Primary anastomosis closure after endoscopic ultrasound-directed transgastric intervention

Background and study aims Endoscopic ultrasound-directed transgastric intervention (EDGI) is a technique that creates an anastomosis between the gastric pouch or jejunum to the excluded stomach in Roux-en-Y gastric bypass (RYGB) anatomy to allow access to the pancreaticobiliary system. Thus far, management of anastomosis closure at the time of lumen-apposing metal stent (LAMS) removal has varied widely. This study aimed to assess the efficacy of primary closure at the time of LAMS removal using a through-the-scope (TTS) tack-based suture system.  Patients and methods This was a two-center retrospective study of RYGB patients who underwent single-stage EDGI using a 20-mm LAMS and subsequent primary anastomosis closure with the X-tack system at the time of stent removal. Patient demographics, procedure details, clinical outcomes, and imaging findings are reported. Results Nineteen patients (median age 63 years, 84% female) underwent single-stage EDGI with a median follow-up of 31.5 months. Adverse events occurred in two patients (11%) who had abdominal pain requiring hospitalization. The median LAMS dwell time was 32 days (range 16-86). All patients (100%) who underwent follow-up studies after LAMS removal had confirmed anastomosis closure (n = 18). Most patients had documented weight loss at the time of LAMS removal and at last follow-up (68%, n = 13). Conclusions Single-stage EDGI is an effective approach to managing RYGB patients with pancreaticobiliary pathology. Thus far, endoscopic TTS tack-based suturing appears to have a high success rate in anastomosis closure after LAMS removal and should be considered as a primary method for preventing chronic fistulae.

Endoscopic blind limb reduction with septotomy: a novel endoscopic approach to candy cane syndrome after Roux-en-Y gastric bypass

Video 1The endoscopic blind limb reduction with septotomy procedure.

Severe portal venous bleed during ERCP treated with EUS-guided hepaticogastrostomy

Video 1Severe portal venous bleed during ERCP treated with EUS-guided hepaticogastrostomy.

ERCP transpapillary nasogallbladder drainage: a last resort for endoscopic management of cholecystitis

Video 1Clinical case for endoscopic management of cholecystitis.

Ultrasound Assisted Endoscopic Gastric Bypass (USA-EGB): a potential endoscopic alternative to surgical bypass, a pre-clinical proof of concept study

Background and study aims Endoscopic weight loss procedures have gained traction as minimally invasive options for the primary treatment of obesity. Thus far, we have developed endoscopic procedures that reliably address gastric restriction but result in significantly less weight loss than surgical gastrointestinal bypass. The goal of this nonsurvival study was to assess the technical feasibility of an endoscopic procedure, that incorporates both gastric restriction and potentially reversible gastrointestinal bypass. Methods Ultrasound-assisted endoscopic gastric bypass (USA-EGB) was performed in three consecutive live swine, followed by euthanasia and necropsy. Procedure steps were: 1) balloon-assisted enteroscopy that determines the length of the bypassed limb; 2) endoscopic ultrasound-guided gastroenterostomy that creates a gastrointestinal anastomosis using a lumen apposing metal stent; 3) endoscopic pyloric exclusion that disrupts transpyloric continuity resulting in complete gastrointestinal bypass; and 4) gastric restriction that reduces gastric volume. Results Complete gastrointestinal bypass and gastric restriction was achieved in all three swine. The mean total procedure time was 131 minutes (range 113-143), mean length of the bypassed limb was 92.5 cm and 180 cm, using short and long overtubes, respectively. There were no significant complications. Conclusions We successfully described USA-EGB in three consecutive live swine. Further studies are needed to access the procedures safety, efficacy, and clinical use.

Multicenter retrospective cohort of EUS-guided anterograde pancreatic duct access

Background and study aims  Pancreatic duct (PD) cannulation may be difficult during conventional endoscopic retrograde cholangiopancreatography (ERCP) due to underlying pathology, anatomical variants or surgically altered anatomy. Pancreatic access in these cases previously necessitated percutaneous or surgical approaches. Endoscopic ultrasound (EUS) allows for an alternative and can be combined with ERCP for rendezvous during the same procedure, or for other salvage options. Patients and methods  Patients with attempted EUS access of the PD from tertiary referral centers between 2009 and 2022 were included in the cohort. Demographic data, technical data, procedural outcomes and adverse events were collected. The primary outcome was rendezvous success. Secondary outcomes included rates of successful PD decompression and change in procedural success over time. Results  The PD was accessed in 105 of 111 procedures (95 %), with successful subsequent ERCP in 45 of 95 attempts (47 %). Salvage direct PD stenting was performed in 5 of 14 attempts (36 %). Sixteen patients were scheduled for direct PD stenting (without rendezvous) with 100 % success rate. Thus 66 patients (59 %) had successful decompression. Success rates improved from 41 % in the first third of cases to 76 % in the final third. There were 13 complications (12 %), including post-procedure pancreatitis in seven patients (6 %). Conclusions  EUS-guided anterograde pancreas access is a feasible salvage method if retrograde access fails. The duct can be cannulated, and drainage can be achieved in the majority of cases. Success rates improve over time. Future research may involve investigation into technical, patient and procedural factors contributing to rendezvous success.

Safety and clinical outcomes of early dual modality drainage (< 28 days) compared to later drainage of pancreatic necrotic fluid collections: a propensity score-matched study

BACKGROUND

Necrotizing pancreatitis can be complicated by Necrotic Fluid Collections (NFC). Guidelines recommend waiting for 4 weeks from the onset of acute pancreatitis (AP) before considering endoscopic drainage. We aimed to compare outcomes and safety in patients undergoing early versus late drainage of NFC.

METHODS

We performed a retrospective review of all patients who underwent Dual Modality Drainage (DMD) [combined endoscopic and percutaneous drainage] for NFC from January 2007 to December 2020. Patients were stratified into the "early" group (DMD < 28 days from AP onset) and were matched to "late" (DMD ≥ 28 days) drainage group using propensity- core-matching. Primary outcomes of interest were technical success and adverse events. Secondary outcomes included clinical success, late complication rates, and mortality.

RESULTS

We identified 278 patients who underwent DMD for NFC. Thirty-nine belonged to the early group and were matched to 174 patients from the late group. Technical success was similar in both early and late groups (97.4% vs 99.4%: P = 0.244) as were the procedural and early post-procedural (< 14 days) adverse events rates (23.1% vs 27.6%: P = 0.565). Clinical success (92.3% vs 93.1%; P = 0.861) and late complication rates (23.1% vs 31.6%; P = 0.294) were similar. There were 2 deaths (5.7%) in the early vs. 9 (5.2%) in the late group, P = 0.991.

