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The utilization of graphic novels in the realm of clinical medicine is an infrequent occurrence. However, there is a burgeoning interest in their application across a spectrum of pathological conditions with the ultimate aim of enhancing patient care. This study is a prospective pilot designed to assess the influence of graphic novels on the stress levels and behavioral responses of patients diagnosed with pancreatic lesions and who are to undergo endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). Patients exhibiting radiological and clinical pancreatic lesions needing biopsy will be evaluated consecutively. The inclusion criteria encompass the presence of a solid pancreatic mass or a partially solid mass in the event of a cystic component. The exclusion criteria include patients with cognitive impairments, those currently on benzodiazepines or other psychotropic medications, and those with a prior diagnosis of cancer. The authors have developed a comic panel comprising a sequence of six vibrant vignettes, which delineate the standard procedure of EUS-FNB to the patient. Following hospital admission, patients whomeet the enrolment criteria and consent to participate in the studywill be randomly assigned to either the test or the control group. A graphic novel will be distributed to all patients in the test group, who will have the opportunity to peruse it while awaiting the procedure. Subsequent to the EUS-FNB, all enrolled patients will complete the Beck Anxiety Inventory (BAI) and amodified version of the Depression Anxiety Stress Scales-21 (termed mDASS-21 or mASS-14). The BAI, a 21-itemself-report inventory, is employed to gauge the severity of anxiety in adults. The other questionnaire is a modified rendition of the DASS-21, which originally comprised 21 items segregated into three subscales (anxiety, stress, and depression) with seven items each. The anxiety subscale measures physiological arousal, situational anxiety, and the subjective experience of the effects of anxiety, while the stress subscale assesses chronic non-specific arousal, difficulty relaxing, nervous tension, irritability, agitation, and impatience. [ABSTRACT FROM AUTHOR]

Benign postoperative anastomotic strictures after hepaticojejunostomy are difficult to manage. Before interventional techniques were developed, surgical intervention was the only option for treatment. A 28-year-old man underwent Whipple procedure with Roux-en-Y hepaticojejunostomy for abdominal trauma. Two years later, a late anastomotic biliary stricture was diagnosed. A percutaneous cholangiography showed a severe stricture in the hepaticojejunostomy. Because of the severity and length of the stricture, and the failure of repeated percutaneous balloon-dilations, we percutaneously placed a self-expandable metal stent, a nitinol polytetrafluoroethylene fully covered flared-type stent, 3 cm in length, with 10 mm of diameter. The patient was soon discharged home in good general condition that remained stable in the 6 months of follow up. To remove the biliary stent, we carried out single-balloon enteroscopy. The stent was captured with a standard polypectomy snare. To avoid injury to the mucosa, the stent was removed through the overtube, which remained in situ. Cholangiogram showed a normal biliary tree, with resolution of the anastomotic stenosis. The patient remained stable throughout the 8 months of follow up, and required no further biliary procedures. In cases of failure of standard procedures, this new two-step, combined percutaneous and endoscopic approach can be useful and feasible, avoiding surgery-related morbidity and mortality. However, the fact that these procedures should be carried out only by highly experienced endoscopists and interventional radiologists familiar with these specialized procedures cannot be overstressed. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 86-year-old man diagnosed with tracheoesophageal fistula (TEF) treated using the surgical technique of Amplatzer septal occluder composed of a nitinol mesh.

Background and Aims: Post-surgical biliary leaks (PSBL) are one of the most prevalent and significant adverse events emerging after liver or biliary tract surgeries. Endoscopic retrograde cholangiopancreatography (ERCP) alone or combined with another approach (Rendez Vous) as treatment of PSBL obtains optimal outcomes due to the possibility of modifying the resistances in the biliary tree. Methods: A retrospective double-center study was conducted in two tertiary centers. Consecutive patients who underwent at least one attempt of PSBL correction by ERCP or Rendez Vous procedure between January 2018 and August 2023 were included. The primary outcome was overall endoscopic clinical success. In contrast, the secondary outcomes were hospital stay exceeding five days and endoscopic clinical success with the first endoscopic procedure at the tertiary center. Both univariate and multivariate analyses were used to assess outcomes. Results: 65 patients were included. Patients with one or multiple) leaks had more possibility to achieve the endoscopic clinical success compared to those affected by the association of leaks and stricture (96% vs 67%, p value 0.005). Leaks occurring in the main biliary duct had less probability (67%) to achieve the overall endoscopic clinical success compared to those in the end-to-end anastomosis (90%), in the resection plane or biliary stump (96%) or first or secondary order biliary branches (100%, p value 0.038). A leak-bridging stent positioning had more probability of achieving the endoscopic clinical success than a not leak-bridging stent (91% vs 53%, p value 0.005). Conclusions: ERCP and Rendez Vous procedures are safe and effective for treating PSBL, regardless of the type of preceding surgery, even if technical or clinical success was not achieved on the first attempt. A stent should be placed, if feasible, leak-bridging to enhance treatment efficacy. [ABSTRACT FROM AUTHOR]

