In the last 50 years, gastrointestinal endoscopy has evolved rapidly with increasing indications of use for both diagnostic and therapeutic modalities. However, it has also contributed to a significant carbon footprint and healthcare-related climate change. Endoscopy is a high-volume specialty in the United States, with an estimated > 22 million endoscopies performed annually. Therefore, it has also, unfortunately, become the third-highest generator of healthcare-related waste, with an estimated annual emission of 85768 metric tons of carbon dioxide. It is estimated that a single endoscopy session may generate more than 2 kg of waste. At the level of physicians, administrators, industry, and humanity, reducing healthcare-related waste has become one of the significant challenges currently faced. The ultimate professional goal should be to raise awareness, educate, start initiatives to reduce medical waste and perform research to make endoscopy more sustainable. These applications will lead to the establishment and promotion of environmentally friendly practices with standardized metrics to reduce the carbon footprint of gastrointestinal endoscopy.

Background and Objectives: Conflicting guidelines exist for initiating average-risk colorectal cancer screening at the age of 45 years. The United States Preventive Services Task Force (USPSTF) changed its guidelines in 2021 to recommend initiating screening at 45 years due to an increasing incidence of young-onset colorectal cancer. However, the American College of Physicians (ACP) recently recommended not screening average-risk individuals between 45 and 49 years old. We aim to study the national trends in the incidence of sporadic malignant polyps (SMP) in patients from 20 to 49 years old. Materials and Methods: We analyzed the Surveillance, Epidemiology, and End Results database (2000–2017) on patients aged 20–49 years who underwent diagnostic colonoscopy with at least a single malignant sporadic colorectal polyp. Results: Of the 10,742 patients diagnosed with SMP, 42.9% were female. The mean age of incidence was 43.07 years (42.91–43.23, 95% CI). Approximately 50% of malignant polyps were diagnosed between 45 and 49 years of age, followed by 25–30% between 40 and 45. There was an upward trend in malignant polyps, with a decreased incidence of malignant villous adenomas and a rise in malignant adenomas and tubulovillous adenomas. Conclusions: Our findings suggest that almost half of the SMPs under 50 years occurred in individuals under age 45, younger than the current screening threshold recommended by the ACP. There has been an upward trend in malignant polyps in the last two decades. This reflects changes in tumor biology, and necessitates further research and support in the USPSTF guidelines to start screening at the age of 45 years.

Adenoma detection rate (ADR) is challenging to measure, given its dependency on pathology reporting. Polyp detection rate (PDR) (percentage of screening colonoscopies detecting a polyp) is a proposed alternative to overcome this issue. Overall PDR from all colonoscopies is a relatively novel concept, with no large-scale studies comparing overall PDR with screening-only PDR. The aim of the study was to compare PDR from screening, surveillance, and diagnostic indications with overall PDR and evaluate any correlation between individual endoscopist PDR by indication to determine if overall PDR can be a valuable surrogate for screening PDR. Our study analyzed a prospectively collected national endoscopy database maintained by the National Institute of Health from 2009 to 2014. Out of 354,505 colonoscopies performed between 2009–2014, 298,920 (n = 110,794 average-risk screening, n = 83,556 average-risk surveillance, n = 104,770 diagnostic) met inclusion criteria. The median screening PDR was 25.45 (IQR 13.15–39.60), comparable with the median overall PDR of 24.01 (IQR 11.46–35.86, p = 0.21). Median surveillance PDR was higher at 33.73 (IQR 16.92–47.01), and median diagnostic PDR was lower at 19.35 (IQR 9.66–29.17), compared with median overall PDR 24.01 (IQR 11.46–35.86; p < 0.01). The overall PDR showed excellent concordance with screening, surveillance, and diagnostic PDR (r > 0.85, p < 0.01, 2-tailed). The overall PDR is a reliable and pragmatic surrogate for screening PDR and can be measured in real time, irrespective of colonoscopy indication.

