BACKGROUND AND AIMS:ERCP carries potential for serious adverse events, and there is risk for unplanned health encounters after the procedure. The primary objective of this study was to identify the rate of 30-day hospital admission after outpatient ERCP in patients at elevated risk for post-ERCP pancreatitis based on patient- and procedure-related risk factors. We also explored whether pancreatitis rates and lengths of hospital stay differ with delayed hospitalization (versus admission immediately after ERCP) and identified factors associated with 30-day hospital admission. METHODS:High-risk patients in the Stent Versus Indomethacin trial who underwent outpatient ERCP were identified. The primary outcome was hospital admission within 30 days after outpatient ERCP. Patient and procedural factors associated with 30-day hospital admission were explored by means of univariable analysis followed by multivariable analysis, controlling for potential known confounders. RESULTS:Among 768 patients at high risk for post-ERCP pancreatitis who underwent outpatient ERCP and were discharged home, 21.9% required hospitalization within 30 days. Compared with patients who underwent outpatient ERCP but were admitted immediately to the hospital after the procedure, patients who were discharged after ERCP and admitted later had a higher incidence of post-ERCP pancreatitis (40.5% vs 30.9%; P = .04), moderate to severe post-ERCP pancreatitis (24.4% vs 13.8%; P < .01), and longer length of hospital stay (6.2 d vs 3.7 d; P < .001). Factors associated with 30-day hospitalization included patient age (odds ratio [OR], 0.98; 95% CI, 0.97-0.99), biliary stent placement (OR, 1.62; 95% CI, 1.05-2.48), and attempt at pancreatic duct cannulation (OR, 1.64; 95% CI, 1.02-2.64). CONCLUSIONS:High-risk patients who undergo outpatient ERCP and are discharged home are at considerable risk for hospital admission within 30 days and have an increased rate of pancreatitis and longer length of hospital stay compared with outpatients admitted to the hospital immediately after ERCP, and some factors may predict this outcome. These findings should influence decision making and informed consent when electing to proceed with high-risk ERCP, recognizing that patients with sphincter of Oddi dysfunction were over-represented in this cohort, which may limit generalizability to a typical ERCP practice.

Background and study aims:EUS-guided gallbladder drainage (EUS-GBD) using lumen apposing metal stents (LAMS) has excellent technical and short-term clinical success for acute cholecystitis (AC). The goals of this study were to determine the long-term clinical outcomes and adverse events (AEs) of EUS-GBD with LAMS. Patients and methods:A multicenter, retrospective study was conducted at 18 US tertiary care institutions. Inclusion criteria: any AC patient with attempted EUS-GBD with LAMS and minimum 30-day post-procedure follow-up. Long-term clinical success was defined as absence of recurrent acute cholecystitis (RAC) > 30 days and long-term AE was defined as occurring > 30 days from the index procedure. Results:A total of 109 patients were included. Technical success was achieved in 108 of 109 (99.1%) and initial clinical success in 106 of 109 (97.2%). Long-term clinical success was achieved in 98 of 109 (89.9%) over a median follow-up of 140 days (range 30-1188). On multivariable analysis (MVA), acalculous cholecystitis (odds ratio [OR] 15.93, 95% confidence interval [CI] 1.22-208.52, P = 0.04) and the occurrence of a LAMS-specific AE (OR 63.60, 95% CI 5.08-799.29, P <0.01) were associated with RAC. AEs occurred in 38 of 109 patients (34.9%) at any time, and in 10 of 109 (9.17%) > 30 days from the index procedure. Most long-term AEs (7 of 109; 6.42%) were LAMS-specific. No technical or clinical factors were associated with occurrence of AEs. LAMS were removed in 24 of 109 patients (22%). There was no difference in RAC or AEs whether LAMS was removed or not. Conclusions:EUS-GBD with LAMS has a high rate of long-term clinical success and modest AE rates in patients with AC and is a reasonable destination therapy for high-risk surgical candidates.

