Background and study aims The Bethesda ERCP Skill Assessment Tool (BESAT) is a video-based assessment tool of technical endoscopic retrograde cholangiopancreatography (ERCP) skill with previously established validity evidence. We aimed to assess the discriminative validity of the BESAT in differentiating ERCP skill levels. Methods Twelve experienced ERCP practitioners from tertiary academic centers were asked to blindly rate 43 ERCP videos using the BESAT. ERCP videos consisted of native biliary cannulation and sphincterotomy and were recorded from 10 unique endoscopists of various ERCP experience (from advanced endoscopy fellow to > 10 years of ERCP experience). Inter-rater reliability, discriminative validity, and internal structure validity were subsequently assessed. Results The BESAT was found to reliably differentiate between endoscopists of varying levels of ERCP experience with experienced ERCPists scoring higher than novice ERCPists in 11 of 13 (85%) instrument items. Inter-rater reliability for BESAT items ranged from good to excellent (intraclass correlation range: 0.86 to 0.93). Internal structure validity was assessed with item-total correlations ranging from 0.53 to 0.83. Conclusions Study findings demonstrate that the BESAT, a video-based ERCP skill assessment tool, has high inter-rater reliability and has discriminative validity in differentiating novice from expert ERCP skill. Further investigations are needed to determine the role of video-based assessment in improving trainee learning curves and patient outcomes.

Introduction: Lemmel syndrome (LS) is a rare phenomenon manifesting as obstructive jaundice due to biliary compression by a periampullary duodenal diverticula (PDD), in the absence of other obstructing pathology. Due to its infrequent occurrence, it may be overlooked, yet can potentially lead to significant clinical morbidity. Herein, we present a patient diagnosed with obstructive jaundice due to periampullary diverticulitis i.e. LS, that was treated endoscopically. Case Description/Methods: A 47-year-old female was admitted with epigastric abdominal pain, vomiting, jaundice and intermittent fevers. Physical exam revealed scleral icterus and epigastric tenderness. Pertinent labs included T. bilirubin 2.5 mg/dL, D. bilirubin 1.8 mg/dL, AST 352 U/L, ALT 483 U/L, ALP 955 IU/L, serum lipase 263. CT abdomen revealed a 4.3 X 2.5 cm inflamed duodenal diverticulum, causing extrinsic common bile duct (CBD) compression and biliary tree dilation. Given the CT findings and evidence of cholestasis, LS was considered as a possible cause of biliary obstruction. Patient subsequently underwent an ERCP that demonstrated a large PDD with an indwelling food bolus associated with mucosal ulceration. The food bolus was dislodged into the distal duodenum, followed by selective cannulation of the congested, intradiverticular papilla. Cholangiography demonstrated diffuse dilation of the CBD, without other obstructing pathology. A biliary sphincterotomy and papillary dilation were performed followed by placement of a CBD stent. After the ERCP, the patient improved clinically, coinciding with down trending liver biochemistries. Discussion: The estimated prevalence of PDD ranges from 1%-27%, with only a minority (1%-5%) developing pancreaticobiliary complications. The mechanism of developing LS can be attributed to mechanical outflow obstruction due to the debris/enterolith filled PDD, fibrosis of the major papilla with sphincter of Oddi malfunction due to chronic inflammation or induction of primary choledocholithiasis from chronic biliary stasis and bacterial overgrowth. While diagnosis is aided by imaging modalities such as CT or MRCP, ERCP is considered as the gold standard for diagnostic and therapeutic interventions. Surgical interventions such as diverticulectomy and biliodigestive anastomosis are reserved for complicated or recurrent cases. Early recognition and treatment of LS, frequently with diverticular evacuation, biliary drainage and supportive medical care, is usually associated with favorable clinical outcomes (Figure 1).Figure 1.: A) CT of the abdomen showing a 4.3 X 2.5 cm duodenal diverticulum with surrounding inflammation (red arrow) concerning for diverticulitis, causing common bile duct compression via mass effect, resulting in biliary tree dilation (yellow star); B) EGD showing a large peri-ampullary duodenal diverticulum with an indwelling food bolus associated with extensive mucosal ulceration; C) Selective cannulation of the congested, intradiverticular papilla; D) Cholangiography revealing diffuse dilation of the CBD (yellow star), with evidence of obstruction in the peri-ampullary region (red arrow); E) Papillary dilation and placement of a CBD stent through the congested, intradiverticular papilla.

