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.

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.

Can endoscopic atrophy predict histological atrophy? Historical study in United Kingdom and Japan

AIM: To assess the diagnostic concordance between endoscopic and histological atrophy in the United Kingdom and Japan.METHODS: Using published data,a total of 252 patients,126 in the United Kingdom and 126 in Japan,aged 20 to 80 years,were evaluated. The extent of endoscopic atrophy was classified into five subgroups according to a modified Kimura-Takemoto classification system and was compared with histological findings of atrophy at five biopsy sites according to the updated Sydney system.RESULTS: The strength of agreement of the extent of atrophy between histology and visual endoscopic inspection showed good reproducibili ty,wi th a weighted kappa value of 0.76(P < 0.001). Multivariate analysis showed that three factors were associated with decreased concordance: Japanese ethnicity [odds ratio(OR) 0.22,95% confidence interval(CI) 0.11-0.43],older age(OR = 0.32,95%CI: 0.16-0.66) and endoscopic atrophy(OR = 0.10,95%CI: 0.03-0.36). The strength of agreement between endoscopic and histological atrophy,assessed by cancer risk-oriented grading,was reproducible,with a kappa value of 0.81(95%CI: 0.75-0.87). Only nine patients(3.6%) were endoscopically underdiagnosed with antral predominant rather than extensive atrophy and were considered false negatives.CONCLUSION: Endoscopic grading can predict histological atrophy with few false negatives,indicating that precancerous conditions can be identified during screening endoscopy,particularly in patients in western countries.

Lumen-apposing-metal stent misdeployment in endoscopic ultrasound-guided drainages:A systematic review focusing on issues and rescue management

BACKGROUND The introduction of lumen-apposing metal stents(LAMS)for endoscopic ultrasound(EUS)-guided drainages has marked a turning point in the field of interventional ultrasound and it is gathering worldwide diffusion in different clinical settings.Nevertheless,the procedure may conceal unexpected pitfalls.LAMS misdeployment is the most frequent cause of technical failure and it can be considered a procedure-related adverse event when it hampers the conclusion of the planned procedure or results in significant clinical consequences.Stent misdeployment can be managed successfully by endoscopic rescue maneuvers to allow the completion of the procedure.To date,no standardized indication is available to guide an appropriate rescue strategy depending on the type of procedure or of misdeployment.AIM To evaluate the incidence of LAMS misdeployment during EUS-guided choledochoduodenostomy(EUS-CDS),gallbladder drainage(EUS-GBD)and pancreatic fluid collections drainage(EUS-PFC)and to describe the endoscopic rescue strategies adopted under the circumstance.METHODS We conducted a systematic review of the literature on PubMed by searching for studies published up to October 2022.The search was carried out using the exploded medical subject heading terms“lumen apposing metal stent”,“LAMS”,“endoscopic ultrasound”and“choledochoduodenostomy”or“gallbladder”or“pancreatic fluid collections”.We included in the review on-label EUS-guided procedures namely EUS-CDS,EUS-GBD and EUS-PFC.Only those publications reporting EUS-guided LAMS positioning were considered.The studies reporting a technical success rate of 100%and other procedure-related adverse events were considered to calculate the overall rate of LAMS misdeployment,while studies not reporting the causes of technical failure were excluded.Case reports were considered only for the extraction of data regarding the issues of misdeployment and rescue techniques.The following data were collected from each study:Author,year of publication,study design,study population,clinical indication,technical success,reported number of misdeployment,stent type and size,flange misdeployed and type of rescue strategy.RESULTS The overall technical success rate of EUS-CDS,EUS-GBD and EUS-PFC was 93.7%,96.1%,and 98.1%respectively.Significant rates of LAMS misdeployment have been reported for EUS-CDS,EUS-GBD and EUS-PFC drainage,respectively 5.8%,3.4%,and 2.0%.Endoscopic rescue treatment was feasible in 86.8%,80%,and 96.8%of cases.Non endoscopic rescue strategies were required only in 10.3%,16%and 3.2%for EUS-CDS,EUS-GBD,and EUS-PFC.The endoscopic rescue techniques described were over-the-wire deployment of a new stent through the created fistula tract in 44.1%,8%and 64.5%and stent-in-stent in 23.5%,60%,and 12.9%,respectively for EUSCDS,EUS-GBD,and EUS-PFC.Further therapeutic option were endoscopic rendezvous in 11.8%of EUS-CDS and repeated procedure of EUS-guided drainage in 16.1%of EUS-PFC.CONCLUSION LAMS misdeployment is a relatively common adverse event in EUS-guided drainages.There is no consensus on the best rescue approach in these cases and the choice is often made by the endoscopist relying upon the clinical scenario,anatomical characteristics,and local expertise.In this review,we investigated the misdeployment of LAMS for each of the on-label indications focusing on the rescue therapies used,with the aim of providing useful data for endoscopists and to improve patient outcomes.