Background and Aims Difficult biliary cannulation (DBC) is a known risk factor for developing post-ERCP pancreatitis (PEP). To better understand how DBC increases PEP risk, we examined the interplay between technical aspects of DBC and known PEP risk factors. Methods This was a secondary analysis of a multicenter, randomized controlled trial comparing rectal indomethacin alone with the combination of rectal indomethacin and prophylactic pancreatic duct (PD) stent placement for PEP prophylaxis in high-risk patients. Participants were categorized into 3 groups: DBC with high preprocedure risk for PEP, DBC without high preprocedure risk for PEP, and non-DBC at high preprocedure risk for PEP. Results In all, 1601 participants (84.1%) experienced DBC, which required a mean of 12 cannulation attempts (standard deviation, 10) and mean duration of 14.7 minutes (standard deviation, 14.9). PEP rate was highest (20.7%) in DBC with a high preprocedure risk, followed by non-DBC with a high preprocedure risk (13.5%), and then DBC without a high preprocedure risk (8.8%). Increasing number of PD wire passages (adjusted odds ratio [aOR], 1.97; 95% confidence interval [CI], 1.25-3.1) was associated with PEP in DBC, but PD injection, pancreatic sphincterotomy, and number of cannulation attempts were not associated with PEP. Combining indomethacin with PD stent placement lowered the risk of PEP (aOR, .61; 95% CI, .44-.84) in DBCs. This protective effect was evident in up to at least 4 PD wire passages. Conclusions DBC confers higher PEP risk in an additive fashion to preprocedural risk factors. PD wire passages appear to add the greatest PEP risk in DBCs, but combining indomethacin with PD stent placement reduces this risk, even with increasing PD wire passages.

Abstract Background Topical hemostatic powders are a reliable second-line approach in acute gastrointestinal (GI) bleeding (AGIB) treatment, according to the existing guidelines. Increasing evidence supports the use of hemostatic powder TC-325 (Hemospray®) as monotherapy in specific GI bleeding scenarios. This prospective, multi-center study evaluated the performance of TC-325 as monotherapy for GI hemorrhage. Methods Eighteen centres across Europe, and USA contributed between 2016 and 2022 to an international multicentre prospective registry. Adults with AGIB were eligible (melena, hematemesis, hematochezia, Glasgow-Blatchford score ≥ 1 or abnormal Oakland score), unless TC-325 was part of combined hemostasis (adjunctive to clips or thermocautery). The primary endpoint was immediate haemostasis. Secondary outcomes were rebleeding, 7- and 30-day mortality rates. Potential associations with risk factors were investigated with statistical significance set for p ≤ 0.05. Results One hundred and ninety patients were included (age range = 51–81, male:female = 2:1). Peptic ulcer (n = 48), upper GI malignancy (n = 79), post endoscopic treatment-related hemorrhage (n = 37), and lower GI lesions (n = 26) were diagnosed. The primary outcome was recorded in 96.3% (95%CI:92.6–98.5) with rebleeding in 17.4% (95%CI:11.9–24.1) when TC-325 was used as primary monotherapy. Post-hemostasis, 9.9% (95%CI:5.8–15.6) died within 7 days and 21.7% (95%CI:15.6–28.9) within 30 days. Regarding peptic ulcer, the immediate hemostasis was achieved in 88% (95%CI:75–95) and 26% (95%CI:13–43) rebled. Increased American Society of Anaesthesiologists (ASA) score was associated with mortality [OR:23.5 (95%CI:1.60–345); p = 0.02]. The primary outcome was achieved in 100% of cases with malignancy and post GI intervention bleeding, with rebleeding in 17% and 3.1%, respectively. Twenty-six patients received Hemospray® for lower GI bleeding, and in all but one the primary outcome was achieved. Conclusions TC-325 powder as monotherapy represents a safe and effective modality especially in malignancy- or post-endoscopic intervention-related bleeding. In peptic ulcer bleeding it could be helpful when the standard of care treatment is not feasible or unavailable, to stabilise patients.

