONCLUSION COVID-19 transmission in endoscopy units is highly unlikely in a lockdown setting,provided endoscopies are restricted to emergency cases and PPM are implemented.

Use of endoscopic ultrasound-guided gallbladder drainage as a rescue approach in cases of unsuccessful biliary drainage

This narrative review provides an overview of the utilization of endoscopic ultrasound-guided gallbladder drainage(EUS-GBD)as a salvage approach in cases of unsuccessful conventional management.EUS-GBD is a minimally invasive and effective technique for drainage in patients with acute cholecystitis with high risk of surgery.The procedure has demonstrated impressive technical and clinical success rates with low rates of adverse events,making it a safe and effective option for appropriate candidates.Furthermore,EUS-GBD can also serve as a rescue option for patients who have failed endoscopic retrograde cholangiopancreatography or EUS biliary drainage for relief of jaundice in malignant biliary stricture.However,patient selection is critical for the success of EUS-GBD,and proper patient selection and risk assessment are important to ensure the safety and efficacy of the procedure.As the field continues to evolve and mature,ongoing research will further refine our understanding of the benefits and limitations of EUS-GBD,ultimately leading to improved outcomes for patients.

Artificial intelligence in detection of small bowel lesions and their bleeding risk:A new step forward

The present letter to the editor is related to the study with the title“Automatic detection of small bowel(SB)lesions with different bleeding risk based on deep learning models”.Capsule endoscopy(CE)is the main tool to assess SB diseases but it is a time-consuming procedure with a significant error rate.The development of artificial intelligence(AI)in CE could simplify physicians’tasks.The novel deep learning model by Zhang et al seems to be able to identify various SB lesions and their bleeding risk,and it could pave the way to next perspective studies to better enhance the diagnostic support of AI in the detection of different types of SB lesions in clinical practice.

Device-assisted enteroscopy: Are we ready to dismiss the spiral?

Motorized spiral enteroscopy(MSE)is the latest advance in device-assisted enteroscopy.Adverse events related to MSE were discussed in a recent large systematic review and meta-analysis and were directly compared with those of balloon enteroscopy in a case-matched study and a randomized controlled trial.Following the real-life application of MSE,an unexpected safety issue emerged regarding esophageal injury and the technique has been withdrawn from the global market,despite encouraging results in terms of diagnostic and therapeutic yield.We conducted an Italian multicenter real-life prospective study,which was prematurely terminated after the withdrawal of MSE from the market.The primary goals were the evaluation of MSE performance(both diagnostic and therapeutic)and its safety in routine endoscopic practice,particularly in the early phase of introduction in the endoscopic unit.A subanalysis,which involved patients who underwent MSE after unsuccessful balloon enteroscopy,demonstrated,for the first time,the promising performance of MSE as a rescue procedure.Given its remarkable performance in clinical practice and its potential role as a backup technique following a previously failed enteroscopy,it may be more appropriate to refine and enhance MSE in the future rather than completely abandoning it.

Outpatient management of obscure gastrointestinal bleeding:A new perspective in high-risk patients

Mid-gastrointestinal bleeding accounts for approximately 5%-10%of all gastrointestinal bleeding cases,and vascular lesions represent the most frequent cause.The rebleeding rate for these lesions is quite high(about 42%).We hereby recommend that scheduled outpatient management of these patients could reduce the risk of rebleeding episodes.

Two big orifices in the second duodenal portion:A case of an atypical double papilla

With the advent of endoscopic retrograde cholangiopancreatography(ERCP)in the early 1970s,anatomic anomalies of the Vaterian system were described endoscopically[1].Although the occurrence is rare,the common bile duct(CBD)and the pancreatic duct may fail to coalesce during embryologic development.This leads to double major papilla because both ducts open into the duodenum separately[1].In this way the cranial duct communicates with the CBD,while the caudal orifice communicates with the pancreatic duct[2].

