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Innovations in devices and techniques have parallelly propelled the field of therapeutic endoscopy in gastrointestinal tract. With the development of endoscopic resection techniques and the availability of newly designed electrosurgical knives, the minimally invasive management of early gastrointestinal neoplasms has revolutionized. The currently available electrosurgical knives are monopolar devices, not equipped with injection needle and required to be exchanged with coagulation forceps for hemostasis. Monopolar electrosurgical devices require higher voltages with associated risks. A recent innovation in the field of endoscopic knives is a new device called "Speedboat" device, specially designed for use in endoscopic dissection procedures. This is a bipolar device that utilizes radio frequency energy for cutting and microwave energy for achieving hemostasis. Speedboat device possesses hemostasis capability and has an integrated injection needle that imparts an "all-in-one" quality to this device. Preliminary data suggest the safety and utility of this device in performing a variety of endoscopic dissection and resection procedures including endoscopic submucosal dissection, per-oral endoscopic myotomy, and resection of subepithelial tumors. [ABSTRACT FROM AUTHOR]

Lower gastrointestinal (LGI) bleeding indicates bleeding from colon or anorectum. Typically, patients with LGI bleeding present with bright red blood per rectum or hematochezia, although rarely they can present with melena as well. Alternatively, LGI bleeding is also defined as bleeding from a source within potential reach of a colonoscope, that is, colon and terminal ileum. LGI bleedings have more favorable outcomes than upper GI (UGI) bleeding and less common than UGI bleeding. Any patient presenting with GI bleeding should undergo a detailed history and physical examination for clues that may suggest source and possible etiology. Colonoscopy remains the most widely used and preferred instrument of choice for both diagnosis and therapy. This review will discuss in brief the causes, triaging, and role of colonoscopy in the management of LGI bleeding. [ABSTRACT FROM AUTHOR]

Background Fetomaternal outcomes are of primary concern for gastrointestinal (GI) endoscopy in pregnancy. We aimed to systematically review the safety and utility of endoscopic procedures in pregnancy. Methods A systematic literature search was performed using PubMed. All original research articles with sample size > 10 involving endoscopy in pregnancy were included for the review along with case report/series describing novel/rare techniques from 1948 to July 2021. Results After screening 12,197 references, 216 citations were found and finally 66 references were included. Esophagogastroduodenoscopy had favorable fetal outcome (>95%) based on two large retrospective studies and a review of case reports. Sclerotherapy and band ligation of varices were safe according to case series. A large nationwide cohort study established safety of endotherapy for nonvariceal bleed. Botulinum toxin and pneumatic dilation in achalasia are only supported by case reports. Percutaneous endoscopic gastrostomy can be useful to support nutrition based on case reports. A retrospective case–control and cohort study with systemic review justified flexible sigmoidoscopy if strongly indicated. Low birth weight was more common when sigmoidoscopy was done in inflammatory bowel disease based on a prospective study. Colonoscopy was considered safe in second trimester based on a case–control study whereas it can be performed otherwise only in presence of strong indication like malignancy. Capsule endoscopy is promising and can be useful in acute small bowel bleeding although risk of capsule retention is unknown. There are no reports of enteroscopy in pregnancy. Twelve retrospective studies and one prospective study showed high success rate of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) (> 90%) in all trimesters and can be performed if strongly indicated. Pregnancy was an independent risk factor for post-ERCP pancreatitis in a large nationwide case–control study. Radiation-free ERCP with wire-guided bile observation, stent-guided or precut sphincterotomy, endoscopic ultrasound (EUS) guidance, and spyscopy have been described. Safety of EUS is limited to case series and can be used in intermediate probability of choledocholithiasis to guide ERCP and endoscopic cystogastrostomy. Conclusion This review concludes that GI endoscopy during pregnancy can be done effectively if strongly indicated with good fetomaternal outcomes. Precautions are advocated during procedures where radiation exposure is expected. [ABSTRACT FROM AUTHOR]

Background and Aim: Even though ductal interventions in chronic pancreatitis (CP) are known to improve pain, its impact on diabetes is unclear. In this cohort study, we evaluated the impact of ductal interventions on diabetes in these patients. Methods: Consecutive patients with CP visiting the pancreas clinic between August 1, 2011, and July 21, 2012, were enrolled and followed until December 2018. Detailed clinical, laboratory, imaging, and treatment data were recorded at enrolment and follow‐up. Patients were followed up every 6 months through hospital visit and/or telephonic interview. Risk factors for diabetes were evaluated using logistic regression. The impact of ductal interventions on diabetes was evaluated using Kaplan–Meier survival analyses and Cox proportional hazards. Results: A total of 644 patients were enrolled of which 137 were excluded. Of these, 326 (64.3%) patients had idiopathic CP, and 283 (55.8%) patients underwent ductal intervention. The cumulative incidence of diabetes was 57.9%. Median duration between symptom onset and ductal intervention was similar irrespective of diabetes (2.6 [0.6–6.0] vs 3.0 [1.0–5.5] years; P = 0.69). Alcohol intake and pancreatic ductal calculi were independent risk factors for diabetes (odds ratio [95% confidence interval] of 2.05 (1.18–3.55), P = 0.01, and 2.05 (1.28–3.28), P = 0.003, respectively). Kaplan–Meier analyses revealed that diabetes free interval was significantly longer in patients undergoing ductal interventions, predominantly in those with idiopathic CP with obstructive ductal calculi (hazard ratio [95% confidence interval] 0.39 [0.28–0.55]; P < 0.0001). There were no differences in glycemic status in patients with non‐idiopathic CP and those with pre‐existing diabetes. Conclusion: Early ductal intervention could delay development of diabetes in patients with idiopathic CP with obstructive ductal calculi. [ABSTRACT FROM AUTHOR]

Background: Endoscopic treatment of post-cholecystectomy biliary strictures (PCBS) with multiple plastic biliary stents placed sequentially is a minimally invasive alternative to surgery but requires multiple interventions. Temporary placement of a single fully-covered self-expanding metal stent (FCSEMS) may offer safe and effective treatment with fewer re-interventions. Long-term effectiveness of treatment with FCSEMS to obtain PCBS resolution has not yet been studied.Methods: In this prospective multi-national study in patients with symptomatic benign biliary strictures (N = 187) due to various etiologies received a FCSEMS with scheduled removal at 6-12 months and were followed for 5 years. We report here long-term outcomes of the subgroup of patients with PCBS (N = 18). Kaplan Meier analyses assessed long-term freedom from re-stenting. Adverse events were documented.Results: Endoscopic removal of the FCSEMS was achieved in 83.3% (15/18) of patients after median indwell of 10.9 (range 0.9-13.8) months. In the remaining 3 patients (16.7%), the FCSEMS spontaneously migrated and passed without complications. At the end of FCSEMS indwell, 72% (13/18) of patients had stricture resolution. At 5 years after FCSEMS removal, 84.6% (95% CI 65.0-100.0%) of patients who had stricture resolution at FCSEMS removal remained stent-free. In addition, at 75 months after FCSEMS placement, the probability of remaining stent-free was 61.1% (95% CI 38.6-83.6%) for all patients. Stent or removal related serious adverse events occurred in 38.9% (7/18) all resolved without sequalae.Conclusions: In patients with symptomatic PCBS, temporary placement of a single FCSEMS intended for 10-12 months indwell is associated with long-term stricture resolution up to 5 years. Temporary placement of a single FCSEMS may be considered for patients with PCBS not involving the main hepatic confluence.Trial Registration Numbers: NCT01014390; CTRI/2012/12/003166; Registered 17 November 2009. [ABSTRACT FROM AUTHOR]