Background: Adenocarcinomas of the appendix are rare cancers for which no National Comprehensive Cancer Network guidelines exist, and for patients who undergo resection with curative intent, there is a paucity of data on prognostic factors affecting long-term cancer-specific survival. We aimed to compare the cancer-specific survival outcomes in adult patients with appendiceal non-mucinous adenocarcinoma undergoing either local resection versus right hemicolectomy. Methods: This was a retrospective study from the National Cancer Institute Surveillance, Epidemiology, and End Results of patients who underwent curative resection over a 15-year period (2004-2019) for primary appendiceal adenocarcinoma. Out of 16,699 patients, 14,945 were excluded (exclusion criteria were non-adenocarcinoma histological types and patients with regional or distant metastasis as per National Cancer Institute Surveillance, Epidemiology, and End Results stage). Effects of factors (age, race, tumor biology [mucinous versus non-mucinous tumors], the extent of resection of the primary lesion, and lymph nodes) on cancer-specific long-term survival were studied. Survival analysis was performed using the Kaplan-Meier method. Survival outcomes were reported as mean survival (months). Results: Of 1,754 patients, 827 (47.1%) were women, and 927 (52.1%) were men. The mean age in years (+/- standard deviation) was 62.43 +/- 14.3. The racial distribution was as follows: Black 237 (13.5%), White 1,398 (79.7%), and Other 119 (6.8%). A total of 771 (44.6%) underwent local resection (appendectomy or segmental resection of colon without lymph node resection), and 983 (55.4%) underwent hemicolectomy with lymph node resection. Favorable survival prognosticators were age <50 years, White race, and well-differentiated histology. Patients with mucinous tumors experienced better survival. Patients who underwent right hemicolectomy with lymph node resection experienced better survival compared with those who had an appendectomy or segmental colonic resection for non-mucinous tumors rather than mucinous tumors. Conclusion: We report novel demographic, tumor-related, and operative prognostic factors impacting long-term cancer-specific survival in patients who undergo resection for appendiceal adenocarcinoma. The extent of resection of the primary lesion with draining lymph nodes determines long-term cancer specific survival in non-mucinous appendiceal adenocarcinomas. (c) 2023 Elsevier Inc. All rights reserved.

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has been transformed from an innovative technique, into a viable alternative to enteral stenting and surgical gastrointestinal anastomosis for patients with gastric outlet obstruction. Even EUS-GE guided ERCP and EUS-guided gastrointestinal anastomosis for the treatment of afferent loop syndrome have been performed, giving patients more less invasive options. However, EUS-GE is still a technically challenging procedure. In order to improve EUS-GE, several techniques have been reported to improve the technical details. With EUS-GE widely performed, more data about EUS-GE’s clinical outcomes have been reported. The aim of the current review is to describe technical details updates, clinical outcomes, and adverse events of EUS-GE.