Video 1Endoscopic video of ENDOFLIP procedure.

Introduction: IgG4-related disease is an immune-mediated fibroinflammatory condition that affects multiple organs and can mimic malignancy, inflammation, or infection. We report an illustrative case of IgG4-related disease in a middle-aged man with pancreatic mass concerning for malignancy. Case Description/Methods: A 53-year-old male with alcohol use disorder and a family history of pancreatic cancer presented to clinic with concerns of unintentional weight loss, fatigue, and epigastric abdominal pain. His labs were notable for AST 84 U/L, ALT 101 U/L, ALP 452 U/L, and normal bilirubin and lipase levels. CT scan of the abdomen revealed generalized lymphadenopathy (LAD) with mild intrahepatic and extrahepatic biliary dilation, and a grossly normal pancreas. Subsequent PET scan demonstrated a hypermetabolic pancreatic head mass concerning for malignancy (Figure A) and generalized increased activity in the remainder of the pancreas. Extensive hypermetabolic LAD was seen above and below the diaphragm (Figure B). Endoscopic ultrasound (EUS) described diffusely hypoechoic pancreatic parenchyma with scattered hyperechoic foci, no discrete pancreatic mass, and a petite pancreatic duct. Fine needle biopsy of an enlarged portocaval lymph node (Figure C) was negative for malignancy but did demonstrate granulomatous inflammation. Immunohistochemical staining revealed markedly increased number of IgG4-positive plasma cells consistent with IgG4 related disease (D). Flow cytometry to exclude lymphoma was unremarkable. Serum IgG4 was noted to be 4884mg/dl. The patient was initially treated with corticosteroids and later rituximab due to poor response. Discussion: IgG4-related disease may present with generalized lymphadenopathy, enlargement of salivary or lacrimal glands, autoimmune pancreatitis, or retroperitoneal fibrosis. Less common presentations include the development of focal mass lesions that mimic malignancy. In this case, the differential diagnosis included pancreatic malignancy, lymphoma and IgG4-related disease given the findings of lymphadenopathy and a pancreatic mass. As imaging cannot always reliably distinguish between these disease processes, fine needle biopsy is often necessary in securing a diagnosis. This case illustrates the importance of careful consideration and exclusion of pancreatic malignancy, which may present similarly and is far more common.Figure 1.: A.B: PET scan showing pancreatic head mass with generalized increased activity in the remainder of the pancreatic body and tail along with diffuse lymphadenopathy C: EUS showing hyperechoic foci with diffusely hypoechoic pancreatic parenchyma D: immunohistochemical stain showing increased number of IgG4-positive plasma cells.

BACKGROUND AND AIMS:Zenker's diverticulum (ZD) has traditionally been treated with open surgery or rigid endoscopy. With the advances in endoscopy, alternative flexible endoscopic treatments have been developed.METHODS:This document reviews current endoscopic techniques and devices used to treat ZD.RESULTS:The endoscopic techniques may be categorized as the traditional flexible endoscopic septal division and the more recent submucosal tunneling endoscopic septum division, also known as peroral endoscopic myotomy for ZD. This document also addresses clinical outcomes, safety, and financial considerations.CONCLUSIONS:Flexible endoscopic approaches treat symptomatic ZD with results that are favorable compared with traditional open surgical or rigid endoscopic alternatives.