Electrosurgical generator units (ESUs) are instrumental in modern therapeutic gastrointestinal (GI) endoscopy, converting household alternating current into high-frequency current to generate thermal energy within tissues. This review elucidates the essentials of electrosurgery, exploring the thermal effects on tissue, current resistance, voltage, current density, duty cycle, crest factor, and the distinctions between monopolar and bipolar circuitry. The concept of duty cycle, the proportion of time electrical current is delivered, and crest factor, the ratio of peak to root mean square voltage, are essential while comparing differently named modes across various commercially available ESUs. This article discusses the practical applications of electrosurgery in therapeutic GI endoscopy procedures, including endoscopic sphincterotomy, polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, and peroral endoscopic myotomy. It outlines recommended modes and settings for ESUs across various procedures, emphasizing the balance between cutting and coagulation to achieve optimal outcomes while minimizing adverse effects. The review further addresses special considerations for the use of grounding pads and the management of patients with implanted cardiac devices during electrosurgical procedures. This article concludes with a call for a deeper understanding of electrosurgical principles and their application in GI endoscopy to ensure patient safety and procedural success, backed by references to relevant literature and detailed tables summarizing electrosurgical modes and settings for various therapeutic interventions. [ABSTRACT FROM AUTHOR]

Malignancies of the pancreatobiliary system are usually unresectable at the time of diagnosis. As a consequence, a majority of these cases are candidates for palliative care. With advances in chemotherapeutic agents and multidisciplinary care, the survival rate in pancreatobiliary malignancies has improved. Therefore, there is a need to provide an effective and long-lasting palliative care for these patients. Endoscopic palliation is preferred to surgery as the former is associated with equal efficacy and reduced morbidity. The main role of endoscopic palliation in the vast majority of pancreatobiliary malignancies includes biliary and enteral stenting for malignant obstructive jaundice and gastric outlet obstruction, respectively. Recent advances in endoscopic palliation appear promising in imparting long-lasting relief of symptoms. Use of radiofrequency ablation and photodynamic therapy in malignant biliary obstruction has been shown to improve the survival rates as well as the patency of biliary stents. The emergence of endoscopic ultrasound (EUS) as a therapeutic tool has enhanced the capability of minimally invasive palliation in pancreatobiliary cancers. EUS is a valuable alternative to endoscopic retrograde cholangiopancreatography for the palliation of obstructive jaundice. More recently, EUS is emerging as an effective primary modality for biliary and gastric bypass. [ABSTRACT FROM AUTHOR]

Combined obstruction of the bile duct and duodenum is a common occurrence in periampullary malignancies. The obstruction of gastric outlet or duodenum can follow, occur simultaneously, or precede biliary obstruction. The prognosis in patients with combined obstruction is particularly poor. Therefore, minimally invasive palliation is preferred in these patients to avoid morbidity associated with surgery. Endoscopic palliation is preferred to surgical bypass due to similar efficacy, less morbidity, and shorter hospital stay. The success of endoscopic palliation depends on the type of bilioduodenal stenosis and the presence of previously placed duodenal metal stents. Biliary cannulation is difficult in type II bilioduodenal strictures where the duodenal stenosis is located at the level of the papilla. Consequentially, technical and clinical success is lower in these patients than in those with type I and III bilioduodenal strictures. However, in cases with failure of endoscopic retrograde cholangiopancreatography, with the introduction of endoscopic ultrasound for biliary drainage, the success of endoscopic bilioduodenal bypass is likely to increase further. The safety and efficacy of endoscopic ultrasound-guided drainage has been documented in multiple studies. With the development of dedicated accessories and standardization of drainage techniques, the role of endoscopic ultrasound is likely to expand further in cases with double obstruction. [ABSTRACT FROM AUTHOR]

Gastroesophageal reflux disease (GERD) is defined by the presence of troublesome symptoms resulting from the reflux of gastric contents. The prevalence of GERD is increasing globally. An incompetent lower esophageal sphincter underlies the pathogenesis of GERD. Proton pump inhibitors (PPIs) form the core of GERD management. However, a substantial number of patients do not respond well to PPIs. The next option is anti-reflux surgery, which is efficacious, but it has its own limitations, such as gas bloating, inability to belch or vomit, and dysphagia. Laparoscopic placement of magnetic augmentation device is emerging as a useful alternative to conventional anti-reflux surgery. However, invasiveness of a surgical procedure remains a concern for the patients. The proportion of PPI non-responders or partial responders who do not wish for anti-reflux surgery defines the 'treatment gap' and needs to be addressed. The last decade has witnessed the fall and rise of many endoscopic devices for GERD. Major endoscopic strategies include radiofrequency ablation and endoscopic fundoplication devices. Current endoscopic devices score high on subjective improvement, but have been unimpressive in objective improvement like esophageal acid exposure. In this review, we discuss the current endoscopic antireflux therapies and available evidence for their role in the management of GERD. [ABSTRACT FROM AUTHOR]

Background and Aim Peroral endoscopic myotomy (POEM) is a recently introduced technique for the treatment of achalasia cardia (AC). Data regarding safety and efficacy are still emerging. We report our experience of POEM emphasizing its safety, efficacy and follow-up data. Methods Patients with AC (220; mean age 39 years, range 9-74 years) underwent POEM from January 2013 to August 2014 for AC. Retrospective analysis of prospectively collected data was done. POEM was carried out by the standard technique of mucosal incision, submucosal tunneling, and myotomy of the esophageal and gastric muscle bundles followed by closure of the mucosal incision by hemoclips. Eckardt score, high-resolution manometry (HRM) and timed barium esophagogram (TBE) were used to evaluate the results. Post-procedure patients were followed up. Results Technical success rate of POEM was 96%. At 1 year, clinical success rate was 92%. Mean Eckardt score was 7.2 ± 1.55 prior to POEM and 1.18 ± 0.74 after POEM ( P = 0.001). There was significant improvement of esophageal emptying on TBE (38.4 ± 14.0 % vs 71.5 ± 16.1 % ( P = 0.001). Pre-procedure and post-procedure mean lower esophageal sphincter pressure was 37.5 ± 14.5 mmHg and 15.2 ± 6.3 mmHg, respectively. ( P = 0.001) Erosive esophagitis was seen in 16% of patients who underwent POEM. There were no major adverse events. Conclusions Study demonstrates excellent safety profile of POEM with significant relief of symptoms, reduced pressure at HRM and improved emptying at TBE. Further prospective studies are required to compare with other treatment modalities. [ABSTRACT FROM AUTHOR]

This article is a reply to a comment made by Drs. Liu and Hu regarding a study on predictors of persistent pain following extracorporeal shockwave lithotripsy (ESWL) for pancreatic stones. The study excluded patients who did not achieve stone fragmentation after four sessions of ESWL. The researchers focused on identifying predictors of persistent pain despite successful ESWL and found that alcohol consumption, tobacco use, older age, main pancreatic duct (MPD) size, and MPD stricture were independent predictors of persistent pain. The article also clarifies that a guideline recommending the insertion of a single 10-Fr plastic stent for 1 year applies specifically to cases with dominant MPD strictures and is considered a weak recommendation. [Extracted from the article]

Post-cholecystectomy complete transection of bile duct poses a significant management challenge that warrants surgical repair or percutaneous-endoscopic reconnection. In this E-Video article, Martinez and colleagues describe a purely endoscopic reconnection of a completely transected bile duct by means of endoscopic ultrasound (EUS)-guided rendezvous and ERCP in a single session. Secondly where, as in this case, there is complete transection of the bile duct, the guidewire can repeatedly enter the contralateral bile duct or subhepatic space and usually requires retrieval via the distal bile duct by means of a basket under fluoroscopic or cholangioscopic guidance. [Extracted from the article]