INTRODUCTION:Prophylactic pancreatic stent placement (PSP) is effective for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk cases, but the optimal technical approach to this intervention remains uncertain. METHODS:In this secondary analysis of 787 clinical trial patients who underwent successful stent placement, we studied the impact of (i) whether pancreatic wire access was achieved for the sole purpose of PSP or naturally during the conduct of the case, (ii) the amount of effort expended on PSP, (iii) stent length, (iv) stent diameter, and (v) guidewire caliber. We used logistic regression models to examine the adjusted association between each technical factor and post-ERCP pancreatitis (PEP). RESULTS:Ninety-one of the 787 patients experienced PEP. There was no clear association between PEP and whether pancreatic wire access was achieved for the sole purpose of PSP (vs occurring naturally; odds ratio [OR] 0.82, 95% confidence interval [CI] 0.37-1.84), whether substantial effort expended on stent placement (vs nonsubstantial effort; OR 1.58, 95% CI 0.73-3.45), stent length (>5 vs ≤5 cm; OR 1.01, 95% CI 0.63-1.61), stent diameter (≥5 vs <5 Fr; OR 1.13, 95% CI 0.65-1.96), or guidewire caliber (0.035 vs 0.025 in; 0.83, 95% CI 0.49-1.41). DISCUSSION:The 5 modifiable technical factors studied in this secondary analysis of large-scale randomized trial data did not appear to have a strong impact on the benefit of prophylactic PSP in preventing PEP after high-risk ERCP. Within the limitations of post hoc subgroup analysis, these findings may have important implications in procedural decision making and suggest that the benefit of PSP is robust to variations in technical approach.

Background Hemostatic powders are used as second-line treatment in acute gastrointestinal (GI) bleeding (AGIB). Increasing evidence supports the use of TC-325 as monotherapy in specific scenarios. This prospective, multicenter study evaluated the performance of TC-325 as monotherapy for AGIB. Methods Eighteen centers across Europe and USA contributed to a registry between 2016 and 2022. Adults with AGIB were eligible, unless TC-325 was part of combined hemostasis. The primary endpoint was immediate hemostasis. Secondary outcomes were rebleeding and mortality. Associations with risk factors were investigated (statistical significance at P <= 0.05). Results One hundred ninety patients were included (age 51-81 years, male: female 2:1), with peptic ulcer (n=48), upper GI malignancy (n=79), post-endoscopic treatment hemorrhage (n=37), and lower GI lesions (n=26). The primary outcome was recorded in 96.3% (95% confidence interval [CI]: 92.6-98.5) with rebleeding in 17.4% (95%CI 11.9-24.1); 9.9% (95%CI 5.8-15.6) died within 7 days, and 21.7% (95%CI 15.6-28.9) within 30 days. Regarding peptic ulcer, immediate hemostasis was achieved in 88% (95%CI 75-95), while 26% (95%CI 13-43) rebled. Higher ASA score was associated with mortality (OR 23.5, 95%CI 1.60-345; P=0.02). Immediate hemostasis was achieved in 100% of cases with malignancy and post-intervention bleeding, with rebleeding in 17% and 3.1%, respectively. Twenty-six patients received TC-325 for lower GI bleeding, and in all but one the primary outcome was achieved. Conclusions TC-325 monotherapy is safe and effective, especially in malignancy or postendoscopic intervention bleeding. In patients with peptic ulcer, it could be helpful when the primary treatment is unfeasible, as bridge to definite therapy.