CONCLUSIONS

When performed in a tertiary care center with expertise in therapeutic endoscopic ultrasound, early drainage of NFC appears to be feasible and safe. Further studies are needed to validate our results.

Safe implementation of transoral incisionless fundoplication as a new technique in a tertiary care center

Background/Aims

Transoral incisionless fundoplication (TIF) is an accepted anatomic treatment for gastroesophageal reflux disease in selected patients. In this report, we analyze our institution’s programmatic allocation of resources during the safe implementation of TIF as a new procedure.

Methods

A retrospective analysis of all patients who underwent TIF from January 2020 to February 2021 at our institution was performed. The process of initially allocating the operating room (OR) with overnight admission and postoperative esophagram for added safety, and subsequently transitioning TIF to the endoscopy suite (ES) as an outpatient procedure was described. Patient safety and outcomes were evaluated during transition.

Results

Thirty patients who underwent TIF were identified. The mean age was 51.2±16.0 years. TIF was performed in an OR in nine patients (30%) and 21 (70%) in the ES. All the OR patients were admitted overnight and had routine esophagogram. In contrast, four (19%) from the ES group required clinically-indicated admission and three (14.2%) required esophagram. The mean procedure duration was significantly lower in the ES group (65.7 min vs. 84 min, p=0.02).

Conclusions

A stepwise, resource-efficient process was described that allowed safe initiation of TIF as a new technique and its effective transition to a fully outpatient procedure.

Biliary Endoscopy in Altered Anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard treatment of biliary disease with high success rates of greater than 90% in patients with standard anatomy. However, alterations in upper gastrointestinal anatomy can significantly complicate endoscopic biliary intervention. The past decade has seen significant advances in the endoscopic management of patients with altered anatomy. This review article will provide tips and tricks for successful biliary access in the most common surgical alterations with a focus on the management of biliary diseases following Roux-en-Y (RY) reconstructions.

An international experience with single-operator cholangiopancreatoscopy in patients with altered anatomy

Background and study aims  The utility of digital single- operator cholangiopancreatoscopy (D-SOCP) in surgically altered anatomy (SAA) is limited. We aimed to evaluate the technical success and safety of D-SOCP in patients SAA. Patients and methods  Patients with SAA who underwent D-SOCP between February 2015 and June 2020 were retrospectively evaluated. Technical success was defined as completing the intended procedure with the use of D-SOCP. Results  Thirty-five patients underwent D-SOCP (34 D-SOC, 1 D-SOP). Bilroth II was the most common type of SAA (45.7 %), followed by Whipple reconstruction (31.4 %). Twenty-three patients (65.7 %) patients had prior failed ERCP due to the presence of complex biliary stone (52.2 %). A therapeutic duodenoscope was utilized in the majority of the cases (68.6 %), while a therapeutic gastroscope (22.7 %) or adult colonoscope (8.5 %) were used in the remaining procedures. Choledocholithiasis (61.2 %) and pancreatic duct calculi (3.2 %) were the most common indications for D-SOCP. Technical success was achieved in all 35 patients (100 %) and majority (91.4 %) requiring a single session. Complex interventions included electrohydraulic or laser lithotripsy, biliary or pancreatic stent placement, stricture dilation, and target tissue biopsies. Two mild adverse events occurred (pancreatitis and transient bacteremia). Conclusions  In SAA, D-SOCP is a safe and effective modality to diagnose and treat complex pancreatobiliary disorders, especially in cases where standard ERCP attempts may fail.

Effectiveness and Safety of Lumen-Apposing Metal Stents in Endoscopic Interventions for Off-Label Indications

BACKGROUND

Although released only for drainage of pseudocyst and walled-off necrosis (WON) with ≤ 30% solid debris, the utilization of lumen-apposing metal stent (LAMS) in "real-world" practice has deviated from approved indications. We evaluated the contemporary use of LAMS and associated clinical, procedural outcomes in the setting of a tertiary referral center in the USA.

METHODS

Data from 303 consecutive patients who underwent LAMS placement were analyzed. Outcomes included technical and clinical success rates and adverse events.

RESULTS

Of 303 patients, 190 (62.7%) received LAMS for off-label indications. The latter included gallbladder drainage (n = 56, 18.5%), gastroenterostomy (n = 52, 17.2%), treatment of gastrointestinal strictures (n = 37, 12.2%), biliary drainage (n = 20, 6.6%), temporary gastric access for endoscopy (n = 13, 4.3%), symptomatic WON with > 30% solid debris (n = 8, 2.6%), and miscellaneous (n = 4, 1.3%). Technical success rates in the on- and off-label arm were 98.2% and 95.8%, respectively (P = .331; 95% CI 0.08 to 1.96). Clinical success rates in the on- and off-label arm were 89.4% and 83.2%, respectively (P = .137; 95% CI 0.28 to 1.19). The rate of adverse events was 20.5% (n = 39) in the off-label arm and 16.8% (n = 19) in the on-label arm (P = .242; 95% CI 0.69 to 2.34).

CONCLUSION

Off-label use of LAMS out-numbered on-label use in our practice. The safety profile between the groups was similar and with the exception of refractory stricture treatment, efficacy was comparable.

Biliary Sphincterotomy Alone versus Biliary Stent with or without Biliary Sphincterotomy for the Management of Post-Cholecystectomy Bile Leak: A Systematic Review and Meta-Analysis

BACKGROUND

Endoscopic therapy with endoscopic retrograde cholangiopancreatography is considered the first-line treatment in the management of post-cholecystectomy bile leak (PCBL). Currently, there is no consensus on the most effective endoscopic intervention for PCBL. Hence, we performed a systematic review and meta-analysis to compare the effectiveness and safety of the two interventional groups (biliary sphincterotomy [BS] alone vs. biliary stent ± BS) in management of PCBL.

METHODS

We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through January 2021). The primary outcome was to compare the pooled rate of clinical success between the 2 groups. The secondary outcome was to estimate the pooled rate of adverse events.

RESULTS

The pooled rate of clinical success with BS alone (5 studies, 299 patients) was 88% (95% confidence interval (CI): 84-92%, I2: 0%) and for biliary stent ± BS (5 studies, 864 patients) was 97% (CI: 93-100%, I2: 79%). The rate of clinical success in biliary stent ± BS group was significantly higher than BS alone group (OR: 3.91 95% CI: 2.29-6.69, p < 0.001, I2: 13%). The rate of adverse events was numerically lower in biliary stent ± BS group compared to BS alone (3 studies; OR: 0.65 95% CI: 0.41-1.03, p = 0.07) without statistical significance. Low heterogeneity was noted in the analysis.