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.

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.

Differential diagnosis in inflammatory bowel disease colitis:State of the art and future perspectives

Distinction between Crohn's disease of the colonrectum and ulcerative colitis or inflammatory bowel disease(IBD) type unclassified can be of pivotal importance for a tailored clinical management,as each entity often involves specific therapeutic strategies and prognosis.Nonetheless,no gold standard is available and the uncertainty of diagnosis may frequently lead to misclassification or repeated examinations.Hence,we have performed a literature search to address the problem of differential diagnosis in IBD colitis,revised current and emerging diagnostic tools and refined disease classification strategies.Nowadays,the differential diagnosis is an untangled issue,and the proper diagnosis cannot be reached in up to 10% of patients presenting with IBD colitis.This topic is receiving emerging attention,as medical therapies,surgical approaches and leading prognostic outcomes require more and more disease-specific strategies in IBD patients.The optimization of standard diagnostic approaches based on clinical features,biomarkers,radiology,endoscopy and histopathology appears to provide only marginal benefits.Conversely,emerging diagnostic techniques in the field of gastrointestinal endoscopy,molecular pathology,genetics,epigenetics,metabolomics and proteomics have already shown promising results.Novel advanced endoscopic imaging techniques and biomarkers can shed new light for the differential diagnosis of IBD,better reflecting diverse disease behaviors based on specific pathogenic pathways.

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.

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.

Single balloon enteroscopy: Technical aspects and clinical applications

The small bowel has long been considered a black box for endoscopists because of its long length and the presence of multiple complex loop. Most of the small bowel is inaccessible by traditional endoscopic means. In addition, radiographic studies have significant limitations with regard to diagnostic yield, and surgery is an invasive alternative. This limitation was overcome through the development of balloon enteroscopy that becomes established throughout the world for diagnostic and therapeutic examinations of the small bowel. The single-balloon enteroscope (SBE) system (Olympus, Tokyo, Japan) was introduced into the commercial market in 2007. Several study demonstrated its efficacy and safety. Early reports on the use of singleballoon enteroscopy have suggested a high diagnostic yield and similar therapeutic potential to that of the double-balloon endoscope. SBE is viable technique for in the management of small bowel disease. Technically, it is easy to perform, may be efficient, and in the literature data available, seems to provide high diagnostic and therapeutic yield.

Helicobacter pylori eradication and reflux disease onset:Did gastric acid get "crazy"?

Gastroesophageal reflux disease (GORD) is highly prevalent in the general population.In the last decade,a potential relationship between Helicobacter pylori (H.pylori) eradication and GORD onset has been claimed.The main putative mechanism is the gastric acid hypersecretion that develops after bacterial cure in those patients with corpus-predominant gastritis.We performed a critical reappraisal of the intricate pathogenesis and clinical data available in this field.Oesophagitis onset after H.pylori eradication in duodenal ulcer patients has been ascribed to a gastric acid hypersecretion,which could develop following body gastritis healing.However,the absence of an acid hypersecretive status in these patients is documented by both pathophysiology and clinical studies.Indeed,duodenal ulcer recurrence is virtually abolished followingH.pylori eradication.In addition,intra-oesophageal pH recording studies failed to demonstrated increased acid reflux following bacterial eradication.Moreover,oesophageal manometric studies suggest that H.pylori eradication would reduce-rather than favor-acid reflux into the oesophagus.Finally,data of clinical studies would suggest that H.pylori eradication is not significantly associated with eitherreflux symptoms or erosive oesophagitis onset,some data suggesting also an advantage in curing the infection when oesophagitis is already present.Therefore,the legend of "crazy acid" remains-as all the others a fascinating,but imaginary tale.