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported adverse events of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases data from randomized controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through September 2019 using terms such as "wireless capsule endoscopy," "capsule endoscopy," "video capsule endoscopy," "colon capsule," and "colon capsule endoscopy," among others. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Video 1Use of submucosal injection prior to en-bloc endoscopic mucosal resection.Video 2Use of a detachable loop ligating device prior to hot snare resection of a pedunculated polyp.

Achieving competency in ERCP requires acquisition of cognitive (i.e., what to do) and motor skills (i.e., how to do it). We hypothesized that novice advanced endoscopy trainees (AETs) cannot differentiate high versus low-quality ERCP skill but that cognitive skills could be taught through structured didactics. We conducted a randomized controlled trial to determine if 1) AETs recognize low versus high-quality ERCP skill and 2) AET ability to assess ERCP skill improves after a video-based educational intervention.

Biliary drainage using endoscopic ultrasound (EUS-BD) has been developed as a novel technique to obtain biliary access and drainage when ERCP fails. Numerous studies have demonstrated its safety and efficacy specifically pertaining to those with malignant distal biliary obstruction or altered foregut anatomy. The aim of this study is to evaluate the safety and efficacy of EUS-BD in benign indications in patients with normal foregut anatomy. We performed a retrospective comparative study from 5 academic medical centers (2008–2018) involving patients with benign biliary obstruction and native foregut anatomy who had an initial failed ERCP with subsequent attempt at biliary decompression via EUS-BD or by repeating ERCP. 36 patients (mean age 61.6 ± 2.2, 38.9% female) who underwent attempted EUS-BD following initial failed ERCP were compared to 50 patients (mean age 62.7 ± 2.3, 73.5% female) who underwent repeat ERCP following an initial failed cannulation. EUS-BD was technically successful in 28 (77.8%) patients with rendezvous being the most common approach (86.1%). A higher level of pre-procedural bilirubin was found to be associated with technical success of EUS-BD (3.65 ± 0.63 versus 1.1 ± 0.4, p value 0.04). Success of repeat ERCP following failed cannulation was 86%. Adverse events were significantly more frequent in the EUS-BD cohort when compared to the repeat ERCP (10 (27.8%) versus 4 (8.0%), p = 0.02, OR 4.32. EUS-BD remains a viable therapeutic option in the setting of benign biliary disease, with success rates of 77.8%. Adverse events were significantly more common with EUS-BD vs. repeat ERCP, emphasizing the need to perform in expert centers with appropriate multidisciplinary support and to strongly consider the urgency of biliary decompression before considering same session EUS-BD after failed initial biliary access.

Background and Aims: EUS remains a primary diagnostic tool for the evaluation of pancreaticobiliary disease. Although EUS combined with FNA or biopsy sampling is highly sensitive for the diagnosis of neoplasia within the pancreaticobiliary tract, limitations exist in specific clinical settings such as chronic pancreatitis. Enhanced EUS imaging technologies aim to aid in the detection and diagnosis of lesions that are commonly evaluated with EUS. Methods: We reviewed technologies and methods for enhanced imaging during EUS and applications of these methods. Available data regarding efficacy, safety, and financial considerations are summarized. Results: Enhanced EUS imaging methods include elastography and contrast-enhanced EUS (CE-EUS). Both technologies have been best studied in the setting of pancreatic mass lesions. Robust data indicate that neither technology has adequate specificity to serve as a stand-alone test for pancreatic malignancy. However, there may be a role for improving the targeting of sampling and in the evaluation of peritumoral lymph nodes, inflammatory pancreatic masses, and masses with nondiagnostic FNA or fine-needle biopsy sampling. Further, novel applications of these technologies have been reported in the evaluation of liver fibrosis, pancreatic cysts, and angiogenesis within neoplastic lesions. Conclusions: Elastography and CE-EUS may improve the real-time evaluation of intra- and extraluminal lesions as an adjunct to standard B-mode and Doppler imaging. They are not a replacement for EUS-guided tissue sampling but provide adjunctive diagnostic information in specific clinical situations. The optimal clinical use of these technologies continues to be a focus of ongoing research.