Background The combination of rectally administered indomethacin and placement of a prophylactic pancreatic stent is recommended to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients. Preliminary evidence suggests that the use of indomethacin might eliminate or substantially reduce the need for stent placement, a technically complex, costly, and potentially harmful intervention. Methods In this randomised, non-inferiority trial conducted at 20 referral centres in the USA and Canada, patients (aged >= 18 years) at high risk for post-ERCP pancreatitis were randomly assigned (1:1) to receive rectal indomethacin alone or the combination of indomethacin plus a prophylactic pancreatic stent. Patients, treating clinicians, and outcomes assessors were masked to study group assignment. The primary outcome was post-ERCP pancreatitis. To declare non-inferiority, the upper bound of the two-sided 95% CI for the difference in post-ERCP pancreatitis (indomethacin alone minus indomethacin plus stent) would have to be less than 5% (non-inferiority margin) in both the intention-to-treat and per-protocol populations. This trial is registered with ClinicalTrials.gov (NCT02476279), and is complete. Findings Between Sept 17, 2015, and Jan 25, 2023, a total of 1950 patients were randomly assigned. Post-ERCP pancreatitis occurred in 145 (149%) of 975 patients in the indomethacin alone group and in 110 (113%) of 975 in the indomethacin plus stent group (risk difference 36%; 95% CI 06-66; p=018 for non-inferiority). A post-hoc intention-to-treat analysis of the risk difference between groups showed that indomethacin alone was inferior to the combination of indomethacin plus prophylactic stent (p=0011). The relative benefit of stent placement was generally consistent across study subgroups but appeared more prominent among patients at highest risk for pancreatitis. Safety outcomes (serious adverse events, intensive care unit admission, and hospital length of stay) did not differ between groups. Interpretation For preventing post-ERCP pancreatitis in high-risk patients, a strategy of indomethacin alone was not as effective as a strategy of indomethacin plus prophylactic pancreatic stent placement. These results support prophylactic pancreatic stent placement in addition to rectal indomethacin administration in high-risk patients, in accordance with clinical practice guidelines.

Brianna Shinn: NO financial relationship with a commercial interest | William Hirsch: NO financial relationship with a commercial interest | Michel Kahaleh: YES financial relationship with a commercial interest;BSC:Grant/Research Support;BSC:Grant/Research Support;Medtronic:Grant/Research Support;Medtronic:Consulting;Microtech:Consulting;Microtech :Grant/Research Support;Conmed:Grant/Research Support;Cook:Grant/Research Support;Olympus:Grant/Research Support;ERBE :Grant/Research Support;GORE:Grant/Research Support;Emcision:Grant/Research Support;Abvvie :Consulting | Haroon Shahid: NO financial relationship with a commercial interest | Avik Sarkar: NO financial relationship with a commercial interest | Amy Tyberg: YES financial relationship with a commercial interest;Boston Scientific:Consulting;Ambu Inc:Consulting;EndoGastric Solutions:Consulting | Rodrigo Duarte-Chavez: NO financial relationship with a commercial interest | Srikaran Kalahasti: NO financial relationship with a commercial interest | Nikhil Kumta: YES financial relationship with a commercial interest;Apollo Endosurgery:Speaking and Teaching;Boston Scientific:Consulting;Olympus:Consulting;SafeHeal:Consulting;Intuitive Surgical:Consulting | Christopher DiMaio: YES financial relationship with a commercial interest;Boston Scientific:Consulting;Medtronic:Speaking and Teaching;Mauna Kea:Speaking and Teaching;STERIS:Speaking and Teaching;SafeHeal:Consulting;AbbVie:Speaking and Teaching | Shyam Thakkar: YES financial relationship with a commercial interest;Boston Scientific:Consulting;Orpheus Medical:Consulting;Medtronic:Consulting | Sardar Shah-Khan: NO financial relationship with a commercial interest | Shailendra Singh: NO financial relationship with a commercial interest | Cyrus Piraka: YES financial relationship with a commercial interest;US endoscopy:Speaking and Teaching | Tobias Zuchelli: YES financial relationship with a commercial interest;Boston Scientific Corp:Consulting | Yervant Ichkhanian: NO financial relationship with a commercial interest | Faisal Nimri: NO financial relationship with a commercial interest | Natalie Cosgrove: NO financial relationship with a commercial interest | Vladimir Kushnir: NO financial relationship with a commercial interest | Juan Reyes Genere: NO financial relationship with a commercial interest | Daniel Mullady: YES financial relationship with a commercial interest;Boston Scientific :Consulting | Tina Boortalary: NO financial relationship with a commercial interest | Abhishek Agnihotri: NO financial relationship with a commercial interest | Anand Kumar: YES financial relationship with a commercial interest;Olympus:Consulting | Austin Chiang: YES financial relationship with a commercial interest;Medtronic:Employment;Boston Scientific:Consulting;Exact Sciences:Consulting;Olympus:Consulting | Alexander Schlachterman: NO financial relationship with a commercial interest | David Loren: YES financial relationship with a commercial interest;Boston Scientific:Consulting;Olympus America:Consulting;Ambu:Consulting;Pinnacle Biologics:Consulting | Thomas Kowalski: YES financial relationship with a commercial interest;BSCI:Consulting;Olympus:Consulting;Interscope:Consulting