Background Although peroral direct cholangioscopy ( PDCS) is emerging as an alternative to traditional mother-daughter cholangioscopy, it is associated with high failure rates. The aim of the present study was to evaluate the ability to insert and carry out interventions using a prototype multi-bending PDCS. Patients and Methods Prospective, observational clinical feasibility study was done in 41 patients with a variety of biliary diseases. A multi-bending PDCS prototype was inserted using a free-hand technique, a guidewire alone, or with a 5- Fr diameter anchoring balloon. Diagnostic and therapeutic procedures were carried out. Results The free-hand direct insertion technique failed in all attempted cases ( n = 7). Of the remaining 34 cases, successful rate of PDCS insertion into the distal bile duct was achieved by passing the PDCS over a guidewire alone ( n = 6) and/or with a guidewire plus anchoring balloon ( n = 28) for an overall successrate of 88.2% (30/34). In 13 (92.9%) patients without an underlying biliary stricture, PDCS insertion proximal to the bifurcation was possible. In 25 cases, biliary interventions were attempted including biopsy ( n = 13), stone removal ( n = 6), stent removal ( n = 1), and intraductal electrohydraulic lithotripsy ( n = 2) and were successful in 22 (88%). Other than two patients with procedure-related cholangitis with a mild grade of severity, no complications were observed. Conclusions Using a novel multi-bending prototype peroral direct cholangioscope, cholangioscopy had a high diagnostic and therapeutic success rate only when passed over a guidewire and anchoring balloon but not with the free-hand insertion technique. Comparative studies of direct cholangioscopy are warranted. [ABSTRACT FROM AUTHOR]

Artificial Intelligence (AI) is a mathematical process of computer mediating designing of algorithms to support human intelligence. AI in hepatology has shown tremendous promise to plan appropriate management and hence improve treatment outcomes. The field of AI is in a very early phase with limited clinical use. AI tools such as machine learning, deep learning, and 'big data ' are in a continuous phase of evolution, presently being applied for clinical and basic research. In this review, we have summarized various AI applications in hepatology, the pitfalls and AI's future implications. Different AI models and algorithms are under study using clinical, laboratory, endoscopic and imaging parameters to diagnose and manage liver diseases and mass lesions. AI has helped to reduce human errors and improve treatment protocols. Further research and validation are required for future use of AI in hepatology. [ABSTRACT FROM AUTHOR]

Chronic pancreatitis (CP) is a disease characterized by irreversible destruction and fibrosis of the parenchyma, leading to pancreatic exocrine insufficiency. In developed countries, the etiology for 60% to 70% of CP amongst male patients is alcohol and 25% are classified as idiopathic chronic pancreatitis (ICP). The genetic predisposition to CP could be an inappropriate activation of trypsinogen in the pancreas. Two common haplotypes, c.101A > G (p.N34S) and c.−215G > A, and four intronic alterations of the serine protease inhibitor Kazal type 1 ( SPINK1) gene have been found to increase the risk for CP in the Asia Pacific region. Hence, SPINK1 is thought to be a candidate gene for pancreatitis. A loss-of-function alteration in chymotrypsinogen C ( CTRC) gene has been shown to be associated with tropical calcific pancreatitis (TCP). Cathepsin B ( CTSB) is also found to be associated with TCP. However mutations in cationic and anionic trypsinogen gene do not play an important role in causing CP in Asia Pacific region. [ABSTRACT FROM AUTHOR]

In spite of recent developments in the field of enteroscopy the small bowel remains the challenging organ to access. The spiral enteroscopy is a novel technique using a special over-tube (Endo-Ease Discovery SB) system for deep intubation of the small bowel. The aim of the present study was to evaluate the efficacy of spiral enteroscopy with an Olympus enteroscope (SIF Q 180) in an Asian subset of patients. Between January and March 2010, 11 patients underwent spiral enteroscopies. The indication for the procedure was obscure gastrointestinal bleeding in five patients, Crohn's disease in two, malabsorbtion syndrome in two, Peutz-Jeghers syndrome in one and Osler Weber Rendu disease in one patient. Eleven patients (five male and six female) mean age 41.6 years (range 21-62 years) underwent spiral enteroscopy. Spiral enteroscopy advancement was successful in all patients. The average depth of insertion was 249 cm (range 120-400 cm) past the ligament of Treitz, and the average time for the procedure was 27.8 min (range 20-32 min). The findings included ulcers ( n = 3), polyps ( n = 1), arteriovenous malformation ( n = 2), ulcer with stricture ( n = 1), and lymphangiectasia ( n = 1). No major complications were observed. In conclusion, our initial experience with spiral enteroscopy shows that it is easy to perform, takes less time than balloon assisted enteroscopy and is relatively safe. [ABSTRACT FROM AUTHOR]

Background and Aims: A pH of more than 6 is required for clot stability and hemostasis. Intravenous proton pump inhibitors have a rapid onset of action compared to oral and have been preferred for management of non-variceal bleeding. Intravenous pantoprazole has been used extensively. Buffered esomeprazole (BE) is an oral preparation consisting of an inner core of non-enteric-coated esomeprazole with a shell of sodium bicarbonate. The buffer protects against acid degradation of esomeprazole in addition to immediate antacid action. The aim of this study was to assess the efficacy of BE for raising and maintaining an intragastric pH of more than 6 in comparison to i.v. pantoprazole in equivalent dosing. Methods: A randomized two-way cross-over study was conducted. Ten healthy volunteers were randomized to twice daily BE 40 mg or pantoprazole 40 mg i.v. bolus. Intragastric pH was measured with a wireless pH radiotelemetry capsule (Bravo, Medtronic). A 2-week washout period was given between doses. Results: BE achieved a steady pH of more than 6 in a median time of 2 min (range 1–5 min) after the first dose. The mean % time that intragastric pH was more than 6.0 for BE was 96%, and 90% of the 24-h period compared to pantoprazole (47% and 18%), P = 0.000. A median pH (interquartile range) for the BE group was 6.2 (6.175–6.2) which was higher than i.v. pantoprazole 4.60 (4.5–5.0) ( P = 0.005). Conclusion: BE achieves and maintains a pH of more than 6 within minutes of administration. It was significantly superior to i.v. pantoprazole in equivalent dosing. This finding could have implications in the management of non-variceal bleed where a rapid and sustained pH of more than 6 is desirable. [ABSTRACT FROM AUTHOR]

Background and Aim: Single-balloon enteroscopy (SBE) is a novel method of balloon assisted enteroscopy which allows deep intubation of intestine and has therapeutic potential. This prospective study was done in a tertiary care center to evaluate the feasibility, complications, diagnostic and therapeutic yield of SBE in patients with suspected small bowel disorders. Methods: One hundred and six patients (mean age 40.1 years, range 12–76 years, 65 men) with suspected small bowel diseases underwent 131 SBE procedures between February 2007 and July 2008. Results: Indications for SBE included obscure gastrointestinal bleeding (OGIB) (40), chronic abdominal pain with abnormal imaging studies (34), chronic diarrhea (20), polyposis syndromes (11) and foreign body (1).The mean insertion depth was 255.8 ± 84.5 cm beyond the duodenojejunal flexure by the oral route and 163 ± 59.3 cm proximal to the ileocecal valve by the per anal approach. The mean duration of the procedure for antegrade and retrograde enteroscopy was 65.9 ± 19.5 min and 72.3 ± 18.3 min, respectively. Pan-enteroscopy was possible in 25% of cases (five of 20 cases in which total enteroscopy was attempted). Diagnostic yields in cases of OGIB, chronic abdominal pain and chronic diarrhea were 60%, 65% and 55%, respectively. Overall new diagnosis was established in 46% and the extent of known disease was assessed in 15% of cases. In 21% of patients, therapeutic interventions were carried out while surgical treatment was directed to 8.4% of the patients. No major complications were observed. Conclusion: SBE is well tolerated and has good diagnostic yield, having a similar yield to previous double-balloon enteroscopy reports. [ABSTRACT FROM AUTHOR]