Introduction: Liver elastography (LE), and Portal pressure gradient measurement (PPGM) are essential tools to predict prognosis and to guide for the management of patients with chronic liver disease. There is lack of data to establish cutoff values of EUS-guided liver stiffness by Shear Wave Measurement (SWM) that correlates with stage of liver fibrosis. We aimed to determine the efficacy and safety of EUS-PPGM and correlation of EUS-LE, EUS-PPGM values with stages of liver fibrosis in patients who underwent concomitant EUS-guided liver biopsy (EUS-LB). Methods: Patients who underwent concomitant EUS-LE, EUS-PPGM and EUS-LB between January 2021 and May 2023 were analyzed retrospectively at a single tertiary care center. EUS-LE was performed initially in all patients using SWM. EUS-PPGM was performed using therapeutic linear echoendoscope, compact manometer with a 25-gauge (G) needle targeting the left hepatic and portal veins through transgastric approach. Portal hypertension (PH) is defined as portal pressure gradient (PPG) >5 mmHg and clinically significant PH (CSPH) >10 mmHg. EUS-LB was performed using 19G Franseen or Fork-tip biopsy needle. Significant fibrosis (SF) was defined as F2-F4 and non-significant fibrosis (NSF) as F0-F1. Results: Twenty-one patients, 57% (n=12) male, mean age 59±11 years, mean BMI 36.1±11.8 (kg/m2), mean MELD-Na score of 9.5±3.7 underwent PPGM and EUS-LB. All but 2 patients did not undergo EUS-LE. Indications of the procedures were clinical concern for advanced liver disease. The technical success rate of EUS-PPGM was 100% with mean total procedure time 57±17 minutes. Franseen biopsy needle was used in 95% of patients. Mean maximum length of specimen was 1.9±0.6 cm with adequate ( >11) number of portal tracts to establish a histological diagnosis. SF was seen in 60% of patients. The mean EUS-LE by SWM was 23.0±14.4 kPa, and mean PPG was 4.5±4.2 mmHg. PH was found in 43% patients and CSPH in 14% (n=3) patients. PPG was significantly higher in patients with SF compared to NSF (5.8±3.1 vs. 1.9±4.7 mmHg, respectively; P=0.04). Patients with SF have higher mean SWM (29.8±12.0 kPa) compared to NSF (16.0±15.4 kPa; P=0.04). There were no significant adverse events such as pain, bleeding, or perforation during or after the procedure at 24-48 hour follow up (Table 1). Conclusion: EUS-PPGM with concomitant EUS-LB is safe and effective in the evaluation of patients with clinical concerns for advanced liver disease. Patients with significant fibrosis had high mean EUS-SWM values >29.8 kPa. Table 1. - Demographic characteristics, EUS guided elastography, portal pressure gradient measurement and liver histology Patient Age (Years) Gender BMI (kg/m2) Platelet count (109/L) MELD-Na Score Child Pugh Class Esophageal/Gastric varices Portal hypertensive gastropathy EUS Elastography`(kPa) EUS-PPG (mmHg) EUS-LB needle type Max length of specimen (cm) Liver fibrosis stage 1 74 Male 25.8 207 9 A None Absent 7.9 0.0 Franseen 2.3 1 2 46 Female 54.9 162 7 A None Absent 27.4 3.7 Franseen 1.5 4 3 58 Male 28.7 419 7 A None Absent 34.3 3.7 Fork-tip 2.1 3 4 64 Female 40.1 151 8 B None Absent 13.5 12.7 Franseen 1.8 0 5 63 Male 44.5 128 13 A Small EV Present 28.2 7.0 Franseen 1.8 4 6 44 Male 32.4 212 7 A None Absent 7.8 2.7 Franseen 1.8 0 7 74 Male 27.6 355 11 B None Present 5.4 Franseen 2.0 4 8 48 Female 24.2 205 6 A None Absent 31.5 3.0 Franseen 1.8 2 9 50 Male 22.9 202 11 A None Present 37.9 10.0 Franseen 2.1 4 10 61 Female 38.5 274 7 A None Absent 11.3 1.0 Franseen 2.8 0 11 73 Male 45.0 202 15 B None Present 3.2 Franseen 2.0 4 12 61 Male 36.0 239 9 A None Absent 30.0 5.6 Franseen 1.1 3 13 56 Male 35.6 237 6 A None Absent 7.5 6.6 Franseen 3.0 2 14 64 Female 23.8 380 7 A None Absent 11.6 1.0 Franseen 1.6 1 15 41 Female 41.3 319 7 A None Present 51.0 1.3 Franseen 1.8 2 16 42 Female 73.4 663 11 A None Absent 35.3 7.7 Franseen 1.3 4 17 49 Male 24.2 128 17 A None Absent 53.6 2.7 Franseen 3.7 1 18 67 Female 41.6 349 7 A None Absent 14.5 12.0 Franseen 1.3 2 19 57 Female 35.8 249 7 A None Absent 9.0 -2.0 Franseen 1.1 0 20 64 Male 35.3 339 20 A None Absent 13.2 -2.6 Franseen 1.7 0 21 79 Male 27.2 83 8 B EV and GV Present 12.2 9.0 Franseen - - EUS: Endoscopic ultrasound; EV: esophageal varices; GV: gastric varices; LB: liver biopsy; PPG: portal pressure gradient.