Juan Reyes Genere: NO financial relationship with a commercial interest | Ian Sloan: NO financial relationship with a commercial interest | Alexandria Lenyo: YES financial relationship with a commercial interest;Abbott Laboratories:Stock Shareholder;AbbVie:Stock Shareholder | Derek Platt: NO financial relationship with a commercial interest | Philip Frasse: NO financial relationship with a commercial interest | Thomas Hollander: NO financial relationship with a commercial interest | Gabriel Lang: NO financial relationship with a commercial interest | Natalie Cosgrove: NO financial relationship with a commercial interest | Dennis Chen: NO financial relationship with a commercial interest | Koushik Das: YES financial relationship with a commercial interest;Interpace Biosciences:Grant/Research Support | Daniel Mullady: YES financial relationship with a commercial interest;Boston Scientific :Consulting | Dayna Early: NO financial relationship with a commercial interest | Vladimir Kushnir: NO financial relationship with a commercial interest

Pancreatic cystic lesions (PCL) are being discovered incidentally on cross-sectional imaging performed at ever increasing rates,1,2 with an estimated prevalence of 2.6%–9.3% of asymptomatic patients undergoing abdominal computed tomography1 and magnetic resonance imaging (MRI)2 scans and with an increasing prevalence associated with age.1 There are currently no tools to definitively differentiate mucinous cysts (intraductal papillary mucinous neoplasm [IPMN] and mucinous cystic neoplasm), which have malignant potential from benign cysts, let alone definitively assess which mucinous cysts will progress to malignancy.

Arvind Rengarajan: NO financial relationship with a commercial interest | Koushik Das: YES financial relationship with a commercial interest;Interpace Biosciences:Grant/Research Support | Thomas Hollander: NO financial relationship with a commercial interest | Natalie Cosgrove: NO financial relationship with a commercial interest | Dennis Chen: NO financial relationship with a commercial interest | Dayna Early: NO financial relationship with a commercial interest | Juan Reyes Genere: NO financial relationship with a commercial interest | Gabriel Lang: NO financial relationship with a commercial interest | Daniel Mullady: YES financial relationship with a commercial interest;Boston Scientific :Consulting | Vladimir Kushnir: NO financial relationship with a commercial interest

Background Endoscopic eradication therapy (EET) is the standard of care for Barrett's esophagus (BE)-associated neoplasia. Previous data suggest the mean number of EET sessions required to achieve complete eradication of intestinal metaplasia (CE-IM) is 3. This study aimed to define the threshold of EET sessions required to achieve CE-IM. Methods The TREAT-BE Consortium is a multicenter outcomes cohort including prospectively enrolled patients with BE undergoing EET. All patients achieving CE-IM were included. Demographic, endoscopic, and histologic data were recorded at treatment onset along with treatment details and surveillance data. Kaplan-Meier analysis was performed to define a threshold of EET sessions, with 95 %CI, required to achieve CE-IM. A secondary analysis examined predictors of incomplete response to EET using multiple logistic regression and recurrence rates. Results 623 patients (mean age 65.2 [SD 11.6], 79.6 % male, 86.5 % Caucasian) achieved CE-IM in a mean of 2.9 (SD 1.7) EET sessions (median 2) and a median total observation period of 2.7 years (interquartile range 1.4-5.0). After three sessions, 73 % of patients achieved CE-IM (95 %CI 70 %-77 %). Age (odds ratio [OR] 1.25, 95 %CI 1.05-1.50) and length of BE (OR 1.24, 95 %CI 1.17-1.31) were significant predictors of incomplete response. Conclusion The current study found that a threshold of three EET sessions would achieve CE-IM in the majority of patients. Alternative therapies and further diagnostic testing should be considered for patients who do not have significant response to EET after three sessions.