Background and Aim: Difficult common bile duct stones (CBD) are those not amenable to extraction by the standard technique of sphincterotomy followed by use of a Dormia basket or balloon. The role of extracorporeal shock wave lithotripsy (ESWL) in stone fragmentation and clearance of difficult CBD stones and the factors which favor fragmentation were prospectively evaluated in the present study. Methods: A total of 283 patients with large CBD stones were subjected to ESWL. A maximum of 5000 shocks was delivered per session until CBD stones were fragmented to less than 5 mm diameter. CBD was cleared by biliary endotherapy using a basket or balloon. Outcome was assessed by CBD clearance. Results: Total CBD clearance was achieved in 239 patients (84.4%) and partial CBD clearance in 35 patients (12.3%). Three or fewer sessions of ESWL were required in 74.6% of patients. Minor complications were seen in 45 patients (15.9%). There was no procedure-related mortality. Epidural anesthesia, shock frequency of 90/min, radiolucent calculi and presence of fluid around the calculus helped in better fragmentation. Conclusion: A high success rate, negligible complications and non-invasive nature of the procedure make ESWL a useful tool for removing large CBD stones. [ABSTRACT FROM AUTHOR]

Endoscopy is an aerosol-generating procedure which poses a high risk of transmission to the endoscopist. In the article, "Way forward: GI Endoscopy Work flow post Lockdown era", the authors provide with a broad guidance on the strategies of stepwise resumption of endoscopy services in the postlockdown phase. Sud et al [2] rightly pointed out in this article "Way forward: GI Endoscopy Work flow post Lockdown era" that nonurgent endoscopies cannot be delayed forever and we need to have a I blueprint i to deal with this situation. [Extracted from the article]

Crohn's disease (CD) is becoming increasingly recognized in Indian patients. As this disease often affects the small bowel, capsule endoscopy can help diagnose this disease and add valuable information regarding the extent of the disease. Our aim is to report our experience with the wireless capsule endoscope in patients with either known or suspected CD. Patients referred for capsule endoscopy with known or suspected CD were studied. All patients underwent precapsule endoscopy colonoscopy and small bowel series examination. After an overnight fast and bowel preparation, the capsule was ingested and the data were recorded for 8 h on the external recording device. A gastroenterologist experienced in reading capsule endoscopy interpreted images. Eleven patients (mean age 42 years [range 14–70], 7 males) underwent capsule examination. Seven patients had symptoms suggestive of CD with no precapsule evidence of the disease, one had suspected small bowel pseudo-obstruction and three had known CD. All patients had lesions in the small intestine consistent with CD. Two patients had strictures that led to a retained capsule, despite precapsule small bowel series. Capsule endoscopy is emerging as a small bowel imaging modality that can greatly assist in making the diagnosis of CD. Small bowel radiology is unreliable in excluding strictures that may cause capsule retention. [ABSTRACT FROM AUTHOR]

The article reports on pancreato-biliary endoscopy and its evolution. It mentions its treatment of diseases as well as the gradual transformation of endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). An overview of self-expandable metallic stents (SEMS) and novel anti-reflux stents is also presented.

The article explores the contribution of matrix metalloproteinases (MMP) in the development of several diseases. Topics discussed include the impact of MMP in extracellular (ECM) degradation, the genes behind the MMP transcription and the role of MMP levels in the development of chronic pancreatitis. Also mentioned are benefits to be reaped if MMP are fully understood.

Summary: Background: Point‐of‐care ultrasound (POCUS) has transformed inflammatory bowel disease (IBD) management, but the cost to purchase high‐end equipment can be prohibitive. Aim: To assess prospectively the feasibility of POCUS using pre‐existing mid‐end ultrasound equipment without incurring additional cost. Methods: Consecutive IBD patients underwent POCUS with or without faecal calprotectin (FCP) using a mid‐end ultrasound machine. If POCUS with or without FCP could not guide management, we performed additional ileocolonoscopy or cross‐sectional imaging. We evaluated the impact of POCUS on IBD management and its correlation with ileocolonoscopy or cross‐sectional imaging. We analysed pregnant, paediatric and post‐operative patients separately. Results: Among 508 patients with IBD, we analysed 419 (60.4% Crohn's disease [CD]; 61.3% male, age [years]: 36 [18–78]) undergoing 556 POCUS sessions. POCUS with or without FCP independently influenced clinical management in 42.8% of patients with CD and 49.7% with ulcerative colitis (UC). POCUS helped avoid colonoscopy in 51.4% of patients with CD and 51.8% with UC, and cross‐sectional imaging in 38.1% of suspected active small bowel CD. In patients with additional diagnostics, POCUS‐based decisions remained unchanged in 81.2% with CD and 85% with UC. Sensitivity and specificity of POCUS compared to ileocolonoscopy were 80% and 94.4% for CD and 80.8% and 92.8% for UC, respectively. Sensitivity and specificity compared to cross‐sectional imaging were 87.2% and 87.5%, respectively. Conclusion: POCUS using existing mid‐end ultrasound equipment in low‐resource settings influenced IBD clinical decision‐making with excellent accuracy, often avoiding colonoscopy and cross‐sectional imaging. [ABSTRACT FROM AUTHOR]

In spite of the economic development through the past six decades post-independence, nearly 70% of the Indian population still live in villages, and these people very often have limited access to the advanced health-care technology. In an attempt to render cost-effective gastrointestinal care to the rural dwellers, we have initiated a Rural Health Care Project. We have tailor-made and converted a bus into a mobile hospital equipped with basic diagnostic facilities including a custom-made endoscopy unit. This bus travels to rural areas and renders basic diagnostic and therapeutic services including endoscopy. A telemedicine van accompanies the mobile hospital and endoscopy unit and transmits all procedures and data to the main telemedicine center at our parent institute. We have so far performed over 30 000 endoscopic procedures in 4837 villages with a population of over 10 million people. Both the rural dwellers and the staff involved in this project have reported a high level of satisfaction. This project runs on philanthropic donations. [ABSTRACT FROM AUTHOR]

The author reflects on the management of pancreatic leaks or fistulae, which occur due to disruption of the main pancreatic duct or its side-branches. He offers a brief etiology of the disease and its complication. He remarks that the new trend in the management of pancreatic leaks involves suppression of pancreatic secretion, with the use of proton pump inhibitors and somatostatin, and repeated paracentesis.