Introduction: Hemangiomas are structural lesions which usually consists of veins and capillaries in a focal area of submucosal connective tissue. The gastrointestinal tract is an uncommon location for its development, with the most common location being the colorectal region. Esophageal hemangioma is very rare. Here we present a case report of a biopsy proven esophageal hemangioma, with an aim to discuss presentation and management options. Case Description/Methods: 46-year-old woman with no significant past medical history was seen in the clinic for intermittent episodes of melena and anemia requiring oral iron supplementation. Her Hemoglobin was 7.9 with normal platelets and INR. EGD revealed a cystic appearing likely subepithelial lesion with purplish mucosa in the distal esophagus approximately 35 cm from the incisors (Figure 1A). MRI showed 2.2 cm well circumscribed distal esophageal mass with moderately T2 hyperintense and progressively enhancing lesion likely consistent with hemangioma, GIST, neurogenic or stromal tumor (Figure 1B). We did not have any evidence of metastasis on the MRI or CT chest. Endoscopic ultrasound of the mass revealed cystic and solid components with vascularity (Figure 1C). Careful sampling with a one pass fine needle aspiration using a 22 G needle was obtained but was unrevealing. Minor bleeding occurred after FNA but ceased without any intervention. A multidisciplinary tumor board meeting has deemed this pathology to be consistent with a hemangioma based on the endoscopic and imaging features. Further plan is EGD with Endoscopic submucosal dissection of the subepithelial lesion. Discussion: Few case reports have reported hemangioma in the esophagus as it deemed a rare location for the development of this pathology with prevalence of 0.04% In general population. Different modes of management have been reported which include endoscopic submucosal dissection, sclerotherapy, or surgical resection. However, we do not have comparative studies to evaluate the most appropriate treatment modality giving the low incidence of this tumor. Anemia, gastrointestinal bleeding, and dysphagia can be presenting symptoms and have been an indication for resection. Observation can be considered in asymptomatic cases. In our case, the patient presented with acute-on-chronic anemia and gastrointestinal bleeding, hence the plan is for an endoscopic submucosal dissection.Figure 1.: A: Distal esophageal mass with purplish colored mucosa as seen on the EGD. B: MRI appearance of the mass. C: EUS showing the mass with cystic and solid components.

The Wright Center for Graduate Medical Education, USA; Geisinger Commonwealth School of Medicine, USA; A T Still University, USA; SUNY Upstate Medical University, USA; The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, USA; Columbia College, USA; University of Arkansas System, USA; University of Kansas School of Medicine, USA.

The fibrolamellar variant of hepatocellular carcinoma makes up a small percentage of liver tumors. Despite being a subset, it has been noted in the literature to have variations in terms of its epidemiology and intervention recommendations. Using the Surveillance, Epidemiology, and End Results database, 339 cases from 1988 to 2016 were studied. Favorable prognostic epidemiological factors included male sex, younger ages, and white race. Those who underwent any lymph node resection (combined with liver resection) did better than those without lymph node resection; chemotherapy proved beneficial for those where surgery was contraindicated. To our knowledge, this report is the largest conglomerate dataset analyzing prognostic profiles and treatment strategies for fibrolamellar hepatocellular carcinoma.

Introduction: Gastric peroral endoscopic myotomy (G-POEM) is an emerging third space endoscopic technique for the management of refractory gastroparesis. We sought to determine the efficacy and safety of G-POEM for patients with refractory gastroparesis. Methods: This is a retrospective, single-center study of consecutive patients with refractory gastroparesis who underwent G-POEM between February 2020 to September 2022. Primary outcome was clinical success defined as improvement in gastroparesis cardinal symptoms index (GCSI) score by 25% and improvement in percent of gastric emptying at 4 hours. Secondary outcomes included technical success rate (defined as successful completion of all procedural steps), rate of adverse events (AE), frequency of hospitalization due to recurrent symptoms after G-POEM and need for additional endoscopic or surgical interventions. Refractory gastroparesis was defined as persistent symptoms despite dietary modifications and pharmacologic therapy (Table 1). Results: A total of 25 patients, 18 (72%) females, mean age 58.5±14.7 year, and mean BMI 31.3±8.5 Kg/m2 were included. The most common etiology of gastroparesis were idiopathic (36%), diabetes (36%), postsurgical (20%), scleroderma (4%) and marijuana use (4%). Clinical and technical success of procedure were 88% and 100% respectively. The mean duration of symptoms was 41.0±50.6 months. After G-POEM, there were significant improvement in mean GCSI score (32.8±6.8 vs 12.0±7.9, P< 0.001) and tendency of lower percentage of food retention on GES at 4 hours (46.42% vs 44.23%, P=0.3). As per the ASGE severity lexicon, peri-procedural mild AEs were seen in (8%). No patients encountered severe AEs. The common post-procedural AEs were abdominal pain (24%) and nausea (20%). The mean procedure time was 80±24 min and the mean length of hospital stay was 1.0 day. The mean length of follow-up was 7.6±6.1 months. Clinical response was not seen in 3 (12%) patients. Two patients required laparoscopic gastric stimulator placement (1 patient had overlap of esophageal dysmotility, and diabetes) and another patient underwent partial gastrectomy for symptoms relief. After G-POEM, there was a significant reduction in mean emergency room visits due to gastroparesis-related symptoms (1.6±3.3 vs 0.2±0.8 (P< 0.03)). Conclusion: G-POEM is feasible and effective treatment for refractory gastroparesis with a good short term clinical success rate. Predictive factors of long-term success or failure of G-POEM are yet to be explored on large multicenter studies. Table 1. - Baseline characteristics, procedure outcomes and adverse events Baseline characteristics of patients who underwent G-POEM % (n)* Age (years) 58.5 ± 14.7 Sex Female 72% (18) Male 28% (7) Race White 100% (25) Weight (kg) 87.4 ± 28.4 BMI (Kg/m2) 31.3 ± 8.5 Smoking 24% (6) Etiologies of gastroparesis Idiopathic 36% (9) Diabetes 36% (9) Post-Surgical 20% (5) Scleroderma 4% (1) Marijuana 4% (1) Duration of symptoms 41.0 ± 50.6 Duration of follow-up (months) 7.6 +6.1 Procedure outcomes Technical success 100% (25) Clinical success (GCSI improvement >25%) 88% (22) Need for reintervention 12% (3) Mean procedure time(mins) 80 + 24.77 Mean length of hospital stay (days) 1.0 Before G-POEM After G-POEM P-value GCSI score 32.8 ± 6.8 12.0 ± 7.9 < 0.001 Food retention on GES 47.2 ± 27.0 43.4 ± 35.0 0.3 Mean Hospitalization (days) 1.6 ± 3.4 0.2 ± 0.8 0.03 Adverse events Peri-procedure adverse events Post-procedure adverse events Bleeding 1 (4%) Abdominal pain 6 (24%) Serosal injury 1 (4%) Nausea + abdominal pain 5 (20%) Perforation 0 (0%) Wound infection 0 (0%) Mild adverse events 2 (8%) Aspiration pneumonia 0 (0%) Severe adverse events 0 (0%) Stenosis 0 (0%) *Values mean ± SD for continuous variables and n (column %) for categorical variables. GCSI; Gastroparesis cardinal symptom index, GES; Gastric emptying study.