CONCLUSIONS

Biliary stent ± BS is more effective in endoscopic management of PCBL compared to BS alone. This may be related to inter-endoscopist variation in completeness of sphincterotomy and post-sphincterotomy edema, which can influence the preferential trans-papillary flow of bile.

Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a multicenter international experience

BACKGROUND

Endoscopic resection of lesions involving the appendiceal orifice remains a challenge. We aimed to report outcomes with the full-thickness resection device (FTRD) for the resection of appendiceal lesions and identify factors associated with the occurrence of appendicitis.

METHODS

This was a retrospective study at 18 tertiary-care centers (USA 12, Canada 1, Europe 5) between November 2016 and August 2020. Consecutive patients who underwent resection of an appendiceal orifice lesion using the FTRD were included. The primary outcome was the rate of R0 resection in neoplastic lesions, defined as negative lateral and deep margins on post-resection histologic evaluation. Secondary outcomes included the rates of: technical success (en bloc resection), clinical success (technical success without need for further surgical intervention), post-resection appendicitis, and polyp recurrence.

RESULTS

66 patients (32 women; mean age 64) underwent resection of colonic lesions involving the appendiceal orifice (mean [standard deviation] size, 14.5 (6.2) mm), with 40 (61 %) being deep, extending into the appendiceal lumen. Technical success was achieved in 59/66 patients (89 %), of which, 56 were found to be neoplastic lesions on post-resection pathology. Clinical success was achieved in 53/66 (80 %). R0 resection was achieved in 52/56 (93 %). Of the 58 patients in whom EFTR was completed who had no prior history of appendectomy, appendicitis was reported in 10 (17 %), with six (60 %) requiring surgical appendectomy. Follow-up colonoscopy was completed in 41 patients, with evidence of recurrence in five (12 %).

CONCLUSIONS

The FTRD is a promising non-surgical alternative for resecting appendiceal lesions, but appendicitis occurs in 1/6 cases.

Outcomes of peroral endoscopic myotomy in patients with achalasia and prior bariatric surgery: A multicenter experience

Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatric surgery may be technically challenging due to postsurgical scarring and altered anatomy. The aim of the study was to assess the efficacy and safety of POEM for achalasia in patients with prior bariatric surgery. A review of prospectively maintained databases at three tertiary referral centers from January 2015 to January 2021 was performed. The primary outcome of interest was clinical success, defined as a post-treatment Eckardt score ≤ 3 or improvement in Eckardt score by ≥ 1 when the baseline score was <3, and improvement of symptoms. Secondary outcomes were adverse event rates and symptom recurrence. Sixteen patients status post Roux-en-Y gastric bypass (n = 14) and sleeve gastrectomy (n = 2) met inclusion criteria. Indications for POEM were achalasia type I (n = 2), type II (n = 9), and type III (n = 5). POEM was performed either by anterior or posterior approach. The pre-POEM mean integrated relaxation pressure was 26.2 ± 7.6 mm Hg. The mean total myotomy length was 10.2 ± 2.7 cm. The mean length of hospitalization was 1.4 ± 0.7 days. Pre- and postprocedure Eckardt scores were 6.1 ± 2.1 and 1.7 ± 1.8, respectively. The overall clinical success rate was 93.8% (15/16) with mean follow-up duration of 15.5 months. One patient had esophageal leak on postprocedure esophagram and managed endoscopically. Dysphagia recurred in two patients, which was successfully managed with pneumatic dilation with or without botulinum toxin injection. POEM appears to be safe and effective in the management of patients with achalasia who have undergone prior bariatric surgery.

Afferent limb syndrome, biliocutaneous fistula, bilioenterocutaneous fistula, dehiscence of the hepaticojejunostomy: Can we treat all of this endoscopically?

Video 1Afferent limb syndrome, biliocutaneous fistula, bilioenterocutaneous fistula, and dehiscence of the hepaticojejunostomy treated endoscopically.

Endoscopic ultrasound-guided gallbladder drainage as a rescue therapy for unresectable malignant biliary obstruction: a multicenter experience

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is often unsuccessful in patients with duodenal stenosis or malignant ampullary infiltration. While endoscopic ultrasound-guided biliary drainage (EUS-BD) has been proposed as an alternative, EUS-guided gallbladder drainage (EUS-GBD) is an attractive option when both approaches fail. We aimed to assess the effectiveness and safety of EUS-GBD as rescue therapy for malignant distal bile duct obstruction.

METHODS

A multicenter retrospective study was performed on patients with unresectable malignant distal bile duct obstruction who underwent EUS-GBD between 2014 and 2019 after unsuccessful ERCP and EUS-BD. Clinical success was defined as a decrease in serum bilirubin of > 50 % within 2 weeks.

RESULTS

28 patients were included, with a lumen-apposing metal stent used in 26 (93 %) and a self-expandable metal stent in two (7 %). The technical success rate was 100 %. The clinical success rate was 93 %, with an improvement in bilirubin (7.3 [SD 5.4] pre-procedure vs. 2.8 [SD 1.1] post-procedure; P = 0.001). Delayed adverse events included food impaction of the stent (n = 3), with a further two patients developing cholecystitis and bleeding.

CONCLUSION

This study demonstrates the feasibility of gallbladder drainage to relieve malignant distal bile duct obstruction in patients with failed ERCP and EUS-BD.

Spray coagulation with snare-tip versus argon plasma coagulation: An ex vivo study evaluating tissue effects

Background and study aims  Argon plasma coagulation (APC) is an effective and safe modality for many gastrointestinal conditions requiring hemostasis and/or ablation. However, it can be quite costly. A potentially more cost-effective alternative is snare-tip spray coagulation (SC). This study aimed to determine whether SC would be a safe and effective alternative to APC using an ex-vivo model. Methods  Using two resected porcine stomach, 36 randomized gastric areas were ablated for 2 seconds with either APC at 1.0 L/min 20 W (APC20) and 1.4 L/min 40 W (APC40) or SC with Effect 2 60 W (SC60) and 80 W (SC80) from 3 mm. Extent of tissue injury was then analyzed histopathologically. Results  The mean coagulation depth was 790 ± 159 µm and 825 ± 467 µm for SC60 (n = 9) and SC80 (n = 8), respectively. This was compared to 539 ± 151 µm for APC20 (n = 8) and 779 ± 267 µm for APC40 (n = 9). Mean difference (MD) in coagulation depth between SC60 and APC40 was 12 µm (95 % confidence interval [CI], -191 to 214 µm; P  = 0.91) and was 47 µm (95 %CI, -162 to 255 µm; P  = 0.81) between SC80 and APC40. There was a greater depth of injury with APC40 (MD, 240 µm; 95 %CI, 62 to 418 µm; P  = 0.04) and with SC60 (MD, 252 µm; 95 %CI, 141 to 362 µm; P  = 0.004) when compared to APC20. Mean cross-sectional area of coagulation was 2.39 ± 0.852 mm² for SC60 and 2.54 ± 1.83 mm² for SC80 compared to 1.22 ± 0.569 mm² for APC20 and 1.99 ± 0.769 mm² for APC40. Seventy-eight percent reached the muscularis mucosa (MM) and 11 % the submucosa in the SC60 group compared to 50 % and 38 % in SC80 and 56 % and 11 % in APC40, respectively. Thirty-eight percent of APC20 specimens reached the MM. The muscularis propria was unaffected. Conclusions  This small ex-vivo study suggests that SC60 and SC80 may be safe alternatives to APC40 with comparable coagulation depths and area effects.