Background Extracorporeal shockwave lithotripsy (ESWL) and/or endoscopic retrograde cholangiopancreatography (ERCP) are recommended as first-line therapy for painful uncomplicated chronic pancreatitis with obstructed main pancreatic duct (MPD) in the pancreas head/body. However, predictors of pain relief after ESWL are unknown. We evaluated independent predictors of persistent pain in patients who underwent ESWL for chronic pancreatitis. Methods 640 consecutive adult patients with chronic pancreatitis, who underwent successful ESWL with ERCP and pancreatic duct (PD) stent placement, were followed for 12 months. The pain was assessed at baseline and at 12 months using the Izbicki Pain Score, with a score decrease of >50% considered pain relief. Independent predictors of pain relief were derived from logistic regression analysis. Results Of 640 patients (mean age 36.71 [SD 12.19] years; 60.5% men), 436 (68.1%) had pain relief and 204 (31.9%) had persistent pain. On univariate analysis, older age, male sex, alcohol and tobacco intake, longer duration of symptoms, dilated MPD and MPD stricture were associated with persistent pain at 12 months (P<0.05). Consumption of alcohol (odds ratio [OR] 1.93, 95%CI 1.26–2.97), tobacco (OR 4.09, 95%CI 2.43–6.90), duration of symptoms (OR 1.02, 95%CI 1.01–1.04), MPD size (OR 1.22, 95%CI 1.11–1.33), and MPD stricture (OR 8.50, 95%CI 5.01–14.42) were independent predictors of persistent pain. Conclusions Alcohol, tobacco, duration of symptoms, MPD size and stricture were independent predictors of persistent pain after successful ESWL. A multidisciplinary team approach that includes behavioral therapy and surgical options should be considered for such patients. [ABSTRACT FROM AUTHOR]

The field of cholangioscopy is undergoing rapid evolution, marked by continuous innovation. The advent of SpyGlass cholangioscopy has initiated a new chapter, transforming the practice with advancements that include single-operator procedures and the introduction of disposable cholangioscopes. Despite these strides, significant needs remain, including enhancement of optical imaging, improving maneuverability, and expansion of therapeutic channels. This article delves into the recent progress within cholangioscopy, with a particular focus on the clinical applications of the Leinzett Lan-EP-3516 cholangioscope for the management of portal biliopathy. We present a detailed case study demonstrating how this cutting-edge cholangioscope—distinguished by its various sizing options and compatibility with portable devices for immediate imaging—played an important role in the successful treatment of a distal common biliary duct stricture and choledocholithiasis. The device's cost-effectiveness and superior imaging quality signify a notable advancement in cholangioscopic technology, facilitating enhanced treatment pathways for patients with complex biliary disorders. This case exemplifies the dynamic and expanding utility of cholangioscopy in therapeutic interventions and underscores its escalating significance in clinical settings. [ABSTRACT FROM AUTHOR]

The human microbiome is a diverse consortium of microbial kingdoms that play pivotal roles in host health and diseases. We previously reported a dysbiotic bacteriome in chronic pancreatitis patients with diabetes (CPD) compared with patients with it's nondiabetic (CPND) phenotype. In this study, we extended our exploration to elucidate the intricate interactions between the mycobiome, bacteriome, and hosts' plasma metabolome with the disease phenotypes. A total of 25 participants (CPD, n = 7; CPND, n = 10; healthy control, n = 8) were recruited for the study. We observed elevated species richness in both the bacterial and fungal profiles within the CP diabetic cohort compared to the nondiabetic CP phenotype and healthy control cohorts. Notably, the CP group displayed heterogeneous fungal diversity, with only 40% of the CP nondiabetic patients and 20% of the CP diabetic patients exhibiting common core gut fungal profiles. Specific microbial taxa alterations were identified, including a reduction in Bifidobacterium adolescentis and an increase in the prevalence of Aspergillus penicilloides and Klebsiella sp. in the disease groups. In silico analysis revealed the enrichment of pathways related to lipopolysaccharide (LPS), apoptosis, and peptidase, as well as reduced counts of the genes responsible for carbohydrate metabolism in the CP groups. Additionally, distinct plasma metabolome signatures were observed, with CPD group exhibiting higher concentrations of sugars and glycerolipids, while the CPND cohort displayed elevated levels of amino acids in their blood. The fatty acid-binding protein (FABP) concentration was notably greater in the CPD group than in the HC group (4.220 vs. 1.10 ng/ml, p = 0.04). Furthermore, compared with healthy controls, disease groups exhibited fewer correlations between key fungal taxa (Aspergillus sp., Candida sp.) and bacterial taxa (Prevotella copri, Bifidobacteria sp., Rumminococcaceae). Our study unveils, for the first time, a dysbiotic mycobiome and emphasizes unique host bacterial-mycobial interactions in CP patient with diabetes, potentially influencing disease severity. These findings provide crucial insights for future mechanistic studies aiming to unravel the determinants of disease severity in this complex clinical context. [ABSTRACT FROM AUTHOR]

Objectives: Pancreas divisum (PD) as a cause of pancreatitis has been debated. In this study, we report the association of multiple gene polymorphisms on the risk of RAP in the presence of PD.Design: We enrolled 687 individuals (167 IRAP, 276 ICP, and 244 unrelated healthy controls) from May 2015 to September 2016. Patients were divided into those with/without PD. Associations between the significantly prevalent SNPs and IRAP/ICP in the presence of PD were evaluated. Clinical data were analyzed using Mann-Whitney U/Chi-square test. Effect size of association of SNPs with IRAP/ICP was expressed as odds ratio (OR) (95% CI). Gene-gene interaction was assessed by transheterozygosity analyses. Bonferroni-corrected two-tailed "p" value of ≤ 0.01 was considered statistically significant.Results: Thirty-three (19.8%) and 82 (29.7%) patients with IRAP and ICP, respectively, had PD. Among the patients with IRAP, duration of disease was significantly shorter in those with PD compared to those without (mean [95% CI] duration: 1.6 (1.3-1.9) vs 2.7 (2.3-3.1) years; p = 0.005). There were no differences in gender, race, and diabetes among patients with/without PD in IRAP/ICP groups. Mean (95% CI) pancreatic duct diameter (mm) was significantly higher in the presence of PD in patients with both IRAP [1.6 (1.4-1.9) v/s 1.29 (1.2-1.4); p = 0.03)] and ICP [5.2 (4.5-5.9) v/s 4.5 (3.9-5.1); p = 0.02]. CTSB (rs12338) polymorphisms were significantly associated with IRAP [OR (95% CI) 2.44 (1.41-4.22); p = 0.001] among patients with PD. No association was observed with ICP. Transheterozygosity analysis did not show any significant associations of combination of SNPs with IRAP in the presence of PD.Conclusion: Risk of RAP due to PD increases in patients with rs12338 polymorphism in the cathepsin B gene. [ABSTRACT FROM AUTHOR]

Background and Aim: Resection for Crohn's disease (CD) related strictures is definitive but carries risk of morbidity, recurrence, and short bowel syndrome. On the contrary, the durability of endotherapy (ET) for CD‐related strictures is questionable. Prospective comparative studies are limited. We aimed to prospectively compare the outcomes of ET in CD strictures with a case‐matched surgical therapy (ST) cohort. Methods: Patients undergoing ET or resection for primary CD strictures (symptomatic, non‐traversable, < 5 cm length, n ≤ 3) between January 2021 and March 2022 in a high‐volume tertiary center were compared with regard to recurrent symptoms, escalation of therapy, re‐intervention, and re‐operation based on propensity matched analysis. Results: Fifty‐nine patients [49% ET, 57.6% male, median (years): 34 (15–74)] had ≥ 12 months of follow up. Before propensity matching, cumulative re‐intervention rate was significantly higher with ET [34.5% (10/29) vs 3.3% (1/30) ST, P = 0.002]. Recurrent symptoms (34.5% vs 26.7%, P = 0.42), escalation of medical therapy (27.5% vs 23.3%, P = 0.64), and re‐operation (7.4% vs 3.1%, P = 0.55) were comparable. In propensity matched analysis adjusted for demographics, disease, and stricture characteristics [n = 42, 21 each, 62% male, median (years): 32 (15–60)], cumulative probability of re‐intervention rates was higher in ET (28.6% vs 4.8%, P = 0.042). The cumulative probability of recurrent symptoms (ET: 33.3% vs surgery 33.3%, P = 0.93), therapy escalation (ET: 23.8% vs surgery 28.6%, P = 0.75), and re‐operation (ET: 9.5% vs surgery 4.8%, P = 0.57) was similar. Conclusions: ET for CD strictures require higher re‐interventions compared with resection although re‐operation could be avoided in the majority with comparable symptom free survival at 1 year. [ABSTRACT FROM AUTHOR]