How to preserve the native or reconstructed esophagus after perforations or postoperative leaks: A multidisciplinary 15-year experience

BACKGROUND Esophageal perforation or postoperative leak after esophageal surgery remain a life-threatening condition.The optimal management strategy is still unclear.AIM To determine clinical outcomes and complications of our 15-year experience in the multidisciplinary management of esophageal perforations and anastomotic leaks.METHODS A retrospective single-center observational study was performed on 60 patients admitted at our department for esophageal perforations or treated for an anastomotic leak developed after esophageal surgery from January 2008 to December 2023.Clinical outcomes were analyzed,and complications were evaluated to investigate the efficacy and safety of our multidisciplinary management based on the preservation of the native or reconstructed esophagus,when feasible.RESULTS Among the whole series of 60 patients,an urgent surgery was required in 8 cases due to a septic state.Fifty-six patients were managed by endoscopic or hybrid treatments,obtaining the resolution of the esophageal leak/perforation without removal of the native or reconstructed esophagus.The mean time to resolution was 54.95±52.64 days,with a median of 35.5 days.No severe complications were recorded.Ten patients out of 56(17.9%)developed pneumonia that was treated by specific antibiotic therapy,and in 6 cases(10.7%)an atrial fibrillation was recorded.Seven patients(12.5%)developed a stricture within 12 months,requiring one or two endoscopic pneumatic dilations to solve the problem.Mortality was 1.7%.CONCLUSION A proper multidisciplinary approach with the choice of the most appropriate treatment can be the key for success in managing esophageal leaks or perforations and preserving the esophagus.

The outcomes and safety of patients undergoing endoscopic retrograde cholangiopancreatography combining a single-use cholangioscope and a single-use duodenoscope:A multicenter retrospective international study

Background: Duodenoscope-related multidrug-resistant organism(MDRO) infections raise concerns. Disposable duodenoscopes have been recently introduced in the market and approved by regulatory agencies with the aim to reduce the risk of endoscopic retrograde cholangiopancreatography(ERCP) associated infections. The aim of this study was to evaluate the outcome of procedures performed with single-use duodenoscopes in patients with clinical indications to single-operator cholangiopancreatoscopy. Methods: This is a multicenter international, retrospective study combining all patients who underwent complex biliopancreatic interventions using the combination of a single-use duodenoscope and a single-use cholangioscope. The primary outcome was technical success defined as ERCP completion for the intended clinical indication. Secondary outcomes were procedural duration, rate of cross-over to reusable duodenoscope, operator-reported satisfaction score(1 to 10) on performance rating of the single-use duodenoscope, and adverse event(AE) rate. Results: A total of 66 patients(26, 39.4% female) were included in the study. ERCP was categorized according to ASGE ERCP grading system as 47(71.2%) grade 3 and 19(28.8%) grade 4. The technical success rate was 98.5%(65/66). Procedural duration was 64(interquartile range 15-189) min, cross-over rate to reusable duodenoscope was 1/66(1.5%). The satisfaction score of the single-use duodenoscope classified by the operators was 8.6 ± 1.3 points. Four patients(6.1%) experienced AEs not directly related to the single-use duodenoscope, namely 2 post-ERCP pancreatitis(PEP), 1 cholangitis and 1 bleeding.Conclusions: Single-use duodenoscope is effective, reliable and safe even in technically challenging procedures with a non-inferiority to reusable duodenoscope, making these devices a viable alternative to standard reusable equipment.

Role of macroscopic on-site evaluation of endoscopic ultrasoundguided fine-needle aspiration/biopsy:Results of a multicentric prospective study