Despite the introduction of serological neoplastic biomarkers and typical radiological characteristics in clinical practice, liver biopsy (LB) is often still necessary to establish a histological diagnosis, especially in ambiguous cases. Nowadays, LB via the percutaneous approach (PC-LB), under computed tomography (CT) scan or ultrasonography (US) guidance, is the route of choice. However, certain focal liver lesions can be challenging to access percutaneously. In such cases, endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) may represent an attractive, minimally invasive alternative. This retrospective observational study aimed to evaluate the efficacy, diagnostic performance, and safety of EUS-FNB conducted on 58 focal liver lesions located in both liver lobes. The adequacy of FNB samples for focal liver lesions located in the left and right lobes was 100% and 81.2%, respectively, and the difference was statistically significant (p = 0.001). Technical success was 100% for both liver lobes. The overall sensitivity and specificity were 95% and 100%, respectively. EUS-FNB is effective in making an accurate diagnosis with an excellent safety profile for focal liver lesions located in both liver lobes. [ABSTRACT FROM AUTHOR]

The article discusses the treatment of refractory gastric ulcer bleeding with a new endoloop and clips technique. Many patients suffering from influenza A (H1N1) develop severe acute respiratory distress syndrome (ARDS). The case of a 38-year old woman affected with H1N1 infection and treatment is discussed in the article.

These images involved the case of a 51-year-old woman who had a history of chronic abdominal pain, iron deficiency, and diarrhoea but no blood or mucus in her stool. She had never undergone major abdominal surgery, and her past medical evaluation diagnosed her with celiac disease, leading to the adoption of a gluten-free diet alleviating most of her gastrointestinal symptoms. However, years later, her abdominal pain returned, so she underwent an abdominal ultrasound, revealing non-specific bowel loop dilation, and a weakly positive faecal occult blood test led to a colonoscopy. Despite many efforts to advance the scope beyond the transverse colon, colonoscopy was arduous and not complete, even after several changes in decubitus and abdominal compressions. Therefore, a virtual colonoscopy was conducted, revealing no intraluminal masses, but the entire colon was located on the left side of the abdomen. Indeed, the results showed sigma and that most of the colon was curled up in the small pelvis. This rare anatomical variant, known as "Mesenterium commune" (MC), is a type of gut malrotation that develops in childhood due to a lack of omphalomesenteric loop rotation during the embryonic period. This condition can lead to episodes of intestinal obstruction, potentially resulting in an acute abdomen and leading to surgical correction. Symptoms include chronic recurring abdominal pain, nausea, vomiting, and occasionally bloody stools. Few cases of this extremely rare condition have been reported in the literature so far. [ABSTRACT FROM AUTHOR]

Simple Summary: Palliation of gastric outlet obstruction (GOO) and obstructive jaundice due to malignancy is a fundamental step in improving quality of life (QoL) and initiating or restarting systemic oncologic therapy in these patients. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting is still the primary treatment for malignant biliary obstruction (MBO), but it fails more frequently when GOO is concomitant. Poor quality studies are present in the medical literature on the application of endoscopic ultrasound (EUS) guided procedures among patients suffering from double obstruction, and few studies explore outcomes when endoscopy is performed during the same session or within a few days. Our aim was to systematically search the evidence supporting the use of EUS-guided procedures in this scenario in order to evaluate the best strategy for concomitant treatment of MBO and MGOO. Background: The treatments for cancer palliation in patients with concomitant malignant biliary obstruction (MBO) and gastric outlet obstruction (MGOO) are still under investigation due to the lack of evidence available in the medical literature. We performed a systematic search and critical review to investigate efficacy and safety among patients with MBO and MGOO undergoing both endoscopic ultrasound-guided biliary drainage (EUS-BD) and MGOO endoscopic treatment. Methods: A systematic literature search was performed in PubMed, MEDLINE, EMBASE, and the Cochrane Library. EUS-BD included both transduodenal and transgastric techniques. Treatment of MGOO included duodenal stenting or EUS-GEA (gastroenteroanastomosis). Outcomes of interest were technical success, clinical success, and rate of adverse events (AEs) in patients undergoing double treatment in the same session or within one week. Results: 11 studies were included in the systematic review for a total number of 337 patients, 150 of whom had concurrent MBO and MGOO treatment, fulfilling the time criteria. MGOO was treated by duodenal stenting (self-expandable metal stents) in 10 studies, and in one study by EUS-GEA. EUS-BD had a mean technical success of 96.4% (CI 95%, 92.18–98.99) and a mean clinical success of 84.96% (CI 95%, 67.99–96.26). The average frequency of AEs for EUS-BD was 28.73% (CI 95%, 9.12–48.33). Clinical success for duodenal stenting was 90% vs. 100% for EUS-GEA. Conclusions: EUS-BD could become the preferred drainage in the case of double endoscopic treatment of concomitant MBO and MGOO in the near future, with the promising EUS-GEA becoming a valid option for MGOO treatment in these patients. [ABSTRACT FROM AUTHOR]