Endoscopic ultrasound-directed transgastric ERCP (EDGE): a retrospective multicenter study

BACKGROUND

Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) is an alternative to enteroscopy- and laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Although short-term results are promising, the long-term outcomes are not known. The aims of this study were: (1) to determine the rates of long-term adverse events after EDGE, with a focus on rates of persistent gastrogastric or jejunogastric fistula; (2) to identify predictors of persistent fistula; (3) to assess the outcomes of endoscopic closure when persistent fistula is encountered.

METHODS

This was a multicenter retrospective study involving 13 centers between February 2015 and March 2019. Adverse events were defined according to the ASGE lexicon. Persistent fistula was defined as an upper gastrointestinal series or esophagogastroduodenoscopy showing evidence of fistula.

RESULTS

178 patients (mean age 58 years, 79 % women) underwent EDGE. Technical success was achieved in 98 % of cases (175/178), with a mean procedure time of 92 minutes. Periprocedural adverse events occurred in 28 patients (15.7 %; mild 10.1 %, moderate 3.4 %, severe 2.2 %). The four severe adverse events were managed laparoscopically. Persistent fistula was diagnosed in 10 % of those sent for objective testing (9/90). Following identification of a fistula, 5 /9 patients underwent endoscopic closure procedures, which were successful in all cases.

CONCLUSIONS

The EDGE procedure is associated with high clinical success rates and an acceptable risk profile. Persistent fistulas after lumen-apposing stent removal are uncommon, but objective testing is recommended to identify their presence. When persistent fistulas are identified, endoscopic treatment is warranted, and should be successful in closing the fistula.

COVID-19-Induced Bile Duct Casts and Cholangitis: A Case Report

Coronavirus disease 2019 (COVID-19) infection can lead to various complications involving all of the major organ systems. Gastrointestinal manifestations such as nausea, vomiting, and diarrhea are commonly associated with this condition. Biliary complications from COVID-19 constitute an area of active research. In this report, we present a case of secondary sclerosing cholangitis in a critically ill patient (SSC-CIP) associated with COVID-19. A 57-year-old male with a past medical history of hypertension and diabetes presented to the hospital with signs of sepsis. He had abdominal pain, fever, and elevated liver enzymes without an elevated lipase. Abdominal ultrasound and CT scan showed a dilated common bile duct (CBD) with a distal CBD stone. He had experienced a prolonged course of severe critical illness related to COVID-19 prior to this episode, with respiratory failure requiring mechanical ventilation, thromboembolic complications, and he had also required tracheostomy and gastrostomy tube. The patient was diagnosed with cholangitis and was appropriately treated with antibiotics and fluid resuscitation. An endoscopic retrograde cholangiopancreatography (ERCP) was performed. During ERCP, the biliary cast was removed and a bile duct stent was placed. After the procedure, he showed significant improvement and was discharged on an appropriate course of antibiotics. Outpatient ERCP was eventually done to remove the stent and further bile duct casts were removed. The patient was referred for outpatient cholecystectomy.

Critical illness due to COVID-19 can result in SSC-CIP. This can be further complicated by bile duct casts, liver fibrosis, and cirrhosis.

Placing a lumen-apposing metal stent despite ascites: feasibility and safety

BACKGROUND AND AIMS

Placing a lumen-apposing metal stent (LAMS) through ascites carries serious risks, including death from leakage around the LAMS and failure to create a mature fistula between the 2 lumens. However, sometimes no options exist or are equally dangerous. We present 5 patients who underwent LAMS placement despite ascites in 2 different locations.

METHODS

This is a retrospective review of 5 patients who underwent LAMS placement despite ascites in 2 different locations from 2016 to 2018.

RESULTS

Three patients with cholecystitis and 2 patients with afferent limb syndrome and severe ascites were treated with a combination of preprocedural and intraprocedural paracentesis. Serum ascites albumin gradient was measured. Weight was recorded daily. Patients were encouraged to sleep at an incline, and periodic paracentesis (every 3-7 days) was performed when ascites reaccumulated over 4 weeks. Median volume of ascites aspirated was 2 L preprocedurally and 300 mL intraprocedurally. Only 1 patient had ascites with a high serum ascites albumin gradient and was treated with diuretics. Technical and clinical success was achieved in all 5 patients without any adverse events over a median follow-up of 28 weeks.

CONCLUSIONS

In situations in which no better options remain, LAMS placement appears to be safe after adequate and aggressive treatment of the underlying ascites pre-, intra-, and postprocedurally. Larger studies are needed to establish the safety of this approach.

ERCP with overtube-assisted enteroscopy in patients with Roux-en-Y gastric bypass anatomy: a systematic review and meta-analysis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is challenging. Overtube-assisted enteroscopy (OAE) is usually needed to perform ERCP in these patients. There is significant variation in the reported rates of success and adverse events across published studies. We performed a systematic review and meta-analysis to reliably estimate the pooled rates of success and adverse events.

METHODS

We performed a systematic search of multiple electronic databases through February 2020 to identify studies reporting outcomes of OAE-ERCP in post-RYGB patients. The pooled rates of enteroscopy success, technical success, and adverse events were estimated for OAE-ERCP. The pooled rates of success and adverse events were also estimated for ERCP using double-balloon enteroscopes (DBE) alone.

RESULTS

10 studies reporting a total of 398 procedures were included in the meta-analysis. The pooled rates of enteroscopy and technical success of OAE-ERCP were 75.3 % (95 % confidence interval [CI] 64.5 - 83.6) and 64.8 % (95 %CI 53.1 - 74.9) respectively. The pooled rate of adverse events was 8.0 % (95 %CI 5.2 - 12.2). The pooled rates of enteroscopy and technical success of DBE-ERCP (four studies) were 83.5 % (95 %CI 68.3 - 92.2) and 72.5 % (95 %CI 52.3 - 86.4), respectively. The pooled rate of adverse events with DBE-ERCP was 9.0 % (95 %CI 5.4 - 14.5). Substantial heterogeneity was noted.

