Objective EUS-guided gallbladder drainage (EUS-GBD) with electrocautery-enhanced lumen-apposing metal stents (EC-LAMS) is an emerging method of establishing GBD in patients with acute cholecystitis lacking fitness for surgery. Robust data on long-term outcomes are lacking. This study assessed the efficacy, safety and durability of this procedure. Design/method Retrospective review of consecutive patients undergoing this procedure at 12 tertiary institutions across the UK and Ireland between January 2016 and May 2023 was undertaken. Primary outcomes included technical success, clinical success (resolution of acute cholecystitis within 96 hours) and adverse event (AE) rates at 30 days, 1 year and 3 years. Secondary outcomes in the cohort with non-malignant cholecystitis included rates of recurrent cholecystitis and further endoscopic procedures for stone extraction and/or stent removal. Results 64 patients (68.8% female) were included. The most common indication was calculous cholecystitis (45%; n=29) and the median follow-up period was 467 days. Technical and clinical success was achieved in 95.3% (n=61) and 94.6% (n=53), respectively. The 30-day AE rate was 4.7% (n=3). A further AE occurred in 15% (n=4), 7.1% (n=1) and 0% (n=0) at 1, 2 and 3 years, respectively, while the unplanned biliary reintervention rate was 0% (n=0), 7% (n=1) and 0% (n=0). Of those with benign disease, the EC-LAMS was removed in 15.0% (n=3) at 1 year, with only one case of recurrent cholecystitis. Conclusions EUS-GBD with EC-LAMS at tertiary institutions is a highly effective and relatively safe technique in patients who are not fit for surgery. Routine stent removal in non-malignant cases does not appear to impact clinical outcome.

We read Ji Young Bang and colleagues' Article on the DESTIN trial with interest and applaud the authors for completing this impressive study. 1 Bang JY Lakhtakia S Thakkar S et al. Upfront endoscopic necrosectomy or step-up endoscopic approach for infected necrotising pancreatitis (DESTIN): a single-blinded, multicentre, randomised trial.. Lancet Gastroenterol Hepatol. 2024; 9: 22-33 Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Nevertheless, there are a few considerations that we would like to discuss. First, the study compares more aggressive, upfront endoscopic necrosectomy with a more conservative, step-up approach. The total number of reinterventions performed per patient to achieve treatment success was the primary endpoint of the study. However, this variable is influenced by the clinical and partly subjective decisions of the physicians in charge, and the open-label nature of the trial introduces biases. A fifth (seven [21%] of 33) of participants in the step-up group achieved treatment success without necrosectomy, which is notable since all patients had a necrosis extent of at least 33%. This result questions the appropriateness of upfront necrosectomy for all patients and the potential for over-therapy. Since the absolute number of trial participants was small, larger studies to predict which patient groups require necrosectomy are needed. Upfront endoscopic necrosectomy or step-up endoscopic approach for infected necrotising pancreatitis (DESTIN): a single-blinded, multicentre, randomised trialIn stabilised patients with infected necrotising pancreatitis and fully encapsulated collections, an approach incorporating upfront necrosectomy at the index intervention rather than as a step-up measure could safely reduce the number of reinterventions required to achieve treatment success. Full-Text PDF The DESTIN trial: to step up or not? – Authors' replyWe thank Oscar Cahyadi and colleagues and Avinash Tiwari and colleagues for their interest in our Article on the DESTIN trial.1 Although we agree that 21% of patients did not require necrosectomy in the step-up cohort, a substantial majority did. We encourage the authors to examine upfront necrosectomy beyond the prism of an invasive technique: internal lavage with the removal of pus, mechanical access to deep seated bacterial toxins for evacuation, and early debridement that precludes late-stage dense adherence of necrosis to the cavity can all accelerate clinical recovery, leading to shorter lengths of hospital stays (median 9 days vs 19 days; p=0·048) and cost savings (mean adjusted treatment cost of US$576 182 for upfront necrosectomy vs $847 567 for the step-up approach) without statistically significant increases in adverse events. Full-Text PDF