Background and Aim: Dedicated studies evaluating the impact of COVID‐19 on outcomes of pancreatobiliary IgG4 related disease (IgG4‐RD) patients are scarce. Whether COVID‐19 infection or vaccination would trigger IgG4‐RD exacerbation remains unknown. Methods: Pancreatobiliary IgG4‐RD patients ≥ 18 years old with active follow‐up since January 2020 from nine referral centers in Asia, Europe, and North America were included in this multicenter retrospective study. Outcome measures include incidence and severity of COVID‐19 infection, IgG4‐RD disease activity and treatment status, interruption of indicated IgG4‐RD treatment. Prospective data on COVID‐19 vaccination status and new COVID‐19 infection during the Omicron outbreak were also retrieved in the Hong Kong cohort. Results: Of the 124 pancreatobiliary IgG4‐RD patients, 25.0% had active IgG4‐RD, 71.0% were on immunosuppressive therapies and 80.6% had ≥ 1 risk factor for severe COVID. In 2020 (pre‐vaccination period), two patients (1.6%) had COVID‐19 infection (one requiring ICU admission), and 7.2% of patients had interruptions in indicated immunosuppressive treatment for IgG4‐RD. Despite a high vaccination rate (85.0%), COVID‐19 infection rate has increased to 20.0% during Omicron outbreak in the Hong Kong cohort. A trend towards higher COVID‐19 infection rate was noted in the non‐fully vaccinated/unvaccinated group (17.6% vs 33.3%, P = 0.376). No IgG4‐RD exacerbation following COVID‐19 vaccination or infection was observed. Conclusion: While a low COVID‐19 infection rate with no mortality was observed in pancreatobiliary IgG4‐RD patients in the pre‐vaccination period of COVID‐19, infection rate has increased during the Omicron outbreak despite a high vaccination rate. No IgG4‐RD exacerbation after COVID‐19 infection or vaccination was observed. [ABSTRACT FROM AUTHOR]

3 Arteriography with splenic artery embolization. a Arteriography, showing a slight and thin irregular sign of extravascular diffusion in the middle side of the splenic artery, next to the pancreatic body. b Embolization of the splenic artery. During his previous hospital stay at another institution, the patient underwent computed tomography scan, gastroscopy, colonoscopy, magnetic resonance imaging, magnetic resonance cholangiopancreatography, endoscopic ultrasound (EUS), and red blood cell scintigraphy. Because of his cardiovascular comorbidities (cardiopathy, atrial fibrillation, and type II diabetes), the patient was on anticoagulation therapy, which was paused after GI bleeding started. [Extracted from the article]

Computed tomography (CT) revealed bilateral lung involvement and a left pulmonary abscess drained by a percutaneous catheter (Fig. 1 Computed tomography scan of the thorax showing SARS-CoV-2-related pneumonia and left pulmonary drainage (red arrow). Percutaneous endoscopic gastrostomy (PEG) was performed, but the patient developed an early buried bumper syndrome [1][2][3][4] after one month, so the tube was removed and gastroscopy showed an unexpected gastric perforation of the fundus (Fig. [Extracted from the article]

Introduction: Exposed endoscopic full thickness resection (EFTR) is a minimally invasive technique that has shown promising efficacy and safety in the removal of both gastrointestinal (GI) submucosal tumors (SMTs) arising from the muscularis propria (MP) and select epithelial tumors (ETs) unsuitable for conventional resection techniques. Given the chance of realizing endosurgical full-thickness suturing, the Endoscopic Suturing System (ESS) can be used to close wall defects in this setting. However, data concerning its use in EFTR are still limited. Aim: This study was conducted to evaluate the safety and efficacy of exposed EFTR with defect closure using the ESS for the removal of both GI SMTs and select ETs unsuitable for conventional resection techniques. Material and methods: This was a retrospective, single-center, observational cohort study of patients who underwent GI exposed EFTR. Results: Seven patients (M: F 6: 1) with a mean age of 56 ±14.5 years were identified. The indications were MP-originating SMTs of the stomach (n = 2) and duodenum (n = 2), and from submucosa of the rectum (n = 1), and 2 ETs of the rectum. Exposed EFTR and defect closure were successfully performed in 6/7 patients. One case was converted to laparoscopic gastric wedge resection due to technical unfeasibility. We performed an R0 resection in all cases, with the exception of 1 case of rectal EFTR. No macroscopic recurrence was detected at 6-month endoscopic follow-up. Conclusions: GI exposed EFTR with defect closure by the ESS appears to be feasible, effective, and safe in referral centers. Further studies are necessary to clarify the role of the ESS for post-EFTR wall defect closure. [ABSTRACT FROM AUTHOR]