BACKGROUND The concept of macroscopic on-site evaluation(MOSE)was introduced in 2015 when the endoscopist observed better diagnostic yield when the macroscopically visible core on MOSE was superior to 4 mm.Recent studies suggest that MOSE by the endoscopist may be an excellent alternative to rapid on-site evaluation,and some classi-fications have been published.Few studies have assessed the adequacy of histologic cores in MOSE during endoscopic ultrasound-guided fine-needle aspiration/biopsy(EUS-FNA/FNB).AIM To evaluate the performance of MOSE during EUS-FNA/FNB.METHODS This multicentric prospective study was conducted in 16 centers in 3 countries(Egypt,Iraq,and Morocco)and included 1108 patients with pancreatic,biliary,or gastrointestinal pathology who were referred for EUS examination.We prospectively analyzed the MOSE in 1008 patients with available histopathological reports according to 2 classifications to determine the adequacy of the histological core samples.Data management and analysis were performed using a Statistical Package for Social Sciences(SPSS)version 27.RESULTS A total of 1074 solid lesions were biopsied in 1008 patients with available cytopathological reports.Mean age was 59 years,and 509 patients(50.5%)were male.The mean lesion size was 38 mm.The most frequently utilized needles were FNB-Franseen(74.5%)and 22 G(93.4%),with a median of 2 passes.According to 2 classifications,618 non-bloody cores(61.3%)and 964 good samples(95.6%)were adequate for histological evaluation.The overall diagnostic yield of cytopathology was 95.5%.The cytological examination confirmed the diagnosis of malignancy in 861 patients(85.4%),while 45 samples(4.5%)were inconclusive.Post-procedural adverse events occurred in 33 patients(3.3%).Statistical analysis showed a difference between needle types(P=0.035)with a high sensitivity of FNB(97%).The analysis of the relationship between the MOSE-score and the final diagnosis showed a significant difference between the different scores of the MOSE(P<0.001).CONCLUSION MOSE is a simple method that allows endoscopists to increase needle passes to improve sample quality.There is significantly higher FNB sensitivity and cytopathology diagnostic yield with good MOSE cores.

Role and timing of endoscopy in acute biliary pancreatitis

The role and timing of endoscopy in the setting of acute biliary pancreatitis(ABP) is still being debated. Despite numerous randomized trials have been published,there is an obvious lack of consensus on the indications and timing of endoscopic retrograde cholangiopancreatography(ERCP) in ABP in metaanalyses and nationwide guidelines. The present editorial has been written to clarify the role of endoscopy in ABP. In clinical practice the decision to perform an ERCP is often based on biochemical and radiological criteria despite they already have been shown to be unreliable predictors of common bile duct stone presence. Endoscopic ultrasonography(EUS) is not currently a worldwide standard diagnostic procedure early in the course of acute biliary pancreatitis,but it has been shown to be accurate,safe and cost effective in diagnosing biliary obstructions compared with magnetic resonance cholangiopancreatography and ERCP and therefore in preventing unnecessary ERCP and its related complications. Early EUS in ABP allows,if appropriate,immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.

Capsule endoscopy in neoplastic diseases

Until recently, diagnosis and management of small-bowel tumors were delayed by the diffi culty of access to the small bowel and the poor diagnostic capabilities of the available diagnostic techniques. An array of new methods has recently been developed, increasing the possibility of detecting these tumors at an earlier stage. Capsule endoscopy (CE) appears to be an ideal tool to recognize the presence of neoplastic lesions along this organ, since it is non-invasive and enables the entire small bowel to be visualized. High- quality images of the small-bowel mucosa may be captured and small and ? at lesions recognized, without exposure to radiation. Recent studies on a large population of patients undergoing CE have reported small-bowel tumor frequency only slightly above that reported in previous surgical series (range, 1.6%-2.4%) and have also confirmed that the main clinical indication to CE in patients with small-bowel tumors is obscure gastrointestinal (GI) bleeding. The majority of tumors identified by CE are malignant; many were unsuspected and not found by other methods. However, it remains difficult to identify pathology and tumor type based on the lesion’s endoscopic appearance. Despite its limitations, CE provides crucial information leading in most cases to changes in subsequent patient management. Whether the use of CE in combination with other new diagnostic (MRI or multidetector CT enterography) and therapeutic (Push- and-pull enteroscopy) techniques will lead to earlier diagnosis and treatment of these neoplasms, ultimately resulting in a survival advantage and in cost savings,remains to be determined through carefully-designed studies.

Negative capsule endoscopy in patients with obscure gastrointestinal bleeding reliable: Recurrence of bleeding on long-term follow-up

