Background and AimsFluoroscopy-free endoscopic retrograde cholangiopancreatography for common bile duct stone (CBDS) clearance is usually offered only to pregnant patients. We initiated a multicenter, randomized controlled trial comparing clearance of non-complex CBDSs using fluoroscopy-free direct solitary cholangioscopy (DSC) to standard endoscopic retrograde cholangiography (ERC) to evaluate the wider applicability of the DSC-based approach. Here we report the initial results of stone clearance and safety in roll-in cases for the randomized controlled trial.MethodsTwelve expert endoscopists at tertiary care centers in four countries prospectively enrolled 47 patients with non-complex CBDSs for DSC-assisted CBDS removal in an index procedure including fluoroscopy-free cannulation. Successful CBDS clearance was first determined by DSC and subsequently validated by final occlusion cholangiogram as the ERC gold standard.ResultsFully fluoroscopy-free cannulation was successful in 42/47 (89.4%) patients. Brief fluoroscopy with minimal contrast injection was used in 4/47 (8.5%) patients during cannulation. Cannulation failed in 1/47 (2.1%) patients. Fluoroscopy-free complete stone clearance was reached in 38/46 (82.6%) cases. Residual stones were detected in the validation ERC occlusion cholangiogram in three cases. Overall serious adverse event rate was 2.1% (95% confidence interval 0.1-11.3): postprocedural pancreatitis in one patient.ConclusionsIn patients with non-complex CBDS, the fluoroscopy-free technique is easily transferred to endoscopic retrograde cholangiopancreatography experts with acceptable rates of cannulation and stone clearance and few serious adverse events. (ClinicalTrials.gov number, NCT03421340)

Complete hypopharyngeal stenosis is rare and challenging to treat [1]. A 72-year-old man underwent total laryngectomy with bilateral radical neck dissection, total thyroidectomy, and pectoralis major myocutaneous flap reconstruction to treat laryngeal cancer. Following adjuvant radiotherapy, the patient developed an hypopharyngeal stenosis. This was initially treated with endoscopic dilations. However, after 3 years, stricture recurrence led to complete obstruction of the hypopharyngeal lumen that required placement of a percutaneous endoscopic gastrostomy tube for nutrition. After failure of endoscopic ultrasound-guided recanalization [2], an endoscopic magnetic compression anastomosis was attempted ([Video 1]). To our knowledge, this approach, used to repair esophageal atresia in children [3], has never been previously attempted in adults.

ObjectivePeroral endoscopic myotomy (POEM) has become standard treatment for achalasia with comparable efficacy to surgery. In most of published series, the length of myotomy is 12–13 cm. Shorter cuts could have the advantage of shorter procedure time and possibly reduced gastro-oesophageal reflux disease (GORD) rate.DesignThis single-centre, patient-blinded, randomised, non-inferiority clinical trial included 200 patients, who were randomly allocated, to receive either a long-POEM (13 cm; 101 patients) or a short-POEM (8 cm; 99 patients). Primary outcome was defined as an Eckardt symptom score of ≤3 at 24 months after the procedure; a non-inferiority design was chosen with an accepted success range of 6% between the two treatments. Secondary outcomes included operating time, complication rate, postoperative manometry, GORD rate and quality of life.ResultsIn the intention-to-treat analysis, clinical success rates were 89.1% in the long-POEM and 98.0% in the short-POEM group, resulting in an absolute between-group difference of −8.9% (90% CI −14.5 to −3.3).Procedure time was significantly reduced in the short-POEM as compared with the long-POEM group (40 vs 50 min, p<0.0001). Severe adverse events occurred in one patient in both groups.No differences were observed in postoperative GORD: acid exposure >6% on pH monitoring study at 6 months was seen in 34.3% (long-POEM) vs 31.1% (short-POEM), while endoscopic oesophagitis was diagnosed in 37.6% vs 51.5% at 6 months and in 21% vs 24.5% at 24 months. Regular proton pump inhibitor use was not different either (36.8% vs 37.5%).ConclusionsOur study demonstrates non-inferiority of a shorter cut length of POEM as compared with the standard treatment, which saved some procedural time. GORD rate was not reduced by reducing cutting length.Trial registration numberNCT03450928.