Introduction: Gastrointestinal bleeding is a life-threatening complication in patients undergoing extracorporeal membrane oxygenation support. Despite data on increased mortality due to gastrointestinal bleeding, there is little data on the treatment of such conditions under extracorporeal membrane oxygenation, and on the possibilities of advanced endoscopic therapy to non-invasively solve these bleeding complications. No clear treatment in the case of extracorporeal membrane oxygenation support is recommended in the guidelines. Methods: Retrospective observational cohort study including 134 veno-venous extracorporeal membrane oxygenation patients for acute respiratory failure from 2009 to 2018 at IRCCS-ISMETT (Italy). Patients were divided into two groups according to gastrointestinal bleeding episodes and reviewed for type of endoscopic therapy. Gastrointestinal bleeding group was characterized for pre–extracorporeal membrane oxygenation characteristics, management variables—including amount of transfusions and clinical outcomes. Results: Fourteen (14) patients (10.4%) experienced upper (n = 13) or lower (n = 1) gastrointestinal bleeding. Gastrointestinal bleeding and no-gastrointestinal bleeding group had similar characteristics apart from higher creatinine in the gastrointestinal bleeding group (1.9 mg/dL (1.3-4.9) vs 1.2 mg/dL (0.7-1.8), p = 0.03). In 3 of the 14 patients (21%), endoscopy showed no signs of active bleeding (nasogastric or feeding tube decubitus), and no specific intervention was performed. Active bleeding was recognized in 11 of the 14 patients (79 %). No patients died of fatal bleeding in the gastrointestinal bleeding group. Endoscopic therapy was feasible, with a complete bleeding control in all the cases: five Hemospray®, two fibrin glue, two metallic clips, one combined approach metallic clips with epinephrine, and one cyanoacrylate. The extracorporeal membrane oxygenation course was significantly longer in the gastrointestinal bleeding group: 19.5 (15-36) days vs 13.5 (8-25) days, p = 0.01. No significant differences in mortality were found between the two groups (all p values > 0.05). Conclusion: Advanced endoscopic therapy during veno-venous extracorporeal membrane oxygenation may contribute to reducing the negative effects on mortality for gastrointestinal bleeding episodes. [ABSTRACT FROM AUTHOR]

Background and Aims: Post-GI surgical wall defects are frequent and life-threatening complications, with limited literature regarding current treatment. This case series aims to assess the safety, feasibility, and outcomes of endoluminal therapy with the overstitch endoscopic suturing system (Apollo Endosurgery Inc, Austin).Materials and Methods: All patients who underwent endoscopic suturing for post-surgical wall defect management at IRCCS-ISMETT Palermo from October 2017 until January 2019 were retrospectively enrolled. Stratification therapy was applied according to the clinical scenario, time from surgery to endoscopic intervention, and structural condition of the wall defect layers (tissue status and suture feasibility). The therapeutic endoscopic strategy was divided into three groups (A: pure endoscopic direct suture; B: combined therapy with endoscopic direct suture + FC-SEMS placement + anchoring; C: FC-SEMS placement + anchoring). Success was considered the resolution of symptoms and the presence of a regular intestinal transit after a period of 4-6 weeks.Results: Twenty (20) patients (male/female 7/13; mean age 54 ± 13.43 years) were included in the study (group A: 9 patients, group B: 7 patients, group C: 4 patients). The types of operative procedures were bariatric (9/20), post-tracheostomy (3/20), post-operative GI surgery (8/20). The post-surgical defects were predominantly intermediate and chronic (24-72 h: 1/20; 3-30 days: 13/20; > 30 days: 6/20). The overall clinical success was 80% (17/20 patients), with a success of 94% (16/17 patients) when excluding the three cases of tracheo-esophageal fistula. No evidence of migration was detected. The only complication was short stenosis of the distal esophagus, present in 4 patients (19%) and successfully treated with a novel lumen-apposing metal stent.Conclusions: In our experience, considering the absence of clear guidelines, the endoluminal approach with the overstich endoscopic suturing system is a valid alternative to conventional therapy, offering mini-invasiveness, and presenting promising opportunities in terms of technical feasibility and clinical efficacy. [ABSTRACT FROM AUTHOR]

The article describes a case of esophagojejunal anastomotic dehiscence successfully repaired by endoluminal suture and stent positioning in a 32-year-old man who complained of acute abdominal pain and severe sepsis following a laparoscopic wedge resection of the stomach for his gastrointestinal stromal tumor. Topics include a description of how the procedure is performed to treat the man's dehiscence and abscess and the complete resolution of his condition one month after removing his stent.

Combined endoscopical treatments for tracheo-esophageal fistula developed during V-V ECMO for severe COVID-19: A case series Keywords: Covid-19; ECMO; endoscopy; SARS-CoV 2; tracheo-esophageal fistula EN Covid-19 ECMO endoscopy SARS-CoV 2 tracheo-esophageal fistula 506 508 3 03/02/22 20220301 NES 220301 INTRODUCTION Patients affected with acute respiratory distress syndrome due to Covid-19 may require veno-venous extracorporeal membrane oxygenation (V-V ECMO), often undergoing tracheostomy.1,2 Tracheo-esophageal fistula (TEF) can develop as an immediate or late complication of tracheostomy, and can be enhanced by several conditions coexisting in severe Covid-19, such as malnutrition, soft tissue hypo-perfusion, need for high-dose vasopressors, mechanical damage during prone position, long hospitalization and ventilation, and long presence of nasogastric tubes.3 Furthermore, TEF can be dramatic in these patients since it may potentially progress to a mediastinitis, worsening the outcomes. CASE SERIES We experienced four cases of TEF among our first 36 tracheostomized patients on V-V ECMO during the COVID-19 second wave, between October, 2020 and May, 2021 (Table 1). [Extracted from the article]

The article presents a case study of a 77-year-old man with pancreatic head cancer who underwent duodeno-cephalo-pancreatectomy and Roux-en-Y reconstruction. He developed recurrent cholangitis with obstructive jaundice after two years in which percutaneous transhepatic cholangiography (PTC) was attempted.