Goals: No established methods exist to predict who will require a higher number of endoscopic necrosectomy sessions for walled-off necrosis (WON). We aim to identify radiologic predictors for requiring a greater number of necrosectomy sessions. This may help to identify patients who benefit from aggressive endoscopic management. Materials and Methods: This is a multicenter retrospective study of patients with WON at 3 tertiary care centers. WON characteristics on preintervention computed tomography imaging were evaluated to determine if they were predictive of requiring more endoscopic necrosectomy. Results: A total of 104 patients were included. Seventy patients (67.3%) underwent endoscopic necrosectomy, with median of 2 necrosectomies. WON largest transverse diameters (P=0.02), largest coronal diameters (P=0.01), necrosis pattern [likelihood ratio (LR)=17.85, P<0.001], spread (LR=11.02, P=0.01), hemorrhage (LR=8.64, P=0.003), and presence of disconnected pancreatic duct (LR=6.80, P=0.01) were associated with undergoing ≥2 necrosectomies. Patients with septations/loculations were significantly less likely to undergo ≥2 necrosectomies (LR=4.86, P=0.03). Conclusions: Several computed tomography radiologic features were significantly associated with undergoing ≥2 necrosectomies. These could help identify patients who will undergo a higher number of endoscopic necrosectomy sessions.

BACKGROUND AND AIMS:Gastroparesis is a symptomatic chronic disorder of the stomach characterized by delayed gastric emptying in the absence of mechanical obstruction. Several endoscopic treatment modalities have been described that aim to improve gastric emptying and/or symptoms associated with gastroparesis refractory to dietary and pharmacologic management.METHODS:In this report we review devices and techniques for endoscopic treatment of gastroparesis, the evidence regarding their efficacy and safety, and the financial considerations for their use.RESULTS:Endoscopic modalities for treatment of gastroparesis can be broadly categorized into pyloric, nonpyloric, and nutritional therapies. Pyloric therapies such as botulinum toxin injection, stent placement, pyloroplasty, and pyloromyotomy specifically focus on pylorospasm as a therapeutic target. These interventions aim to reduce the pressure gradient across the pyloric sphincter, with a resultant improvement in gastric emptying. Nonpyloric therapies, such as venting gastrostomy and gastric electrical stimulation, are intended to improve symptoms. Nutritional therapies, such as feeding tube placement, aim to provide nutritional support.CONCLUSIONS:Several endoscopic interventions have shown utility in improving the quality of life and symptoms of select patients with refractory gastroparesis. Methods to identify which patients are best suited for a specific treatment are not well established. Endoscopic pyloromyotomy is a relatively recent development that may prove to be the preferred pyloric-directed intervention, although additional and longer-term outcomes are needed.