An 85-year-old man with no significant medical history presented to an outside hospital (OSH) with nausea, vomiting, and abdominal pain. His laboratory evaluation was concerning for biliary obstruction, and a CT of his abdomen and pelvis demonstrated a 10-mm stone in the distal common bile duct with upstream biliary dilation to 20 mm. An ERCP was performed at the OSH with biliary sphincterotomy, balloon sweep with removal of the stone, and placement of an 8.5F × 7-cm plastic stent in the common bile duct. A repeat ERCP was performed 6 weeks later at the OSH for stent removal, at which point the stent was not visualized at the ampulla on endoscopic views. On cholangiogram, the stent had migrated proximally in the bile duct with the proximal end of the stent in the right hepatic duct (Fig. 1). Attempts at the OSH to remove the stent with balloon retrieval and forceps were unsuccessful, and the patient was transferred to a tertiary center for attempted removal (Video 1, available online at www.giejournal.org).1Katsinelos P. Kountouras J. Paroutoglou G. et al.Migration of plastic biliary stents and endoscopic retrieval: an experience of three referral centers.Surg Laparosc Endosc Percutan Tech. 2009; 19: 217-221Crossref PubMed Scopus (38) Google Scholar,2Sejpal D.V. Vamadevan A.S. Trindade A.J. Removal of an embedded, migrated plastic biliary stent with the use of cholangioscopy.Gastrointest Endosc. 2015; 81: 1482-1483Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar An ERCP was performed with a TJF 160VF duodenoscope (Olympus America, Chelmsford, Mass, USA), and on insertion the stent was not visualized at the ampulla. On cholangiogram, the right anterior hepatic duct contained a filling defect consistent with a migrated stent with the distal end of the stent in the mid extrahepatic bile duct (Fig. 2). Attempts to remove the stent with a 15-mm stone extraction balloon, rat-toothed forceps, 4-mm dilation balloon, Soehendra stent retriever (Cook Medical, Bloomington, Ind, USA), and lithotripsy basket were unsuccessful (Fig 3.) A SpyGlass Direct Visualization System (Boston Scientific, Marlborough, Mass, USA) was advanced to the right intrahepatic ducts, and a plastic stent was observed with the distal end of the stent impacted into the bile duct wall (Fig. 4).Figure 4The cholangioscope was inserted into the right anterior hepatic duct for direct visualization. The distal end of the biliary stent was impacted in the bile duct wall. The mini-snare was inserted through the cholangioscope to grasp the distal flange of the stent.View Large Image Figure ViewerDownload Hi-res image Download (PPT) A mini-snare through the cholangioscope was used to grasp the distal flange of the plastic stent because the mini forceps were not thought to have enough grasp to overcome the impaction of the distal end of the stent in the bile duct wall (Fig. 5). Subsequently, the stent was pulled out of the bile duct, and the duodenoscope was removed while the stent remained ensnared. A follow-up cholangiogram was obtained, and there were no filling defects or evidence of a bile leak (Fig. 6). The cholangioscope was reinserted, and stent-related changes were observed in the right anterior hepatic duct (Fig. 7). A clean-based ulcer with heaped-up mucosal borders was observed at the site of stent impaction in the bile duct wall, which had not previously been appreciated on the cholangiogram (Fig. 8).Figure 7Stent-related changes were observed with direct cholangioscopic visualization in the right anterior hepatic duct.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8A clean-based ulcer with heaped-up mucosal edges was noted at the site of distal stent impaction after stent removal.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The proximally migrated plastic biliary stent was successfully removed with ERCP and direct visualization with cholangioscopy using a retrieval snare through the working channel of the cholangioscope. This is another tool that can be considered for inwardly migrated stents that cannot be extracted using conventional ERCP techniques. Dr Mullady is a consultant for Boston Scientific. All other authors disclosed no financial relationships. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI5MjllOWU5NzEzZTA5MjdlYTA0NDBmMDk0OTkwOTg4OSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwOTM2OTAzfQ.I5sKjKcUhdCcw9eT-WfJWxgB6P3oaxQAiAHTGHTDC8CdDm-IBOiyXVDN1mqbjlgLPxPFimPR0R-SEiUMmR-rQkh1dBCmNPyoXfX3BssM7cJPnwZiCPSZ2aeX8pTzecMdYsyG43HCVp7mWQv9gzLYIHJTp-87DZZLZOC6r1n6SHcUZN1JLwBw_pMQcy5IypYnEWSI8lLJoCLagFMjEJkkwUHzalA1nwLrt7d_X0U-JSzn_9Ue4on4rBSI2omR1uRog33Z4DdkxdAonkRoLFQfJGRmfVQwqyAd3wjpdqlM9KqjBJ_BkZoDhbNunYg0cScQ_TOPhloCDeVeLEGUkEpfHg Download .mp4 (136.66 MB) Help with .mp4 files Video 1ERCP was performed and a proximally migrated biliary stent was noted in the right anterior hepatic duct. Retrieval of the stent was unsuccessful using traditional techniques including balloon traction, rat-toothed forceps, dilation balloon, Soehendra stent retriever, and lithotripsy basket. Successful removal was accomplished using single-operator cholangioscopy and a mini-snare.