Background: Biliary complications are a serious source of morbidity after orthotopic and living-related liver transplantation. Endoscopic retrograde cholangiography (ERC) is the gold standard for patients with duct-to-duct anastomosis because it allows a direct approach for interventional procedures. A retrospective study showed results of a sequential multistenting protocol, without stent removal/exchange, with promising results. We conducted a prospective analysis to assess the clinical success, recurrence rate, and adverse event rate related to this protocol.Methods: From May 2012 to April 2018, all consecutive patients with a diagnosis of anastomotic stenosis following liver transplantation were enrolled in the study, and were followed for a period of at least 6 months after the last ERC. During the first ERC, a maximum number of plastic stents (10 Fr) were placed. In subsequent ERCs, scheduled every 3 months up to a maximum of 1 year, additional stents were inserted, as many as possible, without removing the previously placed stents.Results: From May 2012 to May 2018, 87 patients were included in the study and treated with a sequential multistenting protocol. The mean number of stents placed was 3.7 (SD 1.0). Clinical success (stricture resolution and normalization of cholestasis) was achieved in 86 patients (98.9 %). Seven patients (8.0 %) developed complications. Recurrence was recorded in seven patients (8.0 %) after a mean of 992.7 days (SD 622.1).Conclusions: This study represents the first prospective demonstration of the efficacy and safety of a sequential multistenting protocol. A key limitation of the study is the lack of a comparative group treated according to the traditional stent exchange approach. [ABSTRACT FROM AUTHOR]

Background: The most appropriate endo‐therapeutic approach to biliary anastomotic strictures is yet to be defined. Aim: To retrospectively report on the endo‐therapy of duct‐to‐duct anastomotic strictures during 2013 in Italy. Methods: Data were collected from 16 Endoscopy Units at the Italian Liver Transplantation Centers (BASALT study group). Results: Complete endo‐therapy and follow‐up data are available for 181 patients: 101 treated with plastic multistenting, 26 with fully covered self‐expandable metal stenting and 54 with single stenting. Radiological success was achieved for 145 patients (80%), that is, 88% of plastic multistenting, 88% of self‐expandable metal stenting and 61% of single stenting (P < 0.001 vs plastic multistenting; P < 0.05 vs self‐expandable metal stenting). After first‐line endo‐therapy failure, the patients underwent a second‐line endo‐therapy with plastic multistenting for 25%, fully covered self‐expandable metal stenting for 53% and single stenting for 22% of cases, and radiological success was achieved for 84%, that is, 100%, 85% and 63% with plastic multistenting, self‐expandable metal stenting and single stenting (P < 0.05 vs plastic multistenting or self‐expandable metal stenting) respectively. Procedure‐related complications occurred in 7.8% of endoscopic retrograde cholangiopancreatographies. Overall, clinical success was achieved in 87% of patients after a median follow‐up of 25 months. Conclusion: Plastic multistenting is confirmed as the preferred first‐line treatment, while fully covered self‐expandable metal stenting as rescue option for biliary anastomotic strictures. Single stenting has sub‐optimal results and should be abandoned. See Editorial on Page 1197 [ABSTRACT FROM AUTHOR]

Background Anastomotic biliary strictures (ABS) following liver transplantation (LT) are one of the most common complications, occurring in 4.5-32% of patients. Multiple plastic stenting (MPS) requires multiple sessions, with the associated risk, cost and patient discomfort. Fully covered selfexpandable metal stents (FC-SEMS) have increasingly been used in this setting. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs), comparing the role of FC-SEMS and MPS in the treatment of ABS post-LT. Methods We conducted a bibliographic search using PubMed and EMBASE, aimed at identifying available RCTs that compared MPS to FC-SEMS in patients with ABS post LT from January 2000 to October 2017. Primary outcomes were ABS resolution and recurrence, while secondary outcomes were adverse events and number of procedures performed. Pooled estimates were calculated using random-effects models. Results Four RCTs (205 patients) were included. ABS resolution and recurrence did not differ significantly between the groups (odds ratio [OR] 1.05, 95% confidence interval [CI] 0.43-2.56, P=0.92; and OR 2.37, 95%CI 0.54-10.38, P=0.25). The same was true for adverse events (OR 0.91, 95%CI 0.84-3.48, P=0.86) and migration rate (OR 1.31, 95%CI 0.46-3.71, P=0.61). The mean number of endoscopic retrograde cholangiopancreatography procedures was lower for FC-SEMS (mean difference [MD] -2.08). Conclusions FC-SEMS and MPS had equal ABS resolution and recurrence, although there was a trend towards a higher recurrence rate in FC-SEMS that disappeared when trials with a shorter stent indwelling time were excluding. No difference was found in overall adverse events or migration rate. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 48-year-old man who was diagnosed with pancreatic lymphoepithelial cyst through needle biopsy. It notes the patient had an asymptomatic pancreatic neck hypodense lesion, with inhomogeneous slight contrast enhancement. The article discusses the rarity of pancreatic lymphoepithelial cysts with no peculiar morphological characteristics that can help in distinguishing them from other more common forms.