We read with deep interest the position paper from the Italian Association of Hospital Gastroenterologists and Digestive Endoscopists (AIGO) [ [1] Bortoluzzi F. Sorge A. Vassallo R. et al. Sustainability in gastroenterology and digestive endoscopy: position paper from the Italian Association of Hospital Gastroenterologists and Digestive Endoscopists (AIGO). Dig Liver Dis. 2022; 54: 1623-1629 Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar ] reviewing the environmental impact of gastroenterology and digestive endoscopy. Interestingly the position paper provides information on the carbon footprint of gastroenterology and particularly digestive endoscopy. Impressively, gastroenterology is considered the third largest contributor to waste production in healthcare [ [2] Namburar S. von Renteln D. Damianos J. et al. Estimating the environmental impact of disposable endoscopic equipment and endoscopes. Gut. 2022; 71: 1326-1331 Crossref PubMed Scopus (33) Google Scholar ]. After a 5-day audit at two US medical centers, Namburar et al. estimated that the total waste generated during all the endoscopic procedures performed in the USA annually weighs 38 000 t and cover 117 soccer fields to 1 m depth. Considering also the endoscopes reprocessing, the total waste weight increases to 43,500 t [ [2] Namburar S. von Renteln D. Damianos J. et al. Estimating the environmental impact of disposable endoscopic equipment and endoscopes. Gut. 2022; 71: 1326-1331 Crossref PubMed Scopus (33) Google Scholar ]. Moreover, the authors estimated that if all the endoscopies were performed with single-use endoscopes, the total waste mass would increase by 40%. In the position paper by Bortoluzzi F. et al., the authors explore the possible strategies to reduce the carbon footprint in order to create a “green endoscopy”. Reduce, reuse, and recycle are the principles that applied to endoscopy can lead to disease prevention and waste minimization for a more sustainable digestive endoscopy. This approach is interesting, however, to reduce the environmental impact of digestive endoscopy it is mandatory to understand the specific impact of each endoscopic procedure. As a matter of fact, the equipment used during the main endoscopic procedure, such as esophagogastroduodenoscopy (EGD), colonoscopy (CS), endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP), is widely different also according to the procedure purpose. The environmental impact may change depending on the specific endoscopic procedure and a detailed study of the waste generated during the different endoscopies may help in the journey towards a more sustainable gastrointestinal endoscopy. Table 1Waste mass during the 5-day audit. Total EGD/CS EUS ERCP N of procedures per week, n (%) 390 147 (37.8)/148 (38) 63 (16.2) 32 (8) Waste mass per week, kg (%) 263.9 136.9 (51.9) 45.5 kg (17.3) 81.5 kg (30.8) Waste mass per year, kg 11,611 6023,6 2002 3586 Waste mass per single procedure, kg 1.24 (mean) 0.464 0.722 2.54 EGD: esophagogastroduodenoscopy; CS: colonoscopy; EUS: endoscopic ultrosound; ERCP: endoscopic retrograde cholangiopancreatography. Open table in a new tab EGD: esophagogastroduodenoscopy; CS: colonoscopy; EUS: endoscopic ultrosound; ERCP: endoscopic retrograde cholangiopancreatography. Sustainability in gastroenterology and digestive endoscopy: Position Paper from the Italian Association of Hospital Gastroenterologists and Digestive Endoscopists (AIGO)Digestive and Liver DiseaseVol. 54Issue 12PreviewClimate crisis is dramatically changing life on earth. Environmental sustainability and waste management are rapidly gaining centrality in quality improvement strategies of healthcare, especially in procedure-dominant fields such as gastroenterology and digestive endoscopy. Therefore, healthcare interventions and endoscopic procedures must be evaluated through the ‘triple bottom line’ of financial, social, and environmental impact. The purpose of the paper is to provide information on the carbon footprint of gastroenterology and digestive endoscopy and outline a set of measures that the sector can take to reduce the emission of greenhouse gases while improving patient outcomes. Full-Text PDF Author's reply: “Time is over: step back to reusable and step forward to recyclable!”Digestive and Liver DiseaseVol. 55Issue 8PreviewWe would like to thank the Editors of DLD for the opportunity to reply to the comments of Schepis et al. on our recent paper on issues related to sustainability in gastroenterology and digestive endoscopy from the Italian Association of Hospital Gastroenterologists and Digestive Endoscopists (AIGO) [1]. The commentary is of extreme interest, and provides insight into how endoscopic ultrasound (EUS) and retrograde cholangiopancreatography (ERCP) may contribute to the environmental impact of digestive endoscopy [2]. Full-Text PDF

Background and study aims Endoscopic drainage of benign biliary and pancreatic strictures can be challenging, especially when tightness of the stenosis does not allow passage of mechanical and pneumatic dilation catheters. Electroincision of benign biliopancreatic can be considered in selected cases. Patients and methods Three male patients (mean age 33 years, range 9-60) underwent endoscopic retrograde cholangiopancreatography to drain anastomotic biliary stricture (ABS) following orthotopic liver transplantation (n =2) and pancreatic duct stenosis due to abdominal trauma (n= 1). The biliopancreatic strictures could be passed only with a thin 0.020-inch hydrophilic guidewire. Conventional mechanical and pneumatic dilators failed to pass the strictures due to weakness of the guidewire. Therefore, electrosurgical incision by over-the-wire 6Fr cystotome or needle-knife was attempted using pure cut current. Results The two cases of ABS were approached also by cholangioscopy and the 6Fr cystotome easily passed the strictures, allowing subsequent pneumatic dilatation and insertion of multiple plastic stents. The patient with a pancreatic duct stricture underwent electrosurgical incision using a thin needle knife over-the-wire, resulting in insertion of a 7Fr pancreatic stent. No adverse events occurred; all the patients were discharged within 24 to 48 hours.

Aims Visual findings during digital single-operator cholangioscopy (DSOC) still plays a major role in diagnosis of indeterminate biliary strictures (IDBS). A universally accepted classification is lacking. The Monaco Classification was recently proposed to overcome this limitation. The aim of this study was to evaluate efficacy and reproducibility of this classification.