Artificial intelligence (AI) is a broad descriptor term that includes machine learning (ML) in which the algorithm, based on the input raw data, analyzes features in a separate dataset without specifically being programmed and delivers a specified classification (Fig. 1). Deep learning techniques such as convolutional neural networks (CNNs) are transformative ML techniques that enable rapid and accurate image discrimination and classification and as such have many applications within medicine. In gastroenterology, CNNs have been used in several areas of GI endoscopy, including colorectal polyp detection, and classification, including assessment of the presence of advanced neoplasia in colonic polyps, evaluation of histologic inflammation in endocytoscopic images obtained during colonoscopy in patients with ulcerative colitis, analysis of endoscopic images for diagnosis of Helicobacter pylori infection, detection and depth assessment of early gastric cancer, dysplasia in Barrett’s esophagus, and detection of various abnormalities in wireless capsule endoscopy images (Table 1). Although currently an AI system that can be used in clinical practice is not commercially available, the most promising initial application appears to be for real-time colonic polyp detection and classification. Critical appraisal of the improvement in patient outcomes, cost-effectiveness, and safety and the changes in clinical practice required to incorporate and implement these tools are required. Adopting these technologies will be associated with some cost burden; a corresponding reimbursement for their use will undoubtedly affect the rate of incorporation into clinical practice. The accompanying technology committee document (available online at https://doi.org/10.1016/j.vgie.2020.08.013) describes in detail the currently reported applications of AI in gastroenterology, focusing on endoscopic image analysis. 1 Pannala R. Krishnan K. Melson J. et al. Artificial intelligence in gastrointestinal endoscopy. VideoGIE. Epub 2020 Nov 9; Abstract Full Text Full Text PDF Scopus (8) Google Scholar Table 1Reported applications of computer-aided diagnosis and artificial intelligence in various endoscopic procedures Procedure Application Colonoscopy Detection of polyps (real-time and on still images and video) ∗ Applications where use of deep learning has been reported. ; CADeClassification of polyps (neoplastic vs hyperplastic) ∗ Applications where use of deep learning has been reported. ; CADxDetection of malignancy within polyps (depth of invasion on endocytoscopic images) ∗ Applications where use of deep learning has been reported. Presence of mucosal inflammation on endocytoscopic images ∗ Applications where use of deep learning has been reported. Assessment of disease activity in inflammatory bowel disease ∗ Applications where use of deep learning has been reported. Assessment of quality metrics in colonoscopy Wireless capsule endoscopy Lesion detection and classification (bleeding, ulcers, polyps) ∗ Applications where use of deep learning has been reported. Assessment of intestinal motilityCeliac disease (assessment of villous atrophy, intestinal motility)Improve efficiency of image review Deletion of duplicate images and uninformative image frames (eg, images with debris) ∗ Applications where use of deep learning has been reported. Upper endoscopy Identify anatomic location ∗ Applications where use of deep learning has been reported. Diagnosis of Helicobacter pylori infection ∗ Applications where use of deep learning has been reported. Gastric cancer detection and assessing depth of invasion ∗ Applications where use of deep learning has been reported. Esophageal squamous dysplasiaDetection and delineation of early dysplasia in Barrett’s esophagus ∗ Applications where use of deep learning has been reported. Real-time image segmentation in volumetric laser endomicroscopy in Barrett’s esophagus ∗ Applications where use of deep learning has been reported. EUS Differentiation of pancreatic cancer from chronic pancreatitis and normal pancreasDifferentiation of autoimmune pancreatitis from chronic pancreatitisEUS elastography CADe, Computer-aided detection; CADx, computer-aided diagnosis. ∗ Applications where use of deep learning has been reported. Open table in a new tab CADe, Computer-aided detection; CADx, computer-aided diagnosis. Artificial intelligence in gastrointestinal endoscopyVideoGIEVol. 5Issue 12PreviewArtificial intelligence (AI)-based applications have transformed several industries and are widely used in various consumer products and services. In medicine, AI is primarily being used for image classification and natural language processing and has great potential to affect image-based specialties such as radiology, pathology, and gastroenterology (GE). This document reviews the reported applications of AI in GE, focusing on endoscopic image analysis. Full-Text PDF Open Access

Background and Aims: As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type. Methods: The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized. Results: Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving. Conclusions: Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge.