Introduction: Primary small cell carcinoma of the duodenum is an incredibly rare neoplasm with few case reports noted in literature. Management of this condition typically involves radical surgery and/or chemotherapy and is associated with poor prognosis. We present a patient with metastatic small cell carcinoma with morphology favoring duodenum as the primary organ. Case Description/Methods: A 56-year-old man with no pertinent medical history presented with a 1-month history of abdominal pain and nausea. He was referred after lab-work demonstrated elevated total bilirubin, alkaline phosphatase, AST, and ALT (Table 1). On admission Computed tomography (CT) of abdomen revealed a large mass in the gallbladder fossa with extension into the liver and encasement of the superior mesenteric vein. The constellation of enlarged retroperitoneal, peri-peritoneal, peri-gastric, and peri-pancreatic lymph nodes visualized was concerning for metastatic disease. A magnetic resonance cholangiopancreatography (MCRP) confirmed a large mass in the right hepatic lobe extending into the gallbladder, initially appearing to be cholangiocarcinoma (Figure 1). Due to concerns for common bile duct (CBD) compression, endoscopic ultrasound (EUS) guided endoscopic retrograde cholangiopancreatography (ERCP) was performed with successful sphincterotomy and CBD stent placement. A large ulcerated duodenal mass and perihilar lymph node were identified and biopsied during EUS. Pathology from both biopsy sites confirmed a World Health Organization grade 3 poorly differentiated neuroendocrine carcinoma that was morphologically suggestive of small cell carcinoma, with unknown primary. Oncology consults during admission recommended 4-6 cycles of a 21-day regimen of cisplatin and etoposide with adjunct durvalumab. The first cycle of cisplatin and etoposide was complicated by acute kidney injury (AKI), necessitating reduction in etoposide and replacement of cisplatin with carboplatin. After resolution of AKI, he has since had 2 cycles of carboplatin, etoposide, and durvalumab with subsequent CT abdomen suggesting favorable response to treatment Discussion: Primary small cell carcinoma of the duodenum is extremely rare. Given the local invasion seen in this case, gallbladder origin is still possible, however these tumors compose less than 5% of small cell carcinomas. The overall clinical picture and gross visualization under endoscopy are suggestive of duodenum as the primary source for this metastatic small cell carcinoma.Figure 1.: MRCP with mass of the hepatic hilum and right inferior hepatic lobe. Table 1. - Admission Laboratory Results Admission Lab Values Lab Reference Range Alkaline phosphatase 259 units/L 40 - 129 units/L Aspartate Aminotransferase (AST) 79 units/L < 40 units/L Alanine Aminotransferase (ALT) 164 units/L 10 - 50 units/L Total bilirubin 2.32 mg/dL 0.0 - 1.6 mg/dL Direct bilirubin 1.8 mg/dL 0.0 - 0.3 mg/dL