Self-expanding metal stents (SEMS) are routinely used to palliate malignant dysphagia. We recently demonstrated in a large, multicenter, retrospective series that partially covered stents (pcSEMS) had a lower rate of migration than fully covered stents (fcSEMS) or fcSEMS with antimigration fins (fcSEMS-AF) (10.9% vs 25.3% vs 19.3%) with a similar rate of epithelial hyperplasia amongst all three (12.6%). Adjunctive techniques such as anchoring sutures (fcSEMS-S) have been studied to reduce the rate of migration with fcSEMS (18.0%).

Introduction Dual endoscopic therapy has been considered the standard of care for endoscopic management of GI bleeding. We aimed to look at the outcomes of Hemospray as a monotherapy treatment for GI bleeds. Methods Data was collected on patients with GI bleeds treated with Hemospray monotherapy in 18 centres. Haemostasis was defined as cessation of bleeding within 5 minutes of hemospray application. Results 62 patients with peptic ulcer bleeds were treated. There was an immediate haemostasis of 90% (56/62), re-bleed rate of 16% (7/44) (Table 1). 69% were Forrest 1a/1b ulcers. 72 patients with malignancy related bleeds. There was a haemostasis rate of 100% and a re-bleed rate of 18% (11/63). There was a haemostasis rate of 100% with post endoscopic therapy bleeds. 48% were post endoscopic mucosal resection. 22 patients with lower GI bleeds were treated. 36% secondary to colonic tumours. There was a haemostasis rate of 96% (21/22) and re-bleed of 26% (5/19). A 100% haemostasis was achieved in 5 patients treated for gastric angiodysplasia with one re-bleed. Conclusions Results show high haemostasis and comparable re-bleed rates with Hemospray monotherapy treatment. It may play a potential role in actively bleeding peptic ulcers in difficult anatomical positions to help bridge towards definitive therapy. These data may represent the evolution of new treatment paradigms as experience with haemostatic powders increases.

Background and Aim Upper gastrointestinal tumors account for 5% of upper gastrointestinal bleeds. These patients are challenging to treat due to the diffuse nature of the neoplastic bleeding lesions, high rebleeding rates, and significant transfusion requirements. TC-325 (Cook Medical, North Carolina, USA) is a hemostatic powder for gastrointestinal bleeding. The aim of this study was to examine the outcomes of upper gastrointestinal bleeds secondary to tumors treated with Hemospray therapy. Methods Data were prospectively collected on the use of Hemospray from 17 centers. Hemospray was used during emergency endoscopy for upper gastrointestinal bleeds secondary to tumors at the discretion of the endoscopist as a monotherapy, dual therapy with standard hemostatic techniques, or rescue therapy. Results One hundred and five patients with upper gastrointestinal bleeds secondary to tumors were recruited. The median Blatchford score at baseline was 10 (interquartile range [IQR], 7-12). The median Rockall score was 8 (IQR, 7-9). Immediate hemostasis was achieved in 102/105 (97%) patients, 15% of patients had a 30-day rebleed, 20% of patients died within 30 days (all-cause mortality). There was a significant improvement in transfusion requirements following treatment (P < 0.001) when comparing the number of units transfused 3 weeks before and after treatment. The mean reduction was one unit per patient. Conclusions Hemospray achieved high rates of immediate hemostasis, with comparable rebleed rates following treatment of tumor-related upper gastrointestinal bleeds. Hemospray helped in improving transfusion requirements in these patients. This allows for patient stabilization and bridges towards definitive surgery or radiotherapy to treat the underlying tumor.