CONCLUSIONS

OAE-ERCP appears to be effective and safe in post-RYGB patients. Among the currently available techniques, OAE-ERCP is the least invasive approach in this challenging group of patients. Future studies comparing the effectiveness and safety of alternative novel techniques, such as endosonography-directed transgastric ERCP, with OAE-ERCP are needed.

Full-thickness resection device (FTRD) for treatment of upper gastrointestinal tract lesions: the first international experience

Background and study aims  The Full-Thickness Resection Device (FTRD) provides a novel treatment option for lesions not amenable to conventional endoscopic resection techniques. There are limited data on the efficacy and safety of FTRD for resection of upper gastrointestinal tract (GIT) lesions. Patients and methods  This was an international multicenter retrospective study, including patients who had an endoscopic resection of an upper GIT lesion using the FTRD between January 2017 and February 2019. Results  Fifty-six patients from 13 centers were included. The most common lesions were mesenchymal neoplasms (n = 23, 41 %), adenomas (n = 7, 13 %), and hamartomas (n = 6, 11 %). Eighty-four percent of lesions were located in the stomach, and 14 % in the duodenum. The average size of lesions was 14 mm (range 3 to 33 mm). Deployment of the FTRD was technically successful in 93 % of patients (n = 52) leading to complete and partial resection in 43 (77 %) and 9 (16 %) patients, respectively. Overall, the FTRD led to negative histological margins (R0 resection) in 38 (68 %) of patients. A total of 12 (21 %) mild or moderate adverse events (AEs) were reported. Follow-up endoscopy was performed in 31 patients (55 %), on average 88 days after the procedure (IQR 68-138 days). Of these, 30 patients (97 %) did not have any residual or recurrent lesion on endoscopic examination and biopsy, with residual adenoma in one patient (3 %). Conclusions  Our results suggest a high technical success rate and an acceptable histologically complete resection rate, with a low risk of AEs and early recurrence for FTRD resection of upper GIT lesions.

EUS-directed transenteric ERCP in non-Roux-en-Y gastric bypass surgical anatomy patients (with video)

BACKGROUND AND AIMS

Enteroscopy-assisted ERCP is challenging in patients with surgically altered upper GI anatomy. This study evaluated a novel procedure, EUS-directed transenteric ERCP (EDEE), in the de novo creation of an enteroenteric anastomosis for the performance of ERCP in non-Roux-en Y gastric bypass (RYGB) patients.

METHODS

This was a multicenter retrospective study involving 7 centers between January 2014 and October 2018. Primary outcome was clinical success (completion of EDEE and ERCP with intended interventions), and secondary outcomes were technical success and rate/severity of adverse events.

RESULTS

Eighteen patients (mean age, 63 years; 13 women) were included. The most common type of surgical anatomy was Whipple (10/18) and Roux-en-Y hepaticojejunostomy (6/18). Technical success rate of EUS-guided lumen-apposing metal stent (LAMS) placement was 100% and of ERCP was 94.44% (17/18). Fourteen patients underwent separate-session EDEE with a median of 21 days (interquartile range [IQR], 11.5-36) between the 2 procedures. Median total procedure time was 111 minutes (IQR, 81-192). Clinical success and adverse events occurred in 17 (94.4%) and 1 (5.6%; abdominal pain) patients, respectively, during a median follow-up of 88 days (IQR, 54-142).

CONCLUSIONS

This study suggests that EDEE using LAMSs is feasible and safe in patients with non-RYGB surgical anatomy and complex pancreaticobiliary pathologies.

Gastric outlet obstruction: when you cannot do an endoscopic gastroenterostomy or enteral stent, try an endoscopic duodenojejunostomy or jejunojejunostomy

Background and Aims

Certain situations preclude an endoscopic gastroenterostomy (EUS-GE) or enteral stent placement in gastric outlet obstruction (GOO), leaving patients with the option of a surgical bypass or enteral nutrition beyond the point of obstruction. We present a third option in these situations: an endoscopic duodenojejunostomy (EUS-DJ) or jejunojejunostomy (EUS-JJ).

Methods

This was a retrospective review of 5 patients whose anatomy precluded an endoscopic gastrojejunostomy and an enteral stent, who underwent a successful EUS-DJ or EUS-JJ from 2016 to 2018.

Results

Four EUS-DJs and 1 EUS-JJ were performed, with use of a 15-mm cautery-enhanced lumen-apposing metal stent by direct technique. All cases were technically successful. Three patients tolerated an unrestricted diet, but 2 patients needed enteral supplementation or total parenteral nutrition because of severe gastroparesis. There was 1 moderate adverse event: bleeding from severe reflux esophagitis and gastroparesis. No reinterventions were needed on any of these stents, for a median follow-up time of 23 weeks.

Conclusions

When anatomy precludes an EUS-GE or enteral stent, an EUS-DJ or EUS-JJ may have similarly successful outcomes and could help avoid the need for enteral feeding tubes or surgery.

EUS-Guided Choledochoduodenostomy for Distal Malignant Biliary Obstruction Using Electrocautery-Enhanced Lumen-Apposing Metal Stents: First US, Multicenter Experience

BACKGROUND AND AIMS

EUS-guided biliary drainage has emerged as a technique to enable endobiliary drainage in failed ERCP. A newer model, lumen-apposing metal stents (LAMS), with a cautery-enhanced delivery system became available in the USA in late 2015. This cautery-tipped version may facilitate EUS-guided choledochoduodenostomy (EUS-CD), but data using this model are lacking.

METHODS

We reviewed outcomes of attempted EUS-CD using cautery-enhanced LAMS from 6, US centers. The following data were collected: patient and procedure details, technical success, adverse events, clinical success (resolution of jaundice or improvement in bilirubin > 50%), and biliary re-interventions.

RESULTS

EUS-CD was attempted in 67 patients (mean age 68.8) with malignant obstruction after failed ERCP between September 2015 and April 2018. EUS-CD was technically successful in 64 (95.5%). A plastic or metal stent was inserted through the lumen of the deployed LAMS in 50 of 64 (78.1%) patients to maintain a non-perpendicular LAMS axis into the bile duct. Adverse events occurred in 4 (6.3%) and included: abdominal pain (n = 2), peritonitis that responded to antibiotics (n = 1), and bleeding requiring transfusion (n = 1). Among 40 patients with follow-up of > 4 weeks, clinical success was achieved in 100%. Biliary re-interventions for obstruction were needed in 7(17.5%), in 3 of 6 (50.0%) that underwent EUS-CD with LAMS alone versus 4 of 34 (5%) with LAMS plus an axis-orienting stent (p = 0.02).