Objectives: Endoscopic full‐thickness resection (EFTR) is emerging as an effective modality for mucosal and submucosal lesions in the colorectum. In this systematic review and meta‐analysis, we aimed to analyze the success and safety of device‐assisted EFTR in the colon and rectum. Methods: A literature search was performed in the Embase, PubMed, and Medline databases for studies evaluating device‐assisted EFTR between inception to October 2022. The primary outcome of the study was clinical success (R0 resection) with EFTR. Secondary outcomes included technical success, procedure duration, and adverse events. Results: In all, 29 studies with 3467 patients (59% male patients, 3492 lesions) were included in the analysis. The lesions were located in right colon (47.5%), left colon (28.6%), and rectum (24.3%). EFTR was performed for subepithelial lesions in 7.2% patients. The pooled mean size of the lesions was 16.6 mm (95% confidence interval [CI] 14.9–18.2, I2 98%). Technical success was achieved in 87.1% (95% CI 85.1–88.9%, I2 39%) procedures. The pooled rate of en bloc resection was 88.1% (95% CI 86–90%, I2 47%) and R0 resection was 81.8% (95% CI 79–84.3%, I2 56%). In subepithelial lesions, the pooled rate of R0 resection was 94.3% (95% CI 89.7–96.9%, I2 0%). The pooled rate of adverse events was 11.9% (95% CI 10.2–13.9%, I2 43%) and major adverse events requiring surgery was 2.5% (95% CI 2.0–3.1%, I2 0%). Conclusion: Device‐assisted EFTR is a safe and effective treatment modality in cases with adenomatous and subepithelial colorectal lesions. Comparative studies are required with conventional resection techniques, including endoscopic mucosal resection and submucosal dissection. [ABSTRACT FROM AUTHOR]

Gastrointestinal (GI) endoscopy is among the highest waste generator in healthcare facilities. The major reasons include production of large‐volume non‐renewable waste, use of single‐use devices, and reprocessing or decontamination processes. Single‐use endoscopic accessories have gradually replaced reusable devices over last two decades contributing to the rising impact of GI endoscopy on ecosystem. Several reports of infection outbreaks with reusable duodenoscopes raised concerns regarding the efficacy and adherence to standard disinfection protocols. Even the enhanced reprocessing techniques like double high‐level disinfection have not been found to be the perfect ways for decontamination of duodenoscopes and therefore, paved the way for the development of single‐use duodenoscopes. However, the use of single‐use endoscopes is likely to amplify the net waste generated and carbon footprint of any endoscopy unit. Moreover, single‐use devices challenge one of the major pillars of sustainability, that is, "reuse." In the era of climate change, a balanced approach is required taking into consideration patient safety as well as financial and environmental implications. The possible solutions to provide optimum care while addressing the impact on climate include selective use of disposable duodenoscopes and careful selection of accessories during a case. Other options include use of disposable endcaps and development of effective high‐level disinfection techniques. The collaboration between the healthcare professionals and the manufacturers is paramount for the development of environmental friendly devices with low carbon footprint. [ABSTRACT FROM AUTHOR]

Background/Aims The functional luminal imaging probe (FLIP) can measure tissue distensibility and geometric changes through volumetric distention. The esophagogastric junction has been well studied using EndoFLIP, studies on pylorus are lacking. We aim to study biomechanical properties of pylorus using EndoFLIP to create normative data. Methods We performed a prospective study of 20 healthy volunteers (ages, 18-54 years; 10 men) who underwent pylorus evaluation using 12-cm FLIP placed across the pyloric sphincter. FLIP data were analyzed using FLIP planimetry plots at baseline and after administration of hyoscine butyl bromide injection. Results The median pylorus distensibility index (P-DI) was 8.37 mm²/mmHg (interquartile range, 4.22-13.04 mm²/mmHg) at 40 mL balloon volume. The 90th percentile at 40 mL balloon for P-DI was 14.89 mm²/mmHg, for cross-sectional area was 244.20 mm²/mmHg, and diameter and pressure were 17.58 mm and 48.84 mmHg, respectively. There was significant increase in P-DI after administration of hyoscine butyl bromide injection (P < 0.05). Conclusion The normative values can be used as reference values for pyloric distensibility. This reference can be used in studies of related to pyloric diseases such as gastroparesis. [ABSTRACT FROM AUTHOR]

This article presents the findings of a study on the use of single-use duodenoscopes in endoscopic retrograde cholangiopancreatography (ERCP) procedures. The study found that single-use duodenoscopes have comparable safety profiles and technical performance to reusable duodenoscopes, suggesting they may be a viable alternative to reduce the risk of infections. The study also examined the characteristics of ERCP procedures, including completion time, referral sources, and medications used. Additionally, the article discusses the outcomes of ERCP procedures using single-use duodenoscopes, finding no significant differences in outcomes between expert and less expert endoscopists. The study identified several serious adverse events related to the device or procedure, but rates were similar across different levels of complexity and expertise. The article concludes that while single-use duodenoscopes are a viable option, efforts should be made to minimize adverse events and address the costs and environmental impact of single-use devices. [Extracted from the article]

METHODS: This study was conducted at the Asian Institute of Gastroenterology (AIG Hospitals), Hyderabad, India, from September 20, 2022, to December 15, 2022. All consecutive patients, older than 18 years with suspected SBD, and planned for total enteroscopy were screened for inclusion. The primary outcome was to compare the TER, and secondary outcomes were to compare the technical success, time taken to reach the depth of maximal insertion, withdrawal time, total procedure time, diagnostic yield, therapeutic success, and adverse events (AE). RESULTS: Seventy-two patients of the 110 patients screened were randomized in either NMSE (n 5 35) or SBE (n 5 37) group. The most common indication for the procedures was obscure gastrointestinal bleed (48%), others being unexplained abdominal pain with indeterminate radiologic findings (32%) and chronic diarrhea (20%). In NMSE group, the TER was 71.4%, whereas in the SBE group, it was 10.8% (P < 0.0001). The total procedure time (minutes) was much lesser withNMSE (58.17621.5 minutes) vs SBE (114.2 6 33.5 minutes) (P < 0.0001). The diagnostic yield of NMSE (80%) was comparatively higher than SBE (62.1%) (P 5 0.096). Minor AE (grade I) were observed in both the groups: NMSE 8.5% (3/35) and SBE 5.4% (2/37). DISCUSSION: This randomized controlled trial shows that with NMSE higher TER can be achieved in shorter duration with minimal AE, compared with SBE. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented in which the editor discusses various reports in the issue on the topics including one on Endoscopy Organization (WEO), the other on emerging markets in endoscopy and the third on shortage of training and training facilities.