Inflammatory bowel diseases and human reproduction:A comprehensive evidence-based review

To evaluate the effects of inflammatory bowel diseases(IBDs)on human reproduction,we reviewed the current literature using a systematic search for published studies(articles and/or abstracts)without limits for English language.We searched on Medline(through PubMed),the Institute for Scientific Information,the Web of Science and the websites for the registration of controlled trials(http://controlled-trials.com/).Bibliographies of retrieved articles,books,expert opinion review articles and reviewed bibliographies from subject experts were manually searched.Titles and abstracts were screened initially,and potential relevant articles were identified and reviewed.Whenever possible,data were analyzed by comparing IBD patients vs healthy controls,and patients with active IBDs vs those with disease in remission.The effects of IBDs on female fertility,fertility in infertile couples,pregnancy and male infertility were examined separately.Patients with IBDs in remission have normal fertility.At the moment,there is no established guideline for the preservation of fertility in women with IBD undergoing surgery.Further data are needed regarding guidelines for the management of these patients.Data regarding IBDs and infertility are currently completely lacking.Considering the prevalence of intestinal pathology in young adults of childbearing age,this field is of great scientific and clinical interest,opening up important future perspectives.Another important and as yet unexplored point is the response to treatments for infertility in patients with IBDs.In particular,the question is whether the reproductive outcomes(clinical and biological)can be influenced by the IBD of one of the partners.The goals for successful reproductive outcomes in IBD population are correct counseling and disease remission.IBDs significantly affect several reproductive aspects of human(female,male,couple)reproduction.Further data are needed to develop guidelines for the clinical management of subjects of reproductive age with IBDs.

Radiofrequency and malignant biliary strictures:An update

Malignant biliary strictures are usually linked to different types of tumors,mainly cholangiocarcinoma, pancreatic and hepatocellular carcinomas. Palliative measures are usually adopted in patients with nonresectable or borderline resectable biliary disease. Stent placement is a well-known and established treatment in patients with unresectable malignancy. Intraductal radiofrequency ablation(RFA) represents a procedure that involves the use of a biliary catheter device, via an endoscopic approach. Indications for biliary RFA described in literature are: Palliative treatment of malignant biliary strictures, avoiding stent occlusion, ablating ingrowth of blocked metal stents, prolonging stent patency,ablating residual adenomatous tissue after endoscopic ampullectomy. In this mini-review we addressed focus on technical success defined as deployment of the RF catheter, virtually succeeded in all patients included in the studies. About efficacy, three main outcome measures have been contemplated: Biliary decompression and stent patency, survival. Existing studies suggest a beneficial effect on survival and stent patency with RFA, but current impression is limited because most of studies have been performed using a retrospective design, on diminutive and dissimilar cohorts of patients.

Microbiota-gut-brain axis and its affect inflammatory bowel disease:Pathophysiological concepts and insights for clinicians

Despite the bi-directional interaction between gut microbiota and the brain not being fully understood,there is increasing evidence arising from animal and human studies that show how this intricate relationship may facilitate inflammatory bowel disease(IBD)pathogenesis,with consequent important implications on the possibility to improve the clinical outcomes of the diseases themselves,by acting on the different components of this system,mainly by modifying the microbiota.With the emergence of precision medicine,strategies in which patients with IBD might be categorized other than for standard gut symptom complexes could offer the opportunity to tailor therapies to individual patients.The aim of this narrative review is to elaborate on the concept of the gutbrain-microbiota axis and its clinical significance regarding IBD on the basis of recent scientific literature,and finally to focus on pharmacological therapies that could allow us to favorably modify the function of this complex system.

Efficacy and tolerability of high and low-volume bowel preparation compared:A real-life single-blinded large-population study