CONCLUSION

EUS-CD using LAMS with cautery-enhanced delivery systems has high technical and clinical success rates, with a low rate of adverse events. Inserting an axis-orienting stent through the lumen of the LAMS may reduce the need for biliary re-interventions.

Outcomes of an international multicenter registry on EUS-guided gallbladder drainage in patients at high risk for cholecystectomy

Background and study aims  The aim of the current study was to review the outcomes of a large-scale international registry on endoscopic ultrasound-guided gallbladder drainage (EGBD) that encompasses different stent systems in patients who are at high-risk for cholecystectomy. Patients and methods  This was a retrospective international multicenter registry on EGBD created by 13 institutions around the world. Consecutive patients who received EGBD for several indications were included. Outcomes include technical and clinical success, unplanned procedural events (UPE), adverse events (AEs), mortality, recurrent cholecystitis and learning curve of the procedure. Results  Between June 2011 and November 2017, 379 patients were recruited to the study. Technical and clinical success were achieved in 95.3 % and 90.8 % of the patients, respectively. The 30-day AE rate was 15.3 % and 30-day mortality was 9.2 %. UPEs were significantly more common in patients with EGBD performed for conversion of cholecystostomy and symptomatic gallstones ( P  < 0.001); and by endoscopists with experience of fewer than 25 procedures ( P  = 0.033). Both presence of clinical failure ( P  = 0.014; RR 8.69 95 %CI [1.56 - 48.47]) and endoscopist experience with fewer than 25 procedures ( P  = 0.002; RR 4.68 95 %CI [1.79 - 12.26]) were significant predictors of 30-day AEs. Presence of 30-day AEs was a significant predictor of mortality ( P  < 0.001; RR 103 95 %CI [11.24 - 944.04]). Conclusion  EGBD was associated with high success rates in this large-scale study. EGBD performed for indications other than acute cholecystitis was associated with higher UPEs. The number of cases required to gain competency with the technique by experienced interventional endosonographers was 25 procedures.

Safety and efficacy of the use of lumen-apposing metal stents in the management of postoperative fluid collections: a large, international, multicenter study

BACKGROUND

Multiple studies have examined the use of lumen-apposing metal stents (LAMSs) for the drainage of peripancreatic fluid collections. Data on the use of LAMSs for postoperative fluid collections (POFCs) are scarce. POFCs may lead to severe complications without appropriate treatment. We aimed to study the outcomes (technical success, clinical success, rate/severity of adverse events, length of stay, recurrence) of the use of LAMSs for the drainage of POFCs.

METHODS

This international, multicenter, retrospective study involved 19 centers between January 2012 and October 2017. The primary outcome was clinical success. Secondary outcomes included technical success and rate/severity of adverse events using the ASGE lexicon.

RESULTS

A total of 62 patients were included during the study period. The most common etiology of the POFCs was distal pancreatectomy (46.8 %). The mean (standard deviation) diameter was 84.5 mm (30.7 mm). The most common indication for drainage was infection (48.4 %) and transgastric drainage was the most common approach (82.3 %). Technical success was achieved in 60/62 patients (96.8 %) and clinical success in 57/62 patients (91.9 %) during a median (interquartile range) follow-up of 231 days (90 - 300 days). Percutaneous drainage was needed in 8.1 % of patients. Adverse events occurred intraoperatively in 1/62 patients (1.6 %) and postoperatively in 7/62 (11.3 %). There was no procedure-related mortality.

CONCLUSION

This is the largest study on the use of LAMSs for POFCs. It suggests good clinical efficacy and safety of this approach. The use of LAMSs in the management of POFCs is a feasible alternative to percutaneous and surgical drainage.

Endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for high risk surgical patients with acute cholecystitis: a systematic review and meta-analysis

BACKGROUND

Recent evidence suggests that endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an effective and safe alternative to percutaneous drainage (PT-GBD). We conducted a systematic review and meta-analysis to compare these two procedures in high risk surgical patients with acute cholecystitis.

METHODS

A comprehensive electronic literature search was conducted for all articles published up to October 2017 to identify comparative studies between EUS-GBD and PT-GBD. A meta-analysis was performed on outcomes including technical success, clinical success, post-procedure adverse events, length of hospital stay, unplanned hospital readmission, need for reintervention, recurrent cholecystitis, and disease- or treatment-related mortality for these two procedures.

RESULTS

Five comparative studies (206 patients in the EUS-GBD group vs. 289 patients in the PT-GBD group), were included in the final analysis. There were no statistically significant differences in technical success (odds ratio [OR] 0.43, 95 % confidence interval [CI] 0.12 to 1.58; P  = 0.21; I ² = 0 %) and clinical success (OR 1.07, 95 %CI 0.36 to 3.16; P  = 0.90; I ² = 44 %) between the two procedures. EUS-GBD had fewer adverse events than PT-GBD (OR 0.43, 95 %CI 0.18 to 1.00; P  = 0.05; I ² = 66 %). Moreover, patients undergoing EUS-GBD had shorter hospital stays, with pooled standard mean difference of - 2.53 (95 %CI - 4.28 to - 0.78; P = 0.005; I ² = 98 %), and required significantly fewer reinterventions (OR 0.16, 95 %CI 0.04 to 0.042; P <  0.001; I ² = 32 %) resulting in significantly fewer unplanned readmissions (OR 0.16, 95 %CI 0.05 to 0.53; P  = 0.003; I ² = 79 %).

CONCLUSIONS

EUS-GBD was associated with lower rates of post-procedure adverse events, shorter hospital stays, and fewer reinterventions and readmissions compared with PT-GBD in patients with acute cholecystitis who were unfit for surgery.

Endoscopic therapy and surveillance versus esophagectomy for early esophageal adenocarcinoma: A review of early outcomes and cost analysis

BACKGROUND

Endoscopic therapy is considered to be comparable to esophagectomy with respect to oncologic outcomes in early (cT1) esophageal adenocarcinoma (EC). The current study aims to compare early outcomes and financial costs, associated with endoscopic versus surgical therapy for early esophageal adenocarcinoma.

METHODS

Retrospective review of patients undergoing either endoscopic or surgical therapy for cT1 EC between 2010 and 2015.

RESULTS

Age, BMI, and Charlson Comorbidity Scores were similar in patients undergoing endoscopic therapy (N = 20) and esophagectomy (N = 23). For patients undergoing endoscopic therapy a median of 6 endoscopic interventions, were performed per patient (range 2-18). Esophagectomy was associated with a median hospital stay of 9 (8-13) days and greater procedure specific morbidity compared to endoscopic therapy. Costs related to endoscopic therapy were significantly lower compared to esophagectomy ($22,640 vs. $53,849, P < 0.001).

CONCLUSIONS

Endoscopic treatment is associated with decreased morbidity and financial costs when compared to esophagectomy.