A shift from volume to outcome-based ERCP metrics necessitates standardized assessment strategies. However, outcomes metrics require large volumes for accurate calculation, have limited value in trainees, and do not provide feedback regarding skills requiring remediation. We aim to validate a video-based assessment tool – the Bethesda ERCP Skills Assessment Tool (BESAT) – to identify skill variations between novice and experienced endoscopists performing ERCP (ERCPists). We hypothesize skills will improve with experience, with junior trainees scoring lower than experienced ERCPists. Endoscopic and fluoroscopic images of ERCPs for biliary indications with native papillae were video recorded for 10 ERCPists from 3 centers. Videos were de-identified and edited to include up to 4 minutes each of biliary cannulation and sphincterotomy. The BESAT includes 12 technical metrics rated 1-5 (best) across 5 domains (Table) and a global assessment of skill. Eleven raters (>5 years practice with >200 ERCPs/year) scored videos using BESAT. Raters assessed up to 3 videos per ERCPist stratified by experience: novice (Novice-ERCP; ≤4 months ERCP experience) or experienced ERCPist (Exp-ERCP). Exp-ERCP included 1 graduating trainee (12 months), 3 junior (<10 year) and 4 senior attendings (>10 year). Mean (SD) was computed for each skill. Intraclass coefficients determined rater agreement. Differences were compared between ERCP groups via independent samples t-Tests. Exp-ERCP skill differences were measured with one-way ANOVA and Tukey post-hoc test. P was set to ≤ .01 to control for Type 1 error due to multiple comparisons. In total, 43 videos from 2 Novice-ERCP (mean videos 3) and 8 Exp-ERCP (mean videos 2.64) were rated. Inter-rater reliability was excellent (ICC range: 0.86 – 0.93). The Exp-ERCP group had 7.9 (0.49) years of experience (range: 1–15.5). Overall, Exp-ERCP demonstrated significantly greater Global Assessment ERCP skills scores than Novice-ERCP (p<.001) and performed better on 11/13 individual skills (Table and Figure). Differences did not exist for gentleness of manipulation and wire advancement. Novice-ERCP scored significantly lower for Alignment/Maintenance of Positioning, Sphincterotomy, and Procedural Judgment (all p< .01) and scored non-significantly lower to Exp-ERCP for Cannulation and Wire Manipulation. Among Exp-ERCP, skills did not differ apart from senior attendings scoring lower for Cannulation than the graduating trainee (p=.01). BESAT demonstrated a high level of reliability based on rater agreement and was able to rapidly differentiate ERCP skills between novice and experienced ERCPists. However, additional and/or unedited videos may be needed to differentiate skill amongst experienced ERCPists. Further work using additional trainees and videos per ERCPist are planned to validate these findings.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

BACKGROUND AND AIMS:Residual neoplasia after macroscopically complete EMR of large colon polyps has been reported in 10% to 32% of resections. Often, residual polyps at the site of prior polypectomy are fibrotic and nonlifting, making additional resection challenging.METHODS:This document reviews devices and methods for the endoscopic treatment of fibrotic and/or residual polyps. In addition, techniques reported to reduce the incidence of residual neoplasia after endoscopic resection are discussed.RESULTS:Descriptions of technologies and available outcomes data are summarized for argon plasma coagulation ablation, snare-tip coagulation, avulsion techniques, grasp-and-snare technique, EndoRotor endoscopic resection system, endoscopic full-thickness resection device, and salvage endoscopic submucosal dissection.CONCLUSIONS:Several technologies and techniques discussed in this document may aid in the prevention and/or resection of fibrotic and nonlifting polyps.

BackgroundBarrett's esophagus (BE) and esophageal adenocarcinoma (EAC) incidence has been increasing in the United States for greater than 30years. For the majority of EAC patients, treatment is limited and prognosis poor. Doublecortin like kinase-1 (DCLK1) is a cancer stem cell marker with elevated expression in BE patients with high grade dysplasia and/or EAC. This prospective cohort study was designed to compare serum DCLK1 levels before and after EAC treatment with endoscopic mucosal resection (EMR) and/or radio-frequency ablation (RFA).MethodsBarrett's esophagus patients with low or high-grade dysplasia (n=9) and EAC patients (Stage I/II) eligible for treatment were enrolled (n=14). Serum was obtained at enrollment and at end of treatment (EoT) where possible (n=6). Normal control samples (n=5) were obtained from patients with normal upper endoscopies. Serum was analyzed for DCLK1 protein content by ELISA. Kruskal-Wallis, Mann Whitney U, Pearson correlation, and Receiver Operating Characteristic tests were used to analyze the data.ResultsSerum DCLK1 levels were increased by >50% in Barrett's Esophagus (n=9) and EAC patients (n=14) vs controls (n=5, p=0.0007). These levels were reduced >50% at EoT compared to EAC (p=0.033). Although age was significantly lower in controls, this factor was not statistically related to DCLK1 serum levels (p=0.66).ConclusionsEAC treatment results in significantly decreased serum DCLK1 levels, suggesting that DCLK1 may be useful as a non-invasive disease regression biomarker following treatment.ImpactBiomarkers for EAC therapeutic response have been poorly studied and no reliable marker has been discovered thus far. These results demonstrate that DCLK1 may have potential as a circulating biomarker of the response to therapy in EAC, which could be used to improve patient outcomes.