Background and Aim: Tissue acquisition in pancreatic cystic lesions (PCL) is the ideal method for diagnosis and risk stratification for malignancy of these lesions. Direct sampling from the walls of PCL with different devices has shown better results than cytology from cystic fluid. We carried out a retrospective, multicenter study to evaluate the feasibility, safety, and diagnostic yield of a micro‐forceps, specifically designed to be used through a 19‐gauge needle after endoscopic ultrasonography (EUS)‐guided puncture of PCL. Methods: We retrospectively collected data from patients who underwent EUS‐through‐the‐needle biopsy (EUS‐TTNB) in PCL at six referral centers. Results: The sampling procedure was carried out in 56 patients (mean age 57.5 ± 13.1 years, M:F 17:39), and was technically successful in all of them (100%; 95% confidence interval [CI], 94–100%). Adverse events occurred in 9/56 (16.1%; 95% CI, 8–28%) patients, with self‐limited intracystic hemorrhage the most common (7/56, 12.5%; 95% CI, 5–24%). All adverse events were mild, and resolved without any specific intervention. Specimens were considered adequate for histological diagnosis in 47/56 (83.9%; 95% CI, 72–92%). In two of these patients, despite the histological adequacy, a diagnosis could not be reached. In two other cases, a specimen sufficient for a cytological diagnosis was obtained. Overall diagnostic yield by combining cytological and histological samples was 47/56 (83.9%; 95% CI, 72–92%). Conclusion: EUS‐TTNB with micro‐forceps in PCL is feasible, safe, and has a high diagnostic yield. Future prospective studies are needed to better assess the clinical impact of EUS‐TTNB on the management of PCL. [ABSTRACT FROM AUTHOR]

We therefore decided to perform the revision without removing the stent, and instead inserted the endoscope parallel to the stent, into the space between the stent and the wall (Video 1). In conclusion, moving the endoscope alongside the stent appeared to be feasible and safe after appropriate stent fixation, thus avoiding the need to remove a well-positioned stent. 3 Endoscopic examination with the stent in place. a Endoscopic view of the space next to the stent (white arrow), which the endoscope explored moving in parallel to the stent. [Extracted from the article]

The histology on the hilar tissue identified inflammatory tissue without any sign of dysplasia/neoplasia, compatible with a foreign body reaction. 1 Computed tomography scan showing dilation of intrahepatic bile ducts and nodular hilar tissue (red circle). The patient fully recovered after removal of biliary drainage, and the cholangiography showed a more regular hilar biliary tree with normal bile and contrast outflow. [Extracted from the article]

The article presents the case study of a 50-year-old woman with rectal tumor. The patient underwent ultra-low rectal endoscopic submucosal dissection using a high-definition narrowband endoscope with submucosal injection of saline mixed with diluted indigocarmine and epinephrine. The patient suffered multifocal bleeding, however it was successfully controlled with hemospray.

Purpose: Hepatitis C virus (HCV) predominantly infects hepatocytes, although it is known that receptors for viral entry are distributed on a wide array of target cells. Chronic HCV infection is indeed characterized by multiple non-liver manifestations, suggesting a more complex HCV tropism extended to extrahepatic tissues and remains to be fully elucidated. In this study, we investigated the gastrointestinal mucosa (GIM) as a potential extrahepatic viral replication site and its contribution to HCV recurrence. Methods: We analyzed GIM biopsies from a cohort of 76 patients, 11 of which were HCV-negative and 65 HCV-positive. Of these, 54 biopsies were from liver-transplanted patients. In 29 cases, we were able to investigate gastrointestinal biopsies from the same patient before and after transplant. To evaluate the presence of HCV, we looked for viral antigens and genome RNA, whilst to assess viral replicative activity, we searched for the replicative intermediate minus-strand RNA. We studied the genetic diversity and the phylogenetic relationship of HCV quasispecies from plasma, liver and gastrointestinal mucosa of HCV-liver-transplanted patients in order to assess HCV compartmentalization and possible contribution of gastrointestinal variants to liver re-infection after transplantation. Results: Here we show that HCV infects and replicates in the cells of the GIM and that the favorite hosts were mostly enteroendocrine cells. Interestingly, we observed compartmentalization of the HCV quasispecies present in the gastrointestinal mucosa compared to other tissues of the same patient. Moreover, the phylogenetic analysis revealed a high similarity between HCV variants detected in gastrointestinal mucosa and those present in the re-infected graft. Conclusions: Our results demonstrated that the gastrointestinal mucosa might be considered as an extrahepatic reservoir of HCV and that could contribute to viral recurrence. Moreover, the finding that HCV infects and replicates in neuroendocrine cells opens new perspectives on the role of these cells in the natural history of HCV infection. [ABSTRACT FROM AUTHOR]

Background: Early detection of small pancreatic cancer is important because expected survival is markedly better for tumors ≤2 cm. A new endoscopic ultrasound-(EUS) guided biopsy needle with side fenestration has been recently developed to enable fine-needle biopsy (FNB) under EUS guidance. The aim of this study was to evaluate the outcome of EUS-FNB using a 22-gauge ProCore needle in solid pancreatic lesions ≤2 cm, in terms of diagnostic accuracy and yield. Methods: From January 2011 to December 2012, all consecutive EUS-guided tissue sampling of small pancreatic lesions (≤2 cm) were performed using 22-gauge ProCore needles; the data of these patients were analyzed retrospectively. Results: Sixty-eight patients with a mean age of 65.7 years were included. The mean lesion size was 16.5 mm (range 5-20). None of the patients developed complications. On pathological examination, the tissue retrieved was judged adequate in 58 out of 68 cases (85.3 %) and the presence of a tissue core was recorded in 36 out of 68 cases (52.9 %). The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 80, 100, 100, 40, and 82 %, respectively. Conclusion: Our results suggested that EUS-FNB of small pancreatic lesions using a 22-gauge ProCore needle is effective and safe, and supports our hypothesis that EUS-FNB is highly useful in establishing the nature of small pancreatic lesions. [ABSTRACT FROM AUTHOR]

A blog related to the accuracy of endoscopic transpapillary sampling methods related to bile duct cancer is presented.