Liquid Nitrogen Spray Cryotherapy in Treatment of Barrett's Esophagus, where do we stand? A Systematic Review and Meta-Analysis

Radiofrequency ablation (RFA) is the preferred treatment option for Barrett's esophagus (BE) to achieve complete eradication (CE) of dysplasia (D), and intestinal metaplasia (IM). Cryotherapy, using liquid nitrogen (LNC), is a cold-induced tissue-injury technique option for the ablation of BE. We conducted a systematic review and meta-analysis to assess the overall efficacy and safety of LNC in the treatment of BE. We conducted a search of multiple electronic databases and conference proceedings from inception through June 2018. The primary outcome was to estimate the pooled rates of CE-IM, CE-D, and CE-HGD. The secondary outcome was to estimate the risk of adverse events and recurrence of disease after LNC. Nine studies reported 386 patients who were treated with LNC. The pooled rate of CE-IM was 56.5% (95% CI 48.5-64.2, I2 = 47), pooled rate of CE-D was 83.5% (95% CI 78.3-87.7, I2 = 22.8), and pooled rate of CE-HGD was 86.5% (95% CI 64.4-95.8, I2 = 88.1). Rate of adverse events was 4.7%, and the risk of BE recurrence was 12.7%. On subgroup analysis, the pooled rate of CE-IM with LNC in patients who failed RFA was 58.4% (95% CI 47.2-68.8, I2 = 32.5), and the pooled rate of CE-D in the same population was 81.9% (95% CI 72.5-88.6, I2 = 5.9). CE-D rates with LNC are comparable to RFA while CE-IM rates appear to be lower than the rates achievable with RFA. CE-IM rate in RFA failed patients is 58.4% and thus LNC is a rescue option to consider in this population.

Durability and long-term outcomes of direct EUS-guided gastroenterostomy using lumen-apposing metal stents for gastric outlet obstruction

Background and study aims  EUS-guided gastroenterostomy (GE) is a novel, minimally invasive endoscopic procedure for the treatment of gastric outlet obstruction (GOO). The direct-EUS-GE (D-GE) approach has recently gained traction. We aimed to report on a large cohort of patients who underwent DGE with focus on long-term outcomes. Patients and methods  This two-center, retrospective study involved consecutive patients who underwent D-GE between October 2014 and May 2018. The primary outcomes were technical and clinical success. Secondary outcomes were adverse events (AEs), rate of reintervention, procedure time, time to resume oral diet, and post-procedure length of stay (LOS). Results  A total of 57 patients (50.9 % female; median age 65 years) underwent D-GE for GOO. The etiology was malignant in 84.2 % and benign in 15.8 %. Technical success and clinical success were achieved in 93 % and 89.5 % of patients, respectively, with a median follow-up of 196 days in malignant GOO and 319.5 days in benign GOO. There were 2 (3.5 %) AEs, one severe and one moderate. Median procedure time was 39 minutes (IQR, 26 - 51.5 minutes). Median time to resume oral diet after D-GE was 1 day (IQR 1 - 2 days). Median post D-GE LOS was 3 days (IQR 2 - 7 days). Rate of reintervention was 15.1 %. Conclusions  D-GE is safe and effective in management of both malignant and benign causes of GOO. Clinical success with D-GE is durable with a low rate of reintervention based on a long-term cohort.

Carcinoids of the ampulla: Long-term follow-up after endoscopic resection

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Background: Neuroendocrine tumors (NET) or carcinoids of the ampulla are exceedingly rare in comparison to duodenal NET. Surgical management is widely accepted as the treatment of choice, but for patients that refuse surgery or are poor operative candidates, endoscopic resection may be option. We present a consecutive case series at a tertiary care center describing our experience with endoscopic resection of ampullary NET. Methods: This is a restrospective review with a long-term follow-up of patients with ampullary NET that were endoscopically resected. Outcomes were analyzed based on the histopathologic classification system proposed by the World Health Organization in 2000. Results: Twelve patients (9 male, 3 female), ranging in age from 41 to 86 (mean 59) underwent endoscopic ampullectomy for ampullary NET, with a mean follow-up time of 5 years. Patients had refused surgery or were poor surgical candidates. All, but one incidentally found case, were symptomatic on presentation, with gastrointestinal bleeding being the main symptom. No patients had a hormonal syndrome. The mean size of the lesions was 21 mm (6 mm to 35 cm). Six (50%) patients had a well-differentiated, benign lesion, 6 (50%) patients had a well-differentiated NET with unknown malignant potential (gangliocytic paragangliomas). Eight (67%) were completely excised during the initial endoscopy with 4 requiring re-excision. Only 2 patients developed recurrence, after 2.5 and 10 years and this necessitated a pancreaticoduodenectomy. Five patients had complications (2 for bleeding and 3 for post-ERCP pancreatitis), with zero deaths. Conclusions: Unlike duodenal carcinoids, ampullary NET are rare. Pancreaticoduodenectomy can be offered to fit patients except for gangliocytic paragangliomas that do not require an aggressive operation. However, for those that refuse surgery or are poor candidates, endoscopic ampullectomy can be an option with acceptable short and long-term outcomes.

An international, multicenter, comparative trial of EUS-guided gastrogastrostomy-assisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy

BACKGROUND AND AIMS

ERCP is challenging in patients with Roux-en-Y gastric bypass (RYGB) anatomy. EUS-guided gastrogastrostomy (GG) creation is a promising novel technique to access the excluded stomach to facilitate conventional ERCP. We aimed to compare procedural outcomes and adverse events (AEs) between EUS-guided GG-assisted ERCP (EUS-GG-ERCP) and enteroscopy-assisted ERCP (e-ERCP) in patients with RYGB.

METHODS

Patients with RYGB anatomy who underwent EUS-GG-ERCP or e-ERCP between 2014 and 2016 at 5 tertiary centers were included. The primary outcome was technical success of ERCP, defined as successful cannulation of the selected duct with successful intervention as intended. Secondary outcomes included total procedural time (in the EUS-GG group, total procedural time included EUS-GG creation plus ERCP procedure time), length of hospital stay, and rate/severity of AEs graded according to the American Society for Gastrointestinal Endoscopy lexicon.

RESULTS

A total of 60 patients (mean age, 57.2 ± 13.2; 75% women) were included, of whom 30 (50%) underwent EUS-GG-ERCP and 30 (50%) underwent e-ERCP (double-balloon enteroscope ERCP, 19; single-balloon enteroscope ERCP, 11). The technical success rate was significantly higher in the EUS-GG-ERCP versus the e-ERCP group (100% vs 60.0%, P < .001). Total procedure time was significantly shorter in patients who underwent EUS-GG-ERCP (49.8 minutes vs 90.7 minutes, P < .001). Postprocedure median length of hospitalization was shorter in the EUS-GG group (1 vs 10.5 days, P = .02). Rate of AEs was similar in both groups (10% vs 6.7%, P = 1).