BACKGROUND Low-volume preparations for colonoscopy have shown similar efficacy compared to high-volume ones in randomized controlled trials(RCT).However,most RCTs do not provide data about clinical outcomes including lesions detection rate.Moreover,real-life comparisons are lacking.AIM To compare efficacy(both in terms of adequate bowel preparation and detection of colorectal lesions)and tolerability of a high-volume(HV:4 L polyethylene glycol,PEG)and a low-volume(LV:2 L PEG plus bisacodyl)bowel preparation in a real-life setting.METHODS Consecutive outpatients referred for colonoscopy were prospectively enrolled between 1 December 2014 and 31 December 2016.Patients could choose either LV or HV preparation,with a day-before schedule for morning colonoscopies and a split-dose for afternoon procedures.Adequate bowel preparation according to Boston Bowel Preparation Scale(BBPS),clinical outcomes including polyp detection rate(PDR),adenoma detection rate(ADR),advanced adenoma detection rate(AADR),sessile/serrated lesion detection rate(SDR)and cancer detection rate and self-reported tolerability of HV and LV were blindly assessed.RESULTS Total 2040 patients were enrolled and 1815(mean age 60.6 years,50.2%men)finally included.LV was chosen by 52%of patients(50.8%of men,54.9%of women).Split-dose schedule was more common with HV(44.7%vs 38.2%,P=0.005).High-definition scopes were used in 33.4%of patients,without difference in the two groups(P=0.605).HV and LV preparations showed similar adequate bowel preparation rates(89.2%vs 86.6%,P=0.098),also considering the two different schedules(HV split-dose 93.8%vs LV split-dose 93.6%,P=1;HV daybefore 85.5%vs LV day-before 82.3%,P=0.182).Mean global BBPS score was higher for HV preparations(7.1±1.7 vs 6.8±1.6,P<0.001).After adjustment for sex,age and indications for colonoscopy,HV preparation resulted higher in PDR[Odds ratio(OR)1.32,95%CI:1.07-1.63,P=0.011]and ADR(OR 1.29,95%CI 1.02–1.63,P=0.038)and comparable to LV in AADR(OR 1.51,95%CI 0.97-2.35,P=0.069),SDR and cancer detection rate.The use of standard-definition colonoscopes was associated to lower PDR(adjusted OR 1.59,95%CI:1.22-2.08,P<0.001),ADR(adjusted OR 1.71,95%CI:1.26–2.30,P<0.001)and AADR(adjusted OR 1.97,95%CI:1.09-3.56,P=0.025)in patients receiving LV preparation.Mean Visual Analogue Scale tolerability scored equally(7,P=0.627)but a≥75%dose intake was more frequent with LV(94.6%vs 92.1%,P=0.003).CONCLUSION In a real-life setting,PEG-based low-volume preparation with bisacodyl showed similar efficacy and tolerability compared to standard HV preparation.However,with higher PDR and ADR,HV should still be considered as the reference standard for clinical trials and the preferred option in screening colonoscopy,especially when colonoscopy is performed with standard resolution imaging.

Gastric per-oral endoscopic myotomy:Indications,technique,results and comparison with surgical approach

Gastroparesis is a chronic disease of the stomach that causes a delayed gastric emptying,without the presence of a stenosis.For 30 years the authors identified pylorospasm as one of the most important pathophysiological mechanisms determining gastroparesis.Studies with EndoFLIP,a device that assesses pyloric distensibility,increased the knowledge about pylorospasm.Based on this data,several pyloric-targeted therapies were developed to treat refractory gastroparesis:Surgical pyloroplasty and endoscopic approach,such as pyloric injection of botulinum and pyloric stenting.Notwithstanding,the success of most of these techniques is still not complete.In 2013,the first human gastric per-oral endoscopic myotomy(GPOEM)was performed.It was inspired by the POEM technique,with a similar dissection method,that allows pyloromyotomy.Therapeutical results of GPOEM are similar to surgical approach in term of clinical success,adverse events and post-surgical pain.In the last 8 years GPOEM has gained the attention of the scientific community,as a minimally invasive technique with high rate of clinical success,quickly prevailing as a promising therapy for gastroparesis.Not surprisingly,in referral centers,its technical success rate is 100%.One of the main goals of recent studies is to identify those patients that will respond better to the therapies targeted on pylorus and to choose the better approach for each patient.

Endoscopic ultrasound diagnostic gain over computed tomography and magnetic resonance cholang-iopancreatography in defining etiology of idiopathic acute pancreatitis