Wiriyaporn Ridtitid: NO financial relationship with a commercial interest | Rungsun Rerknimitr: NO financial relationship with a commercial interest | Mohan Ramchandani: NO financial relationship with a commercial interest | Sundeep Lakhtakia: NO financial relationship with a commercial interest | Raj Shah: NO financial relationship with a commercial interest | Janak Shah: NO financial relationship with a commercial interest | Nirav Thosani: YES financial relationship with a commercial interest;Boston Scientific

Objectives Endoscopic sphincterotomy (ES) and papillectomy (EP) are associated with a non-negligible risk of post-procedural bleeding. Despite first-line endoscopic hemostasis being achieved by several methods, patients may experience bleeding persistence or recurrence. In such cases, fibrin glue (FG) injection may be used as a rescue therapy before more invasive approaches. The aim of this study was to evaluate the efficacy and safety of endoscopic FG injection to treat refractory post-ES and post-EP bleeding. Methods Data were collected retrospectively from patients with refractory immediate or delayed bleeding following ES or EP, between October 2007 and November 2019, at a single institution. Clinical success was defined as bleeding control after FG injection. Results Overall, 70 patients were included. Clinical success was reached in 64 (91.4%) patients after one session of FG injection. Of six (8.6%) patients in whom the treatment failed, one required subsequent insertion of a fully covered self-expanding metal stent (FC-SEMS) due to immediate massive bleeding, while five experienced bleeding recurrence. Such events were managed with an additional session of FG injection that failed in two cases. Therefore, one patient underwent FC-SEMS plus selective embolization, whereas the other underwent diagnostic arteriography. No severe periprocedural complications occurred. Two cases of intrabiliary glue migration were treated by endoscopic removal with a retrieval basket. Conclusions Rescue therapy with endoscopic FG injection appears to be effective and safe to treat refractory post-ES and post-EP bleeding. Further studies are required to confirm these preliminary data.

Introduction: Obstructive jaundice is a frequent cause of access to the Emergency Department (ED) and requires rapid hospitalization in order to perform an endoscopic retrograde cholangiopancreatography (ERCP). To reduce overcrowding, Brief Observation Units (BOU) were set up in EDs throughout Italy where patients receive treatment for 48-72 hours, significantly decreasing hospitalizations. The objective of this study is to evaluate the cost-effectiveness of a new model for managing obstructive acute jaundice in BOUs and provide indications regarding the possibility of systematic implementation thereof within EDs. Materials and methods: From 1 January 2019 to 31 December 2019, we evaluated 213 patients (100 M/113F, mean age 65±16.8 years) who presented at the ED with acute obstructive jaundice and were subsequently admitted to the BOU. Each patient underwent blood tests, an ECG, and an ultrasound or CT scan to confirm the diagnosis. In addition, each patient presented with ERCP indications. We analyzed the introduction of the BOU from a clinical, economic and discharge time perspective and made some recommendations regarding the organizational opportunities. Results: Clinical management in BOUs has produced excellent results, but it is not cost-effective. It does, however, produce excellent performance in terms of discharge times. Conclusion: This study shows both good clinical performance in the procedures carried out in the BOU and the opportunity to avoid patient hospitalization, thus optimizing the use of available hospital beds. From an economic perspective, BOUs prove more costly and receive lower reimbursements from the Diagnosis Related Groups (DRG) system. However, despite its inefficacy in terms of costs, it may be used with certain objective advantages, especially in view of the need to liberate as many hospital beds as possible and avoid unnecessary hospitalizations during the current pandemic. Furthermore, BOUs may also improve clinical results and patient safety. Management of obstructive jaundice in BOUs may be seen as an alternative care setting to the traditional methods of admission, although with economic limitations. © 2021 A. CARBONE Editore. All rights reserved.

The plaque situation on 48 surfaces in 31 children 13 years of age was assessed. A re-examination within 2 hours indicated a significant increase in the number of O Plaque Index scores. Following paired comparison of each of the 48 areas, 22 % of the surfaces were found to have changed score. Significantly more scores indicating improvement of the plaque situation were found at the second examination. A re-examination of plaque on consecutive days in a similar group of children showed no significant changes. Re-examination of the gingival conditions within 2 hours indicated a significant increase in the number of scores of 2 and this was confirmed by the paired comparison on the 48 surfaces. The findings indicate systematic errors rather than intra-examiner inconsistency.

A 59-year-old man underwent orthotopic liver transplantation; liver re-transplantation was needed 24 hours later owing to primary liver failure. A large incisional hernia was repaired 5 years later. Increases in his liver function tests were noted 6 years later and magnetic resonance cholangiography showed an anastomotic biliary stricture. During endoscopic retrograde cholangiopancreatography (ERCP), it was impossible to pass beyond the anastomotic biliary stricture, even with the aid of cholangioscopy (SpyGlass DS; Boston Scientific, Natick, Massachusetts, USA). Percutaneous negotiation of the biliary stricture also failed despite cholangioscopy. After multidisciplinary discussion, surgery was considered too risky owing to the previous E-Videos