CONCLUSIONS

EUS-GG-ERCP may be superior to e-ERCP in patients with RYGB anatomy in terms of a higher technical success and shorter procedural times and offers a similar safety profile.

Duration of antibiotic treatment after endoscopic ultrasound-guided drainage of walled-off pancreatic necrosis not affecting outcomes

BACKGROUND AND AIM

Although society guidelines recommend a short course of antibiotics after drainage of walled-off necrosis (WON), the exact duration is unclear.

METHODS

This is a retrospective review of patients with no prior antibiotic exposure who underwent dual-modality drainage (DMD) for sterile WON from 2008 to 2017. Patients were grouped into short duration (SD, ≤5 days) versus long duration (LD, >5 days). The main outcome was the frequency of recurrent infections.

RESULTS

Sixty-one patients (25 in the SD group and 36 in the LD group) were included. Patients in the two groups had comparable age, comorbidities, and severity of disease (P = 0.89). Patients in the SD group were treated with antibiotics for a median of 3 days compared with 8.5 days in the LD group. There were no differences in recurrent febrile episodes within 30 days of procedure-44% of SD group versus 39% of LD (P = 0.69). There was also no difference in time to resolution of WON (64 days for both groups, P = 0.72) or duration of hospitalization post-DMD (SD 7.7 days versus LD 7.5 days, P = 0.42). Three cases of Clostridium difficile colitis were observed in the LD group.

CONCLUSIONS

Longer course of antibiotics seems to have similar outcomes compared with shorter courses in patients with WON treated with DMD. Prolonged-course therapy may predispose to secondary infections like C. difficile colitis. A randomized controlled trial is needed to evaluate the role and duration of peri-procedural antibiotics after drainage of sterile WON.

The ASGE grading system for ERCP can predict success and complication rates in a tertiary referral hospital

BACKGROUND

The utility of the American Society for Gastrointestinal Endoscopy (ASGE) grading scale assessing complexity of endoscopic retrograde cholangiopancreatography (ERCP) has not been evaluated in clinical practice.

METHODS

Patients that underwent ERCP between January 2015 and December 2015 were included. Procedural difficulty was graded according to the grading system proposed by the ASGE workshop. Technical success rates and complications were recorded.

RESULTS

A total of 1355 ERCPs were performed on 934 patients. Patients were equally divided with respect to gender and had a mean age of 58 years (range 29-86). 391 cases were grade 1, 2 (29%), 695 were grade 3 (51%), and 269 were grade 4 (20%). Altered anatomy was observed in 88% of grade 4 patients. Cannulation was achieved in 98% of cases graded 1-3 and in 88% of cases graded 4 (p < 0.05). Complications were recorded in 10% of all cases with post-ERCP pancreatitis (5.4%) and procedure-related bleeding (1.5%) being the more common ones. No statistically significant difference was noted between the groups with regard to complications. Three perforations were seen in grade 1-3 cases (0.3%) compared to 4 cases in grade 4 cases (1.5%), (p = 0.01).

CONCLUSION

The grading system proposed by the ASGE workshop can aid in predicting cannulation success and perforation rates in ERCP. Based on this retrospective study, the most complex ERCP procedures can be achieved with encouraging rates of success. There is a need to validate our study with prospective ones performed in other high-volume centers.

EUS-guided gastroenterostomy: a multicenter study comparing the direct and balloon-assisted techniques

BACKGROUND

EUS-guided gastroenterostomy (EUS-GE) is a developing modality in the management of gastric outlet obstruction (GOO) with several technical approaches, including the direct and balloon-assisted techniques. The aim of this study was to compare the direct with the balloon-assisted modality while further defining the role of EUS-GE in GOO.

METHODS

This multicenter, retrospective study involved consecutive patients who underwent EUS-GE with the direct or balloon-assisted technique for GOO (January 2014 to October 2016). The primary outcome was technical success. Secondary outcomes were success (ability to tolerate at least a full fluid diet), procedure time, and rate/severity of adverse events (AEs).

RESULTS

A total of 74 patients (44.6% women; mean age 63.0 ± 11.7 years) underwent EUS-GE for GOO (direct gastroenterostomy, n = 52; balloon-assisted gastroenterostomy, n = 22). GOO was of malignant and benign etiology in 66.2% and 33.8% of patients, respectively. Technical success was achieved in 94.2% of the direct and 90.9% of the balloon-assisted approach (P = .63). Mean procedure time was shorter with the direct technique (35.7 ± 32.1 minutes vs 89.9 ± 33.3 minutes, P < .001). The clinical success rate was 92.3% for the direct technique and 90.9% for the balloon-assisted modality (P = 1.00), with a mean time to oral intake of 1.32 ± 2.76 days. The AE rate was 6.8% with only 1 severe AE noted. Rate of AEs, postprocedure length of stay, need for reintervention, and survival were similar between the 2 groups.

CONCLUSIONS

EUS-GE is effective and safe in the management of GOO. The direct technique may be the preferred method given its shorter procedure time when compared with the balloon-assisted approach. Prospective trials are needed to confirm these findings.

The microbiology of infected pancreatic necrosis in the era of minimally invasive therapy

We aimed to determine the microbiology of infected walled-off pancreatic necrosis (WON) in an era of minimally invasive treatment, since current knowledge is based on surgical specimens performed over two decades ago. We retrospectively analyzed a prospectively maintained database of patients who were treated for symptomatic WON using combined endoscopic and percutaneous drainage between 2008 and 2017. Aspirates from WON at initial treatment were evaluated. One hundred eighty-two patients were included with a mean age of 56 of whom 67% were male. Culture results were obtained at a median of 45 days from onset of acute pancreatitis of which 41% were infected. Candida spp. accounted for 27%; yet, multidrug-resistant organisms were found in only five patients. Approximately 64% were transferred to our institution for continuation of care. Of those, 55% were infected, most frequently with Candida spp., Enterococcus spp., and coagulase-negative Staphylococcus. Patients seen and admitted initially at our institution had milder forms of pancreatitis, fewer comorbidities, and 85% had symptomatic sterile WON. Empiric antibiotic use successfully predicted infection 70% of the time. Multivariate analysis demonstrated that elderly age, severity of pancreatitis, and prior use of antibiotics were indicators of infection. Necrotic pancreatic tissue remains sterile in the majority of cases treated with minimally invasive therapy, enabling judicious selection of antibiotics. Candida and Enterococcus spp. were common. Patients at highest risk for infection were previously treated with antibiotics and those transferred from outside institutions.