BACKGROUND About 10%-30%of acute pancreatitis remain idiopathic(IAP)even after clinical and imaging tests,including abdominal ultrasound(US),contrast-enhanced computed tomography(CECT)and magnetic resonance cholangiopancreatography(MRCP).This is a relevant issue,as up to 20%of patients with IAP have recurrent episodes and 26%of them develop chronic pancreatitis.Few data are available on the role of EUS in clarifying the etiology of IAP after failure of one or more cross-sectional techniques.AIM To evaluate the diagnostic gain after failure of one or more previous crosssectional exams.METHODS We retrospectively collected data about consecutive patients with AP and at least one negative test between US,CECT and MRCP,who underwent linear EUS between January 2017 and December 2020.We investigated the EUS diagnostic yield and the EUS diagnostic gain over different combinations of these crosssectional imaging techniques for the etiologic diagnosis of AP.Types and frequency of EUS diagnosis were also analyzed,and EUS diagnosis was compared with the clinical parameters.After EUS,patients were followed-up for a median of 31.5 mo to detect cases of pancreatitis recurrence.RESULTS We enrolled 81 patients(63%males,mean age 61±18,23%with previous cholecystectomy,17%with recurrent pancreatitis).Overall EUS diagnostic yield for AP etiological diagnosis was 79%(20%lithiasis,31%acute on chronic pancreatitis,14%pancreatic solid or cystic lesions,5%pancreas divisum,5%autoimmune pancreatitis,5%ductal abnormalities),while 21%remained idiopathic.US,CECT and MRCP,taken alone or in combination,led to AP etiological diagnosis in 16(20%)patients;among the remaining 65 patients,49(75%)obtained a diagnosis at EUS,with an overall EUS diagnostic gain of 61%.Sixty-eight patients had negative US;among them,EUS allowed etiological diagnosis in 59(87%).Sixty-three patients had a negative CECT;among them,47(74%)obtained diagnosis with EUS.Twenty-four had a negative MRCP;among them,20(83%)had EUS diagnosis.Twenty-one had negative CT+MRCP,of which 17(81%)had EUS diagnosis,with a EUS diagnostic gain of 63%.Patients with biliary etiology and without previous cholecystectomy had higher median values of alanine aminotransferase(154 vs 25,P=0.010),aspartate aminotransferase(95 vs 29,P=0.018),direct bilirubin(1.2 vs 0.6,P=0.015),gammaglutamyl transpeptidase(180 vs 48,P=0.006)and alkaline phosphatase(150 vs 72,P=0.015)Chronic pancreatitis diagnosis was more frequent in patients with recurrent pancreatitis at baseline(82%vs 21%,P<0.001).During the follow-up,AP recurred in 3 patients,one of which remained idiopathic.CONCLUSION EUS is a good test to define AP etiology.It showed a 63%diagnostic gain over CECT+MRCP.In suitable patients,EUS should always be performed in cases of IAP.Further prospective studies are needed.

Feasibility and safety of self-expandable metal stent in nonmalignant disease of the lower gastrointestinal tract

In recent years,self-expandable metal stents(SEMSs)have been employed to treat benign gastrointestinal strictures secondary to several conditions:Acute diverticulitis,radiation colitis,inflammatory bowel disease(IBD),and postanastomotic leakages and stenosis.Other applications include endometriosis and fistulas of the lower gastrointestinal tract.Although it may be technically feasible to proceed to stenting in the aforementioned benign diseases of the lower gastrointestinal tract,the outcome has been reported to be poor.In fact,in some settings(such as complicated diverticulitis and postsurgical anastomotic strictures),stenting seems to have a limited evidence-based benefit as a bridge to surgery,while in other settings(such as endometriosis,IBD,radiation colitis,etc.),even society guidelines are not able to guide the endoscopist through decisional algorithms for SEMS placement.The aim of this narrative paper is to review the scientific evidence regarding the use of SEMSs in nonmalignant diseases of the lower gastrointestinal tract,both in adult and pediatric settings.

Gastrointestinal tract injuries after thermal ablative therapies for hepatocellular carcinoma:A case report and review of the literature

BACKGROUND Radiofrequency ablation(RFA)and microwave ablation(MWA)represent the standard of care for patients with early hepatocellular carcinoma(HCC)who are unfit for surgery.The incidence of reported adverse events is low,ranging from 2.4%to 13.1%for RFA and from 2.6%to 7.5%for MWA.Gastrointestinal tract(GIT)injury is even more infrequent(0.11%),but usually requires surgery with an unfavourable prognosis.Due to its low incidence and the retrospective nature of the studies,the literature reporting this feared complication is heterogeneous and in many cases lacks information on tumour characteristics,comorbidities and treatment approaches.CASE SUMMARY A 77-year-old man who had undergone extended right hepatectomy for HCC was diagnosed with early disease recurrence with a small nodule compatible with HCC in the Sg4b segment of the liver with a subcapsular location.He was treated with percutaneous RFA and a few week later he was urgently admitted to the Surgery ward for abdominal pain and fever.A subcutaneous abscess was diagnosed and treated by percutaneous drainage.A fistulous tract was then documented by the passage of contrast material from the gastric antrum to the abdominal wall.The oesophagogastroduodenoscopy confirmed a circular wall defect at the lesser curvature of gastric antrum, leading directly to the purulentabdominal collection. An over-the-scope clip (OTSC) was used to successfullyclose the defectCONCLUSIONThis is the first reported case of RFA-related GIT injury to have been successfullytreated with an OTSC, which highlights the role of this endoscopic treatment forthe management of this complication.