The role of video capsule endoscopy (VCE) in inflammatory bowel disease (IBD) has evolved from small bowel to a panenteric evaluation tool over the past two decades. We systematically reviewed the techniques, applications, outcomes, and complications of VCE in IBD. A systematic literature search was performed using PubMed, Embase, and Medline. All relevant original articles involving VCE in IBD were included from 2003 to July 2022. After screening 3,089 citations, finally 201 references were included. The diagnostic yield of VCE in suspected Crohn's disease (CD) was highly variable (6–80%) with excellent sensitivity (77–93%) and specificity (80–89%). The diagnostic yield in known CD was 52 to 88.3% leading to a change in management (26–75%) and disease reclassification with variable retention rates. VCE was superior to small bowel series, computed tomography (CT) and could be better than magnetic resonance enterography (MRE), especially for proximal and superficial lesions. Colon or panenteric VCE has strong correlation to ileo-colonoscopy (IC) and combined magnetic resonance imaging and IC, respectively. The VCE retention rate in CD is higher in known CD which significantly decreases after the negative patency capsule test or CT/MRE. VCE can identify lesions beyond the reach of IC in postoperative CD. Colon Capsule Endoscopy is a noninvasive monitoring tool in ulcerative colitis (UC) having a strong correlation with IC and may uncover small bowel involvement. VCE is specifically useful in IBD-unclassified (IBD-U) which can lead to the diagnosis of CD in 16.7 to 61.5%. Various scoring systems have been established and validated for small bowel CD (Lewis score and capsule endoscopy CD activity index—CECDAI), UC (capsule scoring of UC: Capsule Scoring of Ulcerative Colitis), panenteric evaluation (Capsule Endoscopy Crohn's Disease Activity Index, Elaikim score), and flare prediction (APEX score). Technological advances include double head, three-dimensional reconstruction, sampling system, panoramic view (344 and 360 degree lateral), and panenteric capsule. Artificial intelligence and software like TOP100 and Quickview can help reduce capsule reading time with excellent sensitivity and specificity. VCE in IBD has widespread application in suspected and known small bowel CD, monitoring of UC, postoperative CD, IBD-U, and for panenteric evaluation. Patency capsule testing helps to reduce retention rates significantly. Artificial intelligence and technical advances can help evolve this novel technology. [ABSTRACT FROM AUTHOR]

Objectives: To systematically evaluate the patient and procedural risk factors for post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) among patients receiving rectal indomethacin. Methods: Data from a randomized controlled trial (RCT) of high‐risk patients undergoing ERCP who received rectal indomethacin with or without topical epinephrine was evaluated. PEP was defined based on the consensus criteria. Pancreatic stenting was excluded to avoid confounding results with the role of epinephrine spray. Multivariable logistic regression analysis was used to identify patient and procedural risk factors for PEP. Results: Among 960 patients enrolled in the RCT, the PEP incidence was 6.4%. An increased risk of PEP was seen with age <50 years and female gender (odds ratio [OR] 2.40, 95% confidence interval [CI] 1.35–4.26), malignant biliary stricture(s) (OR 3.51, 95% CI 1.52–8.10), >2 guidewire passes into the pancreatic duct (PD) (OR 2.84, 95% CI 1.43–5.64), and pancreatic brush cytology (OR 6.37, 95% CI 1.10–36.90), whereas a decreased risk of PEP was seen with contrast‐ over guidewire‐assisted cannulation (OR 0.14, 95% CI 0.02–0.99) and the use of lactated Ringer's (LR) over other fluid types (OR 0.52, 95% CI 0.27–0.98). There was a significant trend between the number of guidewire passes into the PD and PEP risk (P = 0.002). Conclusions: More than two guidewire passes into the PD and pancreatic brush cytology increased while the use of LR decreased the risk of PEP among high‐risk patients receiving rectal indomethacin. Pancreatic stent placement and/or LR should be considered in patients with >2 guidewire passes into the PD. [ABSTRACT FROM AUTHOR]

After oncologic resection, histological grading and staging of the tumor give important prognostic information about the future risk of recurrence and hence influence the subsequent management plan. Several studies and their meta-analysis have shown that various histological features (e.g., microscopic positive resection margins, plexitis, granuloma, mesenteric inflammatory activity) can predict postoperative clinical/endoscopic/surgical recurrence after resection in Crohn's disease (CD). Inclusion of mesentery in surgical resection specimens has been shown to reduce surgical recurrence after ileocolonic resection in CD. However, there is no uniform histopathological staging system for risk stratification in postoperative CD to systematically predict postoperative recurrence. This is because the prediction to date is based on clinical characteristics (smoking status, disease phenotype, surgical history). Histopathological predictors are still not adopted in routine clinical practice due to the lack of a uniform staging system, heterogeneity of published studies and lack of standardized definition of histological features. In this article, we attempted to incorporate all such histological features in a single histological staging system CNM (Crohn's primary site [resection margin positivity, plexitis, granuloma, depth of infiltration], nodes [presence of granuloma], mesentery [involved or not]) in surgical resection specimen in CD. The proposed CNM classification would help to enable systematic reporting, design future clinical trials, stratify postoperative recurrence risk and choose appropriate postoperative prophylaxis. [ABSTRACT FROM AUTHOR]

The incidence of acute pancreatitis in children has increased over the last few decades. The development of pancreatic fluid collection is not uncommon after severe acute pancreatitis, although its natural course in children and adolescents is poorly understood. Asymptomatic fluid collections can be safely observed without any intervention. However, the presence of clinically significant symptoms warrants the drainage of these fluid collections. Endoscopic management of pancreatic fluid collection is safe and effective in adults. The use of endoscopic ultrasound (EUS)-guided procedure has improved the efficacy and safety of drainage of pancreatic fluid collections, which have not been well studied in pediatric populations, barring a scant volume of small case series. Excellent results of EUS-guided drainage in adult patients also need to be verified in children and adolescents. Endoprostheses used to drain pancreatic fluid collections include plastic and metal stents. Metal stents have wider lumens and become clogged less often than plastic stents. Fully covered metal stents specifically designed for pancreatic fluid collection are available, and initial studies have shown encouraging results in adult patients. The future of endoscopic management of pancreatic fluid collection in children appears promising. Prospective studies with larger sample sizes are required to establish their definitive role in the pediatric age group. [ABSTRACT FROM AUTHOR]

Acute cholangitis is infectious disease of the biliary system and potentially can cause significant morbidity and mortality. With advances in intensive care, antibiotic therapy advances and endoscopic and other modalities of biliary drainage, mortality rates have significantly come down of late. Although most cases respond to antibiotics alone, definitive therapy is required later in most of the patients. Increased biliary pressure leads to biliovenous reflux of bacteria and purulent bile into the circulation leading to systemic inflammation and sepsis with subsequent organ dysfunction. Biliary decompression increases antibiotic penetration in bile. Therefore, patients with high-risk factors and organ dysfunction require early and urgent biliary drainage, respectively, as they are unlikely to respond with antibiotics alone. Biliary decompression is best achieved by endoscopic retrograde cholangiopancreatography ( ERCP) compared to percutaneous and surgical decompression. ERCP can be technically difficult and sometimes unsuccessful especially in patients with altered anatomy and upper gastrointestinal obstruction. Earlier percutaneous transhepatic biliary drainage ( PTBD) and surgery were the only viable options in those patients. PTBD requires a dilated biliary system, is more invasive and cannot achieve ductal clearance in cholangitis as a result of choledocholithiasis, whereas surgery is associated with high morbidity and mortality. Advances in therapeutic endoscopy such as balloon enteroscopy-guided biliary drainage or endoscopic ultrasound guided-biliary drainage have added new dimensions to endoscopic management of acute cholangitis as a result of choledocholithiasis obviating the need for more invasive procedures. [ABSTRACT FROM AUTHOR]