AIM: To assess the rate of recurrent bleeding of the small bowel in patients with obscure bleeding already undergone capsule endoscopy (CE) with negative results. METHODS: We reviewed the medical records related to 696 consecutive CE performed from December 2002 to January 2011, focusing our attention on patients with recurrence of obscure bleeding and negative CE. Evaluating the patient follow-up, we analyzed the recurrence rate of obscure bleeding in patient with a negative CE. Actuarial rates of rebleeding during follow-up were calculated, and factors associated with rebleeding were assessed through an univariate and multivariate analysis. A P value of less than 0.05 was regarded as statistically significant. The sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of negative CE were calculated. RESULTS: Two hundred and seven out of 696 (29.7%) CE studies resulted negative in patient with obscure/overt gastrointestinal bleeding. Overall, 489 CE (70.2%) were positive studies. The median follow-up was 24 mo (range 12-36 mo). During follow-up, recurrence of obscure bleeding was observed only in 34 out of 207 negative CE patients (16.4%); 26 out of 34 with obscure overt bleeding and 8 out of 34 with obscure occult bleeding. The younger age (< 65 years) and the onset of bleeding such as melena are independent risk factors of rebleeding after a negative CE (OR = 2.6703, 95%CI: 1.1651-6.1202, P = 0.0203; OR 4.7718, 95%CI: 1.9739-11.5350, P = 0.0005). The rebleeding rate (CE+ vs CE-) was 16.4% vs 45.1% (χ 2 test, P = 0.00001). The sensitivity, specificity, and PPV and NPV were 93.8%, 100%, 100%, 80.1%, respectively. CONCLUSION: Patients with obscure gastrointestinal bleeding and negative CE had a significantly lower rebleeding rate, and further invasive investigations can be deferred.

Wireless capsule endoscopy

Wireless capsule endoscopy is a new technique that allows complete exploration of the small bowel without exlemal wires. Its role has been analyzed in many small bowel diseases such as obscure gastrointestinal bleeding, Crohn＇s disease and gastrointestinal polyposis syndromes with promising results. Studies on other pathologies （i.e. small bowel tumour, celiac disease） are under evaluation to define the role of this technique.

Implications of small-bowel transit time in the detection rate of capsule endoscopy: A multivariable multicenter study of patients with obscure gastrointestinal bleeding

AIMTo define the role of small-bowel transit time in the detection rate of significant small-bowel lesions.METHODSSmall-bowel capsule endoscopy records, prospectively collected from 30 participating centers in the Lombardy Registry from October 2011 to December 2013, were included in the study if the clinical indication was obscure gastrointestinal bleeding and the capsule reached the cecum. Based on capsule findings, we created two groups: P2 (significant findings) and P0-1 (normal/negligible findings). Groups were compared for age, gender, small-bowel transit time, type of instrument, modality of capsule performance (outpatients vs inpatients), bowel cleanliness, and center volume.RESULTSWe retrieved and scrutinized 1,433 out of 2,295 capsule endoscopy records (62.4%) fulfilling the inclusion criteria. Patients were 67 &#x000b1; 15 years old, and 815 (57%) were males. In comparison with patients in the P0-1 group, those in the P2 group (n = 776, 54%) were older (P &#x0003c; 0.0001), had a longer small-bowel transit time (P = 0.0015), and were more frequently examined in low-volume centers (P &#x0003c; 0.001). Age and small-bowel transit time were correlated (P &#x0003c; 0.001), with age as the sole independent predictor on multivariable analysis. Findings of the P2 group were artero-venous malformations (54.5%), inflammatory (23.6%) and protruding (10.4%) lesions, and luminal blood (11.5%).CONCLUSIONIn this selected, prospectively collected cohort of small-bowel capsule endoscopy performed for obscure gastrointestinal bleeding, a longer small-bowel transit time was associated with a higher detection rate of significant lesions, along with age and a low center volume, with age serving as an independent predictor.

Capsule endoscopy in celiac disease

Video capsule endoscopy is an attractive and patient- friendly tool that provides high quality images of the small bowel. Obscure gastrointestinal bleeding is the primary and most evaluated indication to capsule endoscopy;however,indications are expanding and a small number of preliminary reports have been presented concerning the role of video capsule endoscopy in the diagnosis of celiac disease. The purpose of this review is to update the current knowledge and to hypothesize on future perspectives of the use of video capsule endoscopy in patients with celiac disease.