BACKGROUND:It is well recognized that some individuals experience persistent symptoms following an initial SARS-CoV-2 infection. Symptoms affect physical, cognitive and mental well-being and can adversely impact activities of daily living, including the ability to work.AIMS:To examine the impact of post-COVID-19 syndrome with respect to effects on quality of life and impact on work in a cohort of people referred to a 'Long COVID' service.METHODS:All triaged patients (over 18 years with symptoms more than 12 weeks since the initial infection) completed a symptom assessment questionnaire. Occupation and working status (at work, at work struggling with symptoms and off work) were also recorded. Impact on function and quality of life was assessed using the EQ5D5L questionnaire.RESULTS:A total of 214 patients (median age 51.0 years, 135 females) were seen from January to September 2021. Analysis of occupational status showed: 18% were working, 40% were working but struggling and 35% had stopped working due to symptoms. Those unable to work reported significantly more fatigue, a greater perception of the need for support and lower quality-of-life scores.CONCLUSIONS:This study shows the extensive impact of post-COVID-19 syndrome on the ability to return to work. Specific return-to-work guidance is needed to support a large proportion of those struggling with the condition. The involvement of the Occupational Health team should form part of the multidisciplinary, collaborative approach to support rehabilitation and improve long-term outcomes for this condition.

Background The diagnostic performance of endoscopic retrograde cholangiopancreatography brush cytology for malignant strictures is modest. A novel larger more abrasive brush may have improved diagnostic performance. We compared the utility of the new biliary brush with a conventional brush.Methods The new brush was used in 51 consecutive patients (group 1) referred with a biliary stricture and matched to 102 patients who underwent sampling with a conventional brush (group 2). Demographic data, stricture characteristics, sensitivity, specificity, negative predictive values and positive predictive values were analysed and compared with final diagnosis. Analysis was performed using strict criteria (definite for cancer) and relaxed criteria (suspicious for cancer). All patients had a minimum follow-up of 12 months.Results There was no statistically significant difference in the age and sex distribution between the two groups. Malignancy was diagnosed in 74% in both groups. There was no significant difference in sensitivity between the groups using either strict criteria (sensitivity group 1 47.4% vs group 2 52%, p=0.69) or relaxed criteria (sensitivity group 1 71.1% vs group 2 71.2%, p=1.0).Conclusions Our data suggest that the novel brush design does not confer improved diagnostic performance in malignant biliary strictures when compared in a robust manner. This highlights the difficulties of intraductal brush sampling and the need to develop newer diagnostic techniques.

Over 2.5 million gastrointestinal endoscopic procedures are carried out in the United Kingdom (UK) every year. Procedures are carried out with local anaesthetic r with sedation. Sedation is commonly used for gastrointestinal endoscopy, but the type and amount of sedation administered is influenced by the complexity and nature of the procedure and patient factors. The elective and emergency nature of endoscopy procedures and local resources also have a significant impact on the delivery of sedation. In the UK, the vast majority of sedated procedures are carried out using benzodiazepines, with or without opiates, whereas deeper sedation using propofol or general anaesthetic requires the involvement of an anaesthetic team. Patients undergoing gastrointestinal endoscopy need to have good understanding of the options for sedation, including the option for no sedation and alternatives, balancing the intended aims of the procedure and reducing the risk of complications. These guidelines were commissioned by the British Society of Gastroenterology (BSG) Endoscopy Committee with input from major stakeholders, to provide a detailed update, incorporating recent advances in sedation for gastrointestinal endoscopy. This guideline covers aspects from pre-assessment of the elective ‘well’ patient to patients with significant comorbidity requiring emergency procedures. Types of sedation are discussed, procedure and room requirements and the recovery period, providing guidance to enhance safety and minimise complications. These guidelines are intended to inform practising clinicians and all staff involved in the delivery of gastrointestinal endoscopy with an expectation that this guideline will be revised in 5-years’ time.