Acute cholangitis is infectious disease of the biliary system and potentially can cause significant morbidity and mortality. With advances in intensive care, antibiotic therapy advances and endoscopic and other modalities of biliary drainage, mortality rates have significantly come down of late. Although most cases respond to antibiotics alone, definitive therapy is required later in most of the patients. Increased biliary pressure leads to biliovenous reflux of bacteria and purulent bile into the circulation leading to systemic inflammation and sepsis with subsequent organ dysfunction. Biliary decompression increases antibiotic penetration in bile. Therefore, patients with high-risk factors and organ dysfunction require early and urgent biliary drainage, respectively, as they are unlikely to respond with antibiotics alone. Biliary decompression is best achieved by endoscopic retrograde cholangiopancreatography (ERCP) compared to percutaneous and surgical decompression. ERCP can be technically difficult and sometimes unsuccessful especially in patients with altered anatomy and upper gastrointestinal obstruction. Earlier percutaneous transhepatic biliary drainage (PTBD) and surgery were the only viable options in those patients. PTBD requires a dilated biliary system, is more invasive and cannot achieve ductal clearance in cholangitis as a result of choledocholithiasis, whereas surgery is associated with high morbidity and mortality. Advances in therapeutic endoscopy such as balloon enteroscopy- guided biliary drainage or endoscopic ultrasound guidedbiliary drainage have added new dimensions to endoscopic management of acute cholangitis as a result of choledocholithiasis obviating the need for more invasive procedures. [ABSTRACT FROM AUTHOR]

Background/Aims Achalasia cardia (AC) is a motility disorder, characterized by impaired lower esophageal sphincter relaxation and absence of esophageal peristalsis. AC is rare in children with unclear optimum management strategies. Per oral endoscopic myotomy (POEM) is a novel technique for management of achalasia with encouraging results in adult patients. The efficacy and safety of POEM is not known for pediatric AC. The aim of our study was to evaluate the safety and efficacy of POEM in children with achalasia cardia Methods The data of all children (< 18 years) who underwent POEM at our center was retrospectively analysed. Symptoms were analysed using a validated score (Eckardt score) at regular predefined intervals. Objective parameters including high-resolution manometry, timed barium swallow and esophagogastroduodenoscopy were assessed before the procedure and at 1-year follow-up. Clinical success was defined as an Eckardt score ≤ 3. Results A total of 15 children underwent POEM during the specified period. Ten out of 15 (10/15) completed 1-year follow-up. Median operative time was 100 (38-240) minutes. Mean pre and post procedure LES pressure were 36.64 ± 11.08 mmHg and 15.65 ± 5.73 mmHg, respectively ( P = 0.001). Mean Eckardt score before and after the POEM was 7.32 ± 1.42 and 1.74 ± 0.67, respectively ( P = 0.001). Mean percentage improvement in barium emptying at 5 minutes was 63.70 ± 4.46%. All children had complete resolution of symptoms at 1 year. Median weight gain of children at 1 year was 0.65 kg (range, 0.0-4.6). Conclusions POEM is safe and effective for children and adolescents with achalasia. Future trials with larger sample size are warranted to establish its efficacy in pediatric AC. [ABSTRACT FROM AUTHOR]

Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) has revolutionized the treatment of many pancreaticobiliary conditions. However, little is known about the global practices, training programs, and credentialing of the procedure. The aim of the current study is to address the above questions. Methods: This was an international cross‐sectional survey conducted between October 2020 and May 2021. Participating countries were requested to complete an online survey on ERCP services and training. Results: Eighty‐nine countries responded to the survey. There were significant increases in the proportion of ERCP services provided by the government (P < 0.0001), number of endoscopists per million of population (P < 0.0001), and number of institutions per million of population (P < 0.0001) from low to high human development index (HDI). Eighteen percent of the countries offer the procedure as part of a standard training program, 68.5% do not follow a standardized training curriculum. Risk factors for higher incidence and mortality from pancreatic cancers include higher HDI category, smaller population, a larger number of endoscopists proficient in ERCP, and lower number of institutions providing ERCP training. Countries with very high HDI have four times higher incidence and mortality from pancreatic cancers as compared to those with low HDI. Conclusions: There is still an ongoing need for improving ERCP training in low to very high HDI countries. A structured training program is still lacking in many parts of the world. With increasing incidence and mortality of pancreatic cancers, particularly in high HDI countries, there is a need for further increasing facilities for ERCP training. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article on the use of the wireless Bravo capsule for analysis of the proximal stomach acid environment.

Background: The progression of chronic pancreatitis (CP), an inflammatory disease of the pancreas, causes pancreatic stones to form within the pancreatic ductal lumen/parenchyma, which occurs via protein plug formation. Pain is the most common symptom that necessitates clinical attention, and pain relief is the therapeutic goal for these patients. Endoscopic therapy and surgery are complimentary forms of therapy for pain relief. This study was envisaged to clarify the mechanism by which protein plug/soft stones form in pancreatic ducts prior to undergoing calcification. Methods: Protein plugs were obtained from twenty CP patients undergoing therapeutic ERCP for stone removal. Pancreatic juice was obtained from five CP patients without stones. Proteins were isolated by TCA/acetone precipitation, SDS PAGE and 2-D gel electrophoresis to determine the protein profile. Protein spots from the 2-D gel were excised and subjected to matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) for identification. The effect of altered pH and elevated concentrations of trypsin on pancreatic juice protein was assessed by SDS‒PAGE to determine the protein profile. Differentially expressed protein bands were excised and subjected to MALDI-TOF. In silico analysis was performed by docking lithostathine with the calcite molecule using AutoDock Vina and PyMOL to clarify their interaction during stone formation. Results: Twenty-three and twenty-nine spots from 2D gels of protein plugs and pancreatic juice, respectively, revealed that lithostathine (Reg1A) was the only protein in the protein plugs, whereas digestive enzymes and lithostathine were identified in pancreatic juice. Altered pH levels and increased trypsin concentrations in the pancreatic juice caused a protein to degrade via an unknown mechanism, and this protein was identified as chymotrypsin C (CTRC) by MALDI-TOF. Docking studies showed that the binding affinity of calcite was higher with the cleaved lithostathine, explaining the deposition of calcium that was observed around the protein plugs after calcified stones were formed through precipitation. Conclusion: Our results suggest that chymotrypsin C (CTRC) is degraded in an acidic environment, leading to the precipitation of lithostathine in the ductal lumen. [ABSTRACT FROM AUTHOR]

Background In clinical practice, decision about management of choledocholithiasis is driven by availability of resources and expertise, patients and healthcare professional preferences. This survey is aimed to describe the approach of physicians and surgeons for the management of choledocholithiasis. Method A 36-question online survey was conducted using Google Forms on various aspects of management of choledocholithiasis. Results The responses from 323 participants were included, of which 202 (62.54%) were physicians and 121 (37.46%) were surgeons. The proportion of responders who do not follow American or European Society of Gastrointestinal Endoscopy guidelines is associated with increasing age and experience of responders (p = 0.0001), while place of work (private vs. teaching) and broad specialty (physician vs surgeon) are not associated (p >0.05). For patients with high likelihood of choledocholithiasis, 123 (38.1%) participants prefer to do endoscopic ultrasound/magnetic resonance cholangiopancreatography (EUS/MRCP) rather than directly performing endoscopic retrograde cholangiopancreatography/intraoperative cholangiography (ERCP/IOC). For intermediate likelihood, MRCP is more commonly preferred compared with EUS, due to local availability (44%), expertise (39.6%), healthcare professionals preference (30.7%), and patients preference (17.3%). For difficult common bile duct (CBD) stones, short biliary sphincterotomy with large balloon sphincteroplasty (59.4%), followed by laparoscopic CBD exploration are commonly used approaches. Prophylactic CBD stent placement after ERCP and CBD clearance is common practice. Preoperative ERCP followed by cholecystectomy is more preferred approach than cholecystectomy and CBD exploration. Conclusion There is considerable variability in the management of choledocholithiasis. The practices such as use of EUS/MRCP for high likelihood group, use of prophylactic CBD stent placement after ERCP and CBD clearance, and use of single stage approach especially in patient with intermediate likelihood group should be addressed in future studies. [ABSTRACT FROM AUTHOR]