Aim Gastrointestinal malignant melanoma is a rare mucosal melanoma (MM). Other MM include the respiratory and the genitourinary tract. All mucosal melanomas have a poor prognosis when compared to cutaneous melanomas. Ano-rectal melanomas are by far the most common and most studied gastrointestinal MM. Large-scale clinical data is lacking due to the rarity of the disease. We aim to analyze epidemiology and survival of the Gastrointestinal (G.I.) MM over 45 years using a national database. Methods The Surveillance, Epidemiology and End Results (SEER) database was queried to identify patients with biopsy-proven G.I. Melanomas. We selected tumor site, intervention, and survival information for oncology codes as per the international classification of diseases. Survival analysis was performed using the SPSS v 27 ® IBM software. Results Of the 1105 biopsy-proven confirmed cases of primary G.I. melanoma's, 191 (17.3%) received chemotherapy (C.T.), 202 (18.3%) received radiotherapy (R.T.), 63 (5.7%) received both C.T and R.T., while 684 (61.9%) of the population received surgery alone or combined with C.T. and/or R.T. Statistically significant improvement in survival was noted in all treatment strategies that utilized surgery and also when site-specific MM cohorts underwent a surgical approach with or without C.T and/or R.T. Conclusion This is the most extensive study reporting epidemiological and survival data of treatment strategy outcomes of primary G.I. mucosal melanoma elucidating best overall survival with a management strategy involving surgical intervention.

Mark Aloysius: NO financial relationship with a commercial interest | Niraj Shah: NO financial relationship with a commercial interest | Hemant Goyal: YES financial relationship with a commercial interest;Aimloxy LLC.:Consulting

Mark M. Aloysius, MD, PhD1, Peter Iskander, MD2, Preya Patel, MD2, Udit Asija, MD1, Hemant Goyal, MD2, Niraj J. Shah, MD3, Yichen Wang, MD4, Mahesh Cheryala, MD, MRCP1. The Wright Center for Graduate Medical Education, Geisinger Commonwealth School of Medicine, ATSU-SOMA, Scranton, PA; University of Texas McGovern Medical School, Houston, TX; University of Missouri, Kansas, Mississippi, MS; Mercy Medical Center, Springfield, MA.

Portal hypertension is a serious complication of advanced liver disease. Portal pressure gradient measurement accurately determines severity of portal hypertension, prognosis, and guides medical therapy. Conventionally, interventional radiology-guided hepatic venous portal gradient measures portal pressure gradient indirectly using specialized balloon catheter. Recent advances in endoscopy have paved the novel method of endoscopic ultrasound-guided direct portal pressure gradient measurement to evaluate portal hypertension with equivalent safety in both animal models and humans studies. With the expansion of Endo-Hepatology practice, a concept of “one stop shop” is becoming more popular which is a comprehensive endoscopic approach in the evaluation of chronic liver disease. During the same endoscopic procedure, patients could be evaluated for esophageal or gastric varices, portal hypertensive gastropathy, EUS-guided elastography, EUS-guided portal pressure measurement and EUS-guided liver biopsy when suspecting advanced liver disease or diagnosis remains uncertain. This article focuses on the overview of portal hypertension and EUS-guided interventions such as EUS-guided portal pressure measurement, EUS-guided elastography and EUS-guided liver biopsy in the evaluation of individuals with advanced liver disease.