Cholangiocarcinoma and malignant bile duct obstruction: A review of last decades advances in therapeutic endoscopy

In the last decades many advances have been achieved in endoscopy, in the diagnosis and therapy of cholangiocarcinoma, however blood test, magnetic resonance imaging, computed tomography scan may fail to detect neoplastic disease at early stage, thus the diagnosis of cholangiocarcinoma is achieved usually at unresectable stage. In the last decades the role of endoscopy has moved from a diagnostic role to an invaluable therapeutic tool for patients affected by malignant bile duct obstruction. One of the major issues for cholangiocarcinoma is bile ducts occlusion, leading to jaundice, cholangitis and hepatic failure. Currently, endoscopy has a key role in the work up of cholangiocarcinoma, both in patients amenable to surgical intervention as well as in those unfit for surgery or not amenable to immediate surgical curative resection owing to locally advanced or advanced disease, with palliative intention. Endoscopy allows successful biliary drainage and stenting in more than 90% of patients with malignant bile duct obstruction, and allows rapid reduction of jaundice decreasing the risk of biliary sepsis. When biliary drainage and stenting cannot be achieved with endoscopy alone, endoscopic ultrasound-guided biliary drainage represents an effective alternative method affording successful biliary drainage in more than 80% of cases. The purpose of this review is to focus on the currently available endoscopic management options in patients with cholangiocarcinoma.

Colon capsule endoscopy: Advantages, limitations and expectations. Which novelties?

Since the first reports almost ten years ago, wireless capsule endoscopy has gained new f ields of application. Colon capsule endoscopy represents a new diagnostic technology for colonic exploration. Clinical trials have shown that colon capsule endoscopy is feasible, accurate and safe in patients suffering from colonic diseases and might be a valid alternative to conventional colonoscopy in selected cases such as patients refusing conventional colonoscopy or with contraindications to colonoscopy or when colonoscopy is incomplete. Despite the enthusiasm surrounding this new technique, few clinical and randomized controlled trials are to be found in the current literature, leading to heterogeneous or controversial results. Upcoming studies are needed to prove the substantial utility of colon capsule endoscopy for colon cancer screening, especially in a low prevalence of disease population, and for other indications such as inflammatory bowel disease. Possible perspectives are critically analysed and reported in this paper.

Biodegradable stents in gastrointestinal endoscopy

Biodegradable stents(BDSs)are an attractive option to avoid ongoing dilation or surgery in patients with benign stenoses of the small and large intestines.The experience with the currently the only BDS for endoscopic placement,made of Poly-dioxanone,have shown promising results.However some aspects should be improved as are the fact that BDSs lose their radial force over time due to the degradable material,and that can cause stent-induced mucosal or parenchymal injury.This complication rate and modest clinical efficacy has to be carefully considered in individual patients prior to placement of BDSs.Otherwise,the price of these stents therefore it is nowadays an important limitation.

Endoscopy-guided ablation of pancreatic lesions:Technical possibilities and clinical outlook

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP)-guided ablation procedures are emerging as a minimally invasive therapeutic alternative to radiological and surgical treatments for locally advanced pancreatic cancer (LAPC), pancreatic neuroendocrine tumours (PNETs), and pancreatic cystic lesions (PCLs). The advantages of treatment under endoscopic control are the real-time imaging guidance and the possibility to reach a deep target like the pancreas. Currently, radiofrequency probes specifically designed for ERCP or EUS ablation are available as well as hybrid cryotherm probe combining radiofrequency with cryotechnology. To date, many reports and case series have confirmed the safety and feasibility of that kind of ablation technique in the pancreatic setting. Moreover, EUS-guided fine-needle injection is emerging as a method to deliver ablative and anti-tumoral agents inside the tumuor. Ethanol injection has been proposed mostly for the treatment of PCLs and for symptomatic functioning PNETs, and the use of gemcitabine and paclitaxel is also interesting in this setting. EUS-guided injection of chemical or biological agents including mixed lymphocyte culture, oncolytic viruses, and immature dendritic cells has been investigated for the treatment of LAPC. Data on the long-term efficacy of these approaches, and large prospective randomized studies are needed to confirm the real clinical benefits of these techniques for the management of pancreatic lesions.

Wireless endoscopy in 2020:Will it still be a capsule?

Currently,the major problem of all existing commercial capsule devices is the lack of control of movement.In the future,with an interface application,the clinician will be able to stop and direct the device into points of interest for detailed inspection/diagnosis,and therapy delivery.This editorial presents current commerciallyavailable new designs,European projects and delivery capsule and gives an overview of the progress required and progress that will be achieved-according to the opinion of the authors- in the next 5 year leading to 2020.