Introduction: Gastric outlet obstruction is a clinical syndrome caused by a variety of mechanical obstructions. Peptic ulcer disease used to be responsible for most gastric outlet obstruction, but in the last 40 years the prevalence of malignant tumors has risen significantly. Adhesive disease is an infrequent and insidious cause of mechanical gastric outlet obstruction.Case Presentation: We report the case of a 78-year-old Caucasian man who had a clinical history of a right nephrectomy for malignancy three years earlier and who was admitted for a severe gastric outlet obstruction (score of 1) confirmed both by an upper endoscopy and by a fluoroscopic view after contrast injection. A computed tomography scan and a laparotomy, with omental biopsies, showed a peritoneal carcinomatosis with the development of abdominal adhesions that prompted an abnormal gastric rotation around the perpendicular axis of his antrum with a dislocation in the empty space of his right kidney. Symptoms disappeared after surgical bypass through a gastrojejunostomy.Conclusions: Our patient experienced a very rare complication characterized by the development of adhesions due to peritoneal carcinomatosis caused by a renal carcinoma treated with nephrectomy. These adhesions prompted an abnormal dislocation of his antrum, as an internal hernia, in the empty space of his right kidney. [ABSTRACT FROM AUTHOR]

The article presents a case study of an 81-year-old woman who was diagnosed with pancreatic adenocarcinoma and provides details of the endoscopic ultrasound (EUS)-guided gastroenterostomy.

Background: Liver involvement, including elevated direct-reacting bilirubin levels, is common in patients with sickle cell disease. Fifty to seventy percent of sickle cell patients have pigmented gallstones due to precipitation of unconjugated bilirubin, and cholelithiasis or choledocholithiasis are common complications. The highest prevalence of these complications occurs in patients with Gilbert's syndrome because of the combined effect of increased bilirubin production and reduced bilirubin-diphosphate-glucuronosyltransferase enzyme activity. Cholelithiasis is also a common complication in patients with thalassemia. Endoscopic removal of choledochal stones does not always resolve the clinical picture, as in cases of dysfunction of the Vater's papilla, increased bile density due to persistently impaired bile flow or distortion of the choledocus due to dilatation, or inflammation secondary to gallstone. Case presentation: We report here a case of severe and persistent obstructive jaundice in a child affected with thalassodrepanocytosis and Gilbert's syndrome, previously, and unsuccessfully, treated with endoscopic removal of choledochal stones. Deep and thorough biliary washing, and stenting with a new removable polytetrafluoroethylene (PTFE)-covered flared-type stent led to complete resolution of the obstructive jaundice. Conclusions: This report shows that an aggressive endoscopic approach in this select category of patients can help resolve the severe complication of hemolytic anemia, thus avoiding surgery. [ABSTRACT FROM AUTHOR]

We report two cases of severe postsphincterotomy bleeding in an adult and a pediatric patient treated, as first options, with available techniques to induce hemostasis without success. Because of persisting bleeding, an expandable, partially covered, metallic stent was placed into the choledocho to mechanically compress the bleeding site. The bleeding was stopped. In the following days, both patients remained hemodynamically stable with no further episodes of bleeding. We believe that the application of a covered metallic stent in a severe postendoscopic-sphincterotomy bleeding, refractory to injection therapy, should be considered to avoid additional interventions, which carry a higher risk of complications, even in pediatric patients. [ABSTRACT FROM AUTHOR]

A comparative food ethnobotanical study was carried out in twenty-one local communities in Italy, fourteen of which were located in Northern Italy, one in Central Italy, one in Sardinia, and four in Southern Italy. 549 informants were asked to name and describe food uses of wild botanicals they currently gather and consume. Data showed that gathering, processing and consuming wild food plants are still important activities in all the selected areas. A few botanicals were quoted and cited in multiple areas, demonstrating that there are ethnobotanical contact points among the various Italian regions (Asparagus acutifolius, Reichardia picroides, Cichorium intybus, Foeniculum vulgare, Sambucus nigra, Silene vulgaris, Taraxacum officinale, Urtica dioica, Sonchus and Valerianella spp.). One taxon (Borago officinalis) in particular was found to be among the most quoted taxa in both the Southern and the Northern Italian sites. However, when we took into account data regarding the fifteen most quoted taxa in each site and compared and statistically analysed these, we observed that there were a few differences in the gathering and consumption of wild food plants between Northern and Southern Italy. In the North, Rosaceae species prevailed, whereas in the South, taxa belonging to the Asteraceae, Brassicaceae, and Liliaceae s.l. families were most frequently cited. We proposed the hypothesis that these differences may be due to the likelihood that in Southern Italy the erosion of TK on wild vegetables is taking place more slowly, and also to the likelihood that Southern Italians' have a higher appreciation of wild vegetables that have a strong and bitter taste. A correspondence analysis confirmed that the differences in the frequencies of quotation of wild plants within the Northern and the Southern Italian sites could be ascribed only partially to ethnic/cultural issues. An additional factor could be recent socio-economic shifts, which may be having a continued effort on people's knowledge of wild food plants and the way they use them. Finally, after having compared the collected data with the most important international and national food ethnobotanical databases that focus on wild edible plants, we pointed out a few uncommon plant food uses (e.g. Celtis aetnensis fruits, Cicerbita alpine shoots, Helichrysum italicum leaves, Lonicera caprifolium fruits, Symphytum officinale leaves), which are new, or have thus far been recorded only rarely. [ABSTRACT FROM AUTHOR]