Introduction: Perforation during ERCP is rare (< 1%) but potentially fatal event (up to 20% mortality). Given its rarity, most data is through study of case series from large centers or analysis of large databases. Although a meta-analysis has shown fewer adverse events as a composite (bleeding, pancreatitis, perforation) during ERCP performed at high volume centers, there is very little real-world data on endoscopist and center procedural volumes, ERCP duration, and complexity on the occurrence of perforation. Methods: Patients from Clinical Outcome Research Initiative National Endoscopic Database CORI-NED (2000-2012) who underwent ERCP were stratified based on the endoscopist’s volume (quartiles), center’s volume (quartiles), total procedure duration and complexity grade of the ERCP based on procedure details. Effects of these variables on the perforations that occurred were studied. Continuous variables were compared between perforations (P) and no perforations (NP) using the unpaired t-test with statistical significance set at p< 0.05 (2-tailed). Results: A total of 14,153 ERCPs were performed by 258 endoscopists with 20 reported perforations (0.14%) among 16 endoscopists. Mean patient age in years (±SD) 61.6± 14.8 vs 58.1±18.8 (P vs NP, p=NS, Figure a). Cannulation rate was 100% and 91.5% for P and NP respectively. 13/20 (65%) of endoscopists were high volume performers in the 4th quartile and 11/20 (55%) of perforations occurred in centers with the highest volumes (4th quartile). Total procedure duration in minutes was 40.33 ± 23.5 vs 60.1± 29.9 (P vs NP, p=0.008, highly significant, Figure b). Fluoroscopy duration in minutes was 3.3 ± 2.3 vs 3.3± 2.6 (P vs NP p=NS, Fig 1c). 50% of the procedures were complex and greater than grade 1 difficulty (Table). 3/20 (15%) patients had prior biliary surgery. 13/20 (65%) had sphincterotomies performed with stent insertion. Peritonitis occurred in only 1/20 (0.5%), (Table). Conclusion: Overall adverse events as a composite during ERCP are known to occur at a lower rate with higher volume endoscopists and centers. However, perforations studied from the national database have shown prolonged and more complex procedures performed by high volume endoscopists at high volume centers contributing to perforations. This is likely a result of high-risk procedures undertaken in patients with complex pathology at tertiary and quaternary centers.Figure 1.: (a) Age (years) box plot comparing no perforation group versus perforation group (b) Total ERCP duration (minutes) box plot comparing no perforation group versus perforation group 1. Fluoroscopy duration (minutes) box plot comparing no perforation group versus perforation group Table 1. - Endoscopist & center volume quartiles, indications & complexity of ERCP procedures that resulted in perforations Physician Physician volume quartile Center volume quartile Indication ERCP difficulty grade Dilation of strictures Sphincterotomy performed Stent placement Sphincterotomy Device Peritonitis Prior biliary Surgery 1 4 4 LHD tumor biopsy 3 No No No NA No No 2 4 4 Pancreatic tumor 3 No Yes Yes * No Yes 2 4 4 CBD stone 3 Yes Yes Yes Cotton Cannulotome No No 2 4 4 CBD stricture 3 Yes Yes Yes Cotton Cannulotome No No 3 3 3 RHD tumor biopsy 3 No Yes Yes Cotton Cannulotome No No 4 3 2 CBD stone 1 No Yes Yes Cotton Cannulotome No No 5 4 4 CBD stone 1 No Yes Yes Papillotome Yes No 6 4 3 Stent placement 1 No Yes Yes Autotome No No 7 4 3 CBD stone 1 No No No * No No 8 3 4 CBD stone 1 No No No * No No 9 4 3 Pancreatic tumor 3 No Yes Yes Cotton Cannulotome No No 10 3 3 Sphincter of Oddi dysfunction 3 No Yes Yes * No No 11 4 4 CBD stone 2 No Yes Yes Cannulating Sphincterotome No Yes 11 4 4 Stent replacement 1 No No No NA No No 11 4 4 Pancreatic pseudocyst drainage 4 No Yes Yes Needle Knife Precut No Yes 12 4 4 CBD stone 1 No Yes Yes * No No 13 4 4 CBD stone 1 No No No NA No No 14 3 3 Stent placement 1 No Yes Yes Cotton Cannulotome No No 15 3 3 CBD stone 1 No No No NA No No 16 3 3 CBD stone 3 No No No NA No Yes *unavailable.

Kaposi Sarcoma (KS) is a Human Herpes Virus-8 (HHV-8) associated angio-proliferative disorder commonly seen in patients with HIV. It most commonly involves the skin as classic purple lesions but occasionally involves the gastrointestinal (GI) tract. To date, published data is scarce on primary GI KS. Using a national database, this study analyzes the incidence, demographics, and survival of primary GI KS. We conducted a retrospective analysis (1975-2019) on biopsy-proven primary GI KS cases from 17 registries from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database. A total of 685 patients with GI KS were identified. Female gender, Non-Hispanic Asian or Pacific Islander (NHAPI), married marital status, and large bowel site-specific primary KS to have better overall survival. Luminal gastrointestinal KS was more frequent (84.96%) than solid organ involvement (3.07% of all cases). This study is the most extensive population-based study about the epidemiological and survival data of patients with primary GI KS, revealing GI KS to be a young male disease with best outcomes in the large bowel and anal canal KS while inferior outcomes in extraintestinal GI KS.