Gastroenterologists and anesthesia practitioners base the safety of sedation for endoscopic procedures by asking time of last oral intake. Despite this, many patients have gastric food residue at time of upper endoscopy (EGD) leading to a substantial number of incomplete studies, alteration in the sedation plan, or adverse events. Patient related factors that predict retained contents are incompletely defined.

ID: 3521589 SPRITE ZERO FOR BETTER GASTRIC PREPARATION FOR CAPSULE ENDOSCOPY EXAMINATION: A RANDOMIZED CONTROLLED PILOT STUDY Jia-Hui Zhu, Yang-Yang Qian, Xiao Liu, Zhuan Liao* Introduction: As noninvasive and well-tolerated, magnetically controlled capsule endoscopy (MCE) is widely applied clinically. However, there still requires attention including abdominal distension, insufficient gastric filling and gastric retention. We aimed to compare the feasibility of 400ml Sprite Zero , which can release CO2 with 800ml water, the normal gastric preparation strategy for MCE. Methods: We performed a pilot, open-label, randomized controlled trial at the Endoscopy Center of Changhai Hospital in Shanghai from December 16th, 2019 to January 15th, 2020 with the approval of Ethics Committee of Changhai Hospital. Consecutive patients scheduled to MCE examination with informed consents were randomly assigned to Sprite(S) group or water (W) group with 1:1 ratio consecutively. All patients ingested 400 mg simethicone suspension dissolved in 100 mL water 40 minutes before swallowing capsule. In W group, patients were required to drink 800 mL pure water 10 minutes before swallowing capsule. And for patients in the S group, 400 ml Sprite Zero (SpriteTM soft drink, The Coca-Cola Company, China) were provided for gastric filling. Then, patients put on the data recorder and swallow capsules. MCE examination were performed by the same endoscopist (W.Z.). The primary endpoint was the degree of gastric filling evaluated by the height of gastric mucosal folds and the distance between the adjacent mucosal folds under MCE . Secondary endpoints included the feeling of fullness assessed by visual analogue scale (VAS), gastric transit time (GTT), small bowel transit time (SBTT), completion rate (CR) for small bowel examination and diagnostic yield (DY). The safety was evaluated after a twoweek follow-up period after procedure in case of adverse events. Result: We enrolled 52 patients in S group and 50 patients in W group (Table 1). No adverse events related to capsule were observed. The median score of gastric filling during 0-5 min, 5-10 min and 10-15 min under MCE in S group were all 4.0, the same as those in W group. The amount of liquid intake in S group was fewer than that in W group with a lower feeling of fullness score (7.0 vs 7.5, PZ0.047). The CR of small bowel examination in S group was 100% while in W group was 89.66% (PZ0.245). Although there were no significant differences between S group and W group in GTT and SBTT, the proportion of patients with GTT less than 30 minutes in S group were significantly increased than that in W group (69.57% vs 27.59%, PZ0.03). Conclusion: This pilot study provided a preliminary clinical assessment of a novel gastric preparation strategy for MCE. The results showed that 400 ml Sprite Zero displayed similar gastric filling with improved comfortableness and potential effect in relieving gastric retention of capsule compared with 800 ml water. FRIDAY, MAY 21, 2021 Clinical Endoscopic Practice 2 Lecture

While EUS is highly sensitive and specific for the evaluation of common bile duct (CBD) dilation, its yield in asymptomatic patients with normal liver function tests (LFTs) is unclear.