INTRODUCTION: The diagnostic yield of endoscopic ultrasound (EUS) in non-jaundiced patients with unexplained biliary dilation has been reported to be 6-33%. In our experience, patients with unexplained biliary dilation who use chronic narcotic analgesics might have an even lower diagnostic yield at EUS. However, this correlation has not been well-described as yet. METHODS: We reviewed electronic medical records of patients referred to our center for EUS for the primary indication of unexplained biliary dilation between July 2007 and June 2017. Our database search yielded 767 potential subjects. Exclusion criteria included pancreaticobiliary masses, stones, or calcific chronic pancreatitis seen on prior imaging, a total serum bilirubin >3 mg/dl, or alkaline phosphatase (AP) > 1.5x the upper limit of normal. Data were also separately abstracted on patients with liver tests exceeding the above criteria, yet who had no other exclusion criteria. RESULTS: 41 patients met all inclusion and exclusion criteria. The mean age was 62.4 ± 14.5 years, 37 (90.2%) were female, the mean bile duct diameter at EUS was 12.2 ± 3.8 mm, total bilirubin was 0.6 ± 0.3 mg/dL and AP was 112 ± 62.9 U/L. Most patients (33/41, 80.5%) were symptomatic, reporting abdominal pain or weight loss. A majority (29/41, 70.7%) of patients used oral narcotics. EUS demonstrated choledocholithiasis in 3/29 patients (10.3%) using narcotics and 1/12 (8.3%) not using narcotics. No masses or other relevant pathology was observed. This patient cohort was then combined with 39 additional patients with unexplained biliary dilation who had abnormal liver biochemical tests. Multivariable logistic regression analysis revealed that patients with abnormal liver biochemical tests were 3 times more likely to have positive EUS finding (OR 2.9, CI [1.5,5.7], P = 0.002). Patients using chronic narcotic analgesics were less likely to have positive EUS finding (OR 0.3, CI [0.1, 1.1], P = 0.06). CONCLUSION: A majority of patients referred for EUS to investigate biliary dilation without biochemical cholestasis were women using chronic narcotic analgesics. The diagnostic yield of EUS in this population was low (9.8%) and no neoplasia was found. In contrast, the yield of EUS in patients with biliary dilation and elevated liver tests was strikingly higher at 85%. Use of chronic narcotic analgesics appeared to predict a reassuring EUS examination.

Following endoscopic management of bile leaks with biliary stent placement during endoscopic retrograde cholangiopancreatography (ERCP), both repeat ERCP and esophagogastroduodenoscopy (EGD) have been employed for subsequent stent removal. The former provides assessment of leak resolution and biliary pathology, though with higher costs and resource utilization.

With the development of reliable endoscopic closure techniques and tools, endoscopic full-thickness resection (EFTR) is emerging as a therapeutic option for the treatment of subepithelial tumors and epithelial neoplasia with significant fibrosis. EFTR may be categorized as "exposed" and "nonexposed." In exposed EFTR, the full-thickness resection is undertaken with a tunneled or nontunneled technique, with subsequent closure of the defect. In nonexposed EFTR, a secure serosa-to-serosa apposition is achieved before full-thickness resection of the isolated lesion. This document reviews current techniques and devices used for EFTR and reviews clinical applications and outcomes.