Background: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is a rescue technique for patients with malignant biliary obstruction who fail conventional treatment with ERCP or EUS-guided biliary drainage. The technique has been successfully employed in the management of acute cholecystitis in patients not fit for surgery. However, the evidence for its use in malignant obstruction is less robust. This review article aims to evaluate the data available at present to better understand the safety and efficacy of EUS-guided gallbladder drainage. Methods: A detailed literature review was conducted and several databases were searched for any studies relating to EUS-GBD in malignant biliary obstruction. Pooled rates with 95% confidence intervals were calculated for clinical success and adverse events. Results: Our search identified 298 studies related to EUS-GBD. The final analysis included 7 studies with 136 patients. The pooled rate of clinical success (95% CI) was 85% (78-90%, I-2: 0%). The pooled rate of adverse events (95% CI) was 13% (7-19%, I-2: 0%). Adverse events included: peritonitis, bleeding, bile leakage, stent migration, and stent occlusion. No deaths directly related to the procedure were reported; however, in some of the studies, deaths occurred due to disease progression. Conclusion: This review supports the use of EUS-guided gallbladder drainage as a rescue option for patients who have failed conventional measures.

Patients with familial adenomatous polyposis require periodic upper endoscopic screening and surveillance for polyps and malignancy given their high-risk status. Many endoscopists shy away from performing these examinations in patients with familial adenomatous polyposis out of fear of missing something or uncertainty over how to classify, grade, and score lesions seen at endoscopy. Some endoscopists may also worry about properly deciding on management of lesions identified during upper endoscopy: Should a large duodenal polyp undergo EMR, endoscopic submucosal dissection, or be referred for surgery? Other common concerns include the proper management of ampullary or periampullary lesions, which can be complicated to manage.

Endoscopy has advanced in many ways over the last few decades; this is especially apparent with interventional procedures. Many of the innovations in endoscopy have arisen to support the management of patients in whom surgical intervention is not appropriate, or as a lower-risk alternative. This is perhaps best shown in the area of pancreatico-biliary diseases and the relevant endoscopic procedures. Both endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) have developed in leaps and bounds, with newer innovations including choledochoscopy and improved stent insertion techniques and types. Newer innovations include the use of lumen-apposing stents to allow drainage of large collections as well as formation of anastomoses. Thus, therapeutic endoscopy continues to blur the lines with surgery, and the role of the endoscopist in achieving an enteral and facilitating an oral diet in cases of obstruction is crucial in many clinical settings.

Background and aimDuring the COVID-19 pandemic, health workers' facial exposure to pathogens has been brought into focus. In this study, we aimed to determine the occurrence and degree of facial contamination to both endoscopists and their assistants during endoscopic procedures to help inform future safety measures. MethodsNon-sterile visors worn by endoscopist, assistant and room control visors from 50 procedures were swabbed post procedure for culture. Procedure type, therapy, duration and evidence of visible visor contamination were recorded. After 48-hour incubation, all bacterial colonies were identified using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry. Organisms were classified into skin/environmental, oronasal and enteric. ResultsA total of 104 visors were available for assessment (93 staff; 11 control). In worn visors, skin/environmental flora were isolated from 70, oronasal flora from 8, and enteric flora from 3 with an average colony count of >9.5. Notably, bacteria of enteric origin (Escherichia coli and Enterobacter cloacae) were isolated from three worn visors. In room control, skin/environmental flora were isolated from seven and oronasal flora from one with average colony count of five. No room control visors grew enteric flora. Overall, 9.1% room control and 10.8% worn visors were contaminated with organisms that could possibly have originated from patients. However, enteric flora were only obtained from worn visors. No visors were visibly contaminated. ConclusionThis pilot study demonstrates risk of contamination to faces of endoscopists and assistants. Larger studies are required to determine degree of risk and to give guidance on facial protection during gastrointestinal endoscopy.