UGI series showed marked paresis and atony of the remnant conduit stomach, with prolonged transit time and severe stagnation (Fig. B Video 1 b Postsurgical chronic gastroparesis successfully treated with a novel mini-invasive approach: full-thickness gastric plication using the Overstitch endoscopic suturing system. Gastrectomy versus stomach left in situ with Roux-en-Y reconstruction for the treatment of gastroparesis. [Extracted from the article]

None A 25-year-old woman was referred to our institute for evaluation of an incidental gastric submucosal tumor (SMT) located in the anterior wall of the antrum, proximal to the incisura angularis (Fig. 3 Endoscopic peritoneal exploration revealed an extraluminal growth pattern of the tumor (asterisk: lesion; red dashed line: free-hand cutting line) and its close contact with the left liver lobe (blue dashed line). A step-up approach consisting of standard EFTR followed, if necessary, by laparoscopic resection or laparoscopy-assisted EFTR within the same operative session appears promising in the management of selected cases of gastric SMT. [Extracted from the article]

Focuses on a study which assessed the effectiveness of beta-blockers and endoscopic sclerotherapy in the prevention of first bleeding and reduction of mortality in patients with cirrhosis and esophagogastric varices. Study selection; Data extraction; Data synthesis; Methods; Conclusion.

A 46-year-old man with end-stage renal disease and a surgical history of three kidney transplants underwent colonoscopy to assess eligibility for retransplantation. Colonic perforations are potentially life-threatening complications of both diagnostic and therapeutic colonoscopies, with a reported incidence of 0.03 % - 0.8 % and up to 5 %, respectively [1]. [Extracted from the article]

A computed tomography (CT) scan with hydrosoluble contrast agent showed dislocation of the bumper into the transverse colon, with bowel opacification, due to the presence of a gastrocolic fistula. At the end of the procedure, contrast radiography found no leak of contrast from the colonic side of the fistula; the cutaneous side of the fistula healed by secondary intention. [Extracted from the article]

Curcio G, Sciveres M, Mocciaro F, Riva S, Spada M, Tarantino I, Barresi L, Traina M. Out-of-reach obscure bleeding: Single-balloon enteroscopy to diagnose and treat varices in hepaticojejunostomy after pediatric liver transplant. Abstract: Obscure gastrointestinal (GI) bleeding is defined as bleeding from the GI tract that persists or recurs, with no obvious etiology, after esophagogastroduodenoscopy (EGD), colonoscopy, and radiologic evaluation of the small bowel. We present the case of a 17-yr-old girl who for two years had been suffering from recurrent episodes of melena and/or enterorrhagia. Fifteen yr earlier she had undergone a split-liver transplant with Roux-en-Y biliary reconstruction. A series of endoscopic and radiologic investigations had failed to find the source of the bleeding. Suspecting the presence of ectopic varices, we decided to perform single-balloon enteroscopy (SBE). We observed and aspirated a large amount of fresh red blood in the afferent loop until we found the hepaticojejunostomy. On the edge of the biliary-enteric anastomosis we observed a vascular lesion 5 mm in diameter. Judging this ectopic varix to be the source of bleeding, we placed two endoclips. The second clip placement caused varix rupture with a consequent massive hemorrhage, emergently and successfully treated with cyanoacrylate sclerotherapy. No episodes of rebleeding were observed, and no complications occurred during the entire hospital stay, and after six months of follow-up. This report highlights the importance of afferent loop examination in patients with obscure GI bleeding who have undergone liver transplant with Roux-en-Y biliary reconstruction. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which describes surgical approaches to treating patients with biliary cystadenoma of the liver.

We report a case of a post-transplant patient with hepaticojejunostomy in whom we used a single balloon enteroscopy to access the biliary tree. This procedure seems to be safe and feasible for approaching the biliary anastomosis by means of the overtube and fixation of the small bowel by the balloon. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 25-year-old woman with a history of Barrett’s esophagus with dysplasia, who underwent mini-invasive endoscopic treatment using OverStitch, a novel endoluminal suturing system, for “Candy cane” syndrome.

The article presents a case study of a 70-year-old woman who underwent endoscopic ultrasound-guided gallbladder drainage with a lumen-apposing metal stent in malignant distal biliary obstruction.

The article presents the case study of a 36-year-old Asian man with severe portal hypertension due to hepatitis B virus-related cirrhosis, who underwent endoscopic ultrasound (EUS)-guided angiotherapy.