Introduction: Current guidelines recommend polyp resection strategies, endoscopic resection (ER) or surgical resection (SR) based on high-risk histological features and depth of invasion to ensure complete removal of the malignant lesion, minimizing the risk of progression through micrometastasis. Data comparing cancer-specific survival following ER or SR for localized malignant polyps based on the AJCC staging (Stage 0, I & II & grade) are scarce. Methods: We used the Surveillance Epidemiology and End Results (SEER) database (2004-2015) on patients diagnosed with at least a single malignant colorectal polyp (Table) on the colonoscopies performed for any indication or screening. Data extraction was through a case listing session using SEER*Stat v8.3.9 on combined SEER 18 incidence registries using specific codes for CRC polyps with cancer. Statistical analysis was performed using SPSS v27 for Mac. Results: A total of 63,147 patients with a diagnosis of a colorectal polyp with a malignant component were identified. The mean age was 47.48 years (± 12.15 SD), 45.6% were females. T stages ranged T1-T3. Patients with stage 0 (carcinoma in situ) polyps showed equivalent 5-year cancer-specific survival regardless of ER or SR (mean 170 vs 169 months, 94.2% vs 93.7%, P=0.429, Figure 1A). Stage I and II patients showed superior 5-year survival with SR than ER (mean 165 vs 159 months, 91.1% vs 88%, p< 0.001, Figure 1B). Patients with well-differentiated histological grade demonstrated no survival differences regardless of ER or SR (mean 165 vs 166 months, 92.7% vs 93%, P=0.175, Figure 1C). In contrast, those with polyps of poor differentiation or anaplastic features showed superior 5-year cancer-specific survival with SR than ER (mean 161 vs 145months, 90% vs 88%, P=< 0.001, Figure 1E). Patients with polyps of moderate differentiation showed superior 5-year cancer-specific survival with SR compared with ER (mean 164 vs 159months, 92% vs 90% p< 0.001, Figure 1D) Conclusion: Our results show that cancer-specific survival improved in patients with malignant polyps with AJCC Stage I or II who underwent SR compared with ER, but not Stage 0 (carcinoma in situ). Another novel finding was superior 5-year cancer-specific survival in patients with polyps of moderately-differentiated histological grade, in addition to poorly differentiated and anaplastic grades, which has not been reported before. These novel findings warrant further corroboration from well-constructed clinical trials.Figure 1.: Five-year cancer specific survival comparing endoscopic resection versus surgical resection for colorectal polyps by cancer stage and histological grade.Table 1.: Number of patients diagnosed with polyps with a malignant component by stage and year of diagnosis.

Chronic hepatitis B (CHB) continues to contribute to worldwide morbidity and mortality significantly. Scientists, clinicians, pharmaceutical companies, and health organizations have dedicated substantial Intellectual and monetary resources to finding a cure, increasing immunization rates, and reducing the global burden of CHB. National and international health-related organizations including the center for disease control, the national institute of health, the American Association for the study of liver disease (AASLD), The European association for the study of the Liver (EASL), The Asia Pacific association for the study of the Liver (APASL) and the world health organization release periodic recommendations for disease prevention and treatment. Our review of the most recent guidelines by EASL, AASLD, APASL, and Taiwan Association for the Study of the Liver revealed that an overwhelming majority of cited studies were published before 2018. We reviewed Hepatitis B-related literature published 2018 onwards to identify recent developments and current barriers that will likely direct future efforts towards eradicating hepatitis B. The breakthrough in our understanding of the hepatitis B virus life cycle and resulting drug development is encouraging with significant room for further progress. Data from high-risk populations, most vulnerable to the devastating effects of hepatitis B infection and reactivation remain sparse. Utilization of systems approach, optimization of experimental models, identification and validation of next-generation biomarkers, and precise modulation of the human immune response will be critical for future innovation. Within the foreseeable future, new treatments will likely complement conventional therapies rather than replace them. Most Importantly, pragmatic management of CHB related population health challenges must be prioritized to produce real-world results.