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Background: Antireflux mucosectomy, a new endoscopic treatment for gastroesophageal reflux disease, consists of endoscopic mucosal resection at the esophagogastric junction. This study aim was to evaluate the medium-term efficacy of the antireflux mucosectomy technique for patients with severe gastroesophageal reflux disease symptoms (proton pump inhibitor treatment-dependent or proton pump inhibitor treatment-resistant gastroesophageal reflux disease)., Methods: Between January 2017 and June 2018, 13 patients with severe gastroesophageal reflux disease without hiatal hernia, with positive pH reflux, were included in this monocentric prospective pilot study. The primary outcome was clinical success, defined by improvement evaluated by the Gastroesophageal Reflux Disease Health Related Quality of Life Questionnaire at 24 months. Secondary outcomes were technical success, decreased use of proton pump inhibitors, patient satisfaction, and adverse events., Results: Thirteen patients [females = 8 (62%)], mean age 59 (range, 54-68), were included. The antireflux mucosectomy procedure had technical success in all patients. At 24 months, for 11 patients, gastroesophageal reflux disease symptoms were significantly improved, and mean gastroesophageal reflux disease score decreased from 33 (range, 26-42) to 3 (range, 0-7) (p = 0.001). Ninety-one percent ( n = 10) of patients had a lower proton pump inhibitor intake at 24 months. One patient had 3 endoscopic balloon dilatations for EGJ stenosis, two patients had melena ten days after procedure, and seven patients had thoracic or abdominal pain. Patient's satisfaction at 24 months was 81%., Conclusions: In patients with severe gastroesophageal reflux disease, despite occurrence of several short-term adverse events, antireflux mucosectomy seemed effective in improving gastroesophageal reflux disease symptoms at 24 months. This trial is registered with ClinicalTrials: NCT03357809., Competing Interests: The authors declare that there is no conflict of interest regarding the publication of this paper., (Copyright © 2022 Arthur Laquière et al.)

Background: During endoscopic retrograde cholangiopancreatography (ERCP), access to the common bile duct (CBD) can be problematic after unintentional insertion of the guidewire into the pancreatic duct. We conducted a prospective, randomized study in order to compare biliary cannulation success rates of early double-guidewire (EDG) and repeated single-guidewire (RSG) techniques in patients with inadvertent passage of the guidewire into the pancreatic duct., Methods: Patients with a native papilla were randomly assigned to either the EDG or RSG groups after unintentional insertion of the guidewire into the pancreatic duct. The primary outcome was successful selective CBD cannulation within 10 minutes. The secondary outcomes were successful final selective bile duct cannulation, time to bile duct cannulation, and frequency of post-ERCP pancreatitis (PEP)., Results: 142 patients were randomized and selective bile duct cannulation was achieved in 57/68 patients (84 %) in the EDG group and in 37/74 patients (50 %) in the RSG group within 10 minutes (relative risk 1.34; 95 % confidence interval 1.08-6.18; P  < 0.001). The overall final selective bile duct cannulation rate was 99.3 %. The time to access the CBD was shorter using the EDG technique (6.0 vs. 10.4 minutes; P  = 0.002). Mild PEP was not observed more frequently in the EDG group than in the RSG group., Conclusion: The EDG technique significantly increased the success rate of biliary duct cannulation within 10 minutes compared with an RSG approach., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Objectives: A single-use duodenoscope (SUD) has been recently developed to overcome issues with endoscopic retrograde cholangiopancreatography (ERCP)-related cross-infections. The aim was to evaluate SUD safety and performance in a prospective multi-centre study., Methods: All consecutive patients undergoing ERCP in six French centers were prospectively enrolled. All procedures were performed with the SUD; in case of ERCP failure, operators switched to a reusable duodenoscope. Study outcomes were the successful completion of the procedure with SUD, safety and operators' satisfaction based on a VAS 0-10 and on 22 qualitative items. The study protocol was approved by French authorities and registered (ID-RCB: 2020-A00346-33). External companies collected the database and performed statistical analysis., Results: Sixty patients (34 females, median age 65.5 years old) were enrolled. Main indications were bile duct stones (41.7%) and malignant biliary obstruction (26.7%). Most ERCP were considered ASGE grade 2 (58.3%) or 3 (35.0%). Fifty-seven (95.0%) procedures were completed using the SUD. Failures were unrelated to SUD (one duodenal stricture, one ampullary infiltration, and one tight biliary stricture) and could not be completed with reusable duodenoscopes. Median operators' satisfaction was 9 (7-9). Qualitative assessments were considered clinically satisfactory in a median of 100% of items and comparable to a reusable duodenoscope in 97.9% of items. Three patients (5%) reported an adverse event. None was SUD-related., Conclusions: The use of a SUD allows ERCP to be performed with an optimal successful rate. Our data show that SUD could be used for several ERCP indications and levels of complexity., (© 2021 Japan Gastroenterological Endoscopy Society.)

Background and study aims  Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) for pancreatic neuroendocrine tumors (NETs) and intraductal pancreatic mucinous neoplasia (IPMN) with worrisome features or high-risk stigmata (WF/HRS) has been evaluated in few series with short-term outcomes. This study's primary endpoint was to assess the long-term efficacy of EUS-RFA in patients with NETs or pancreatic cystic neoplasms (PCNs) over at least 3 years. Patients and methods  Twelve patients had 14 NETs with a mean 13.4-mm size (10-20) and 17 patients had a cystic tumor (16 IPMN, 1 MCA) with a 29.1-mm mean size (9-60 were included. They were treated with EUS-guided RFA, evaluated prospectively at 1 year, and followed annually for at least 3 years. Results  The mean duration of follow-up was 42.9 months (36-53). Four patients died during follow-up (17-42 months) from unrelated diseases. At 1-year follow-up, and 85.7 % complete disappearance was seen in 12 patients with 14 NETs. At the end of follow-up (45.6 months), complete disappearance of tumors was seen in 85.7 % of cases. One case of late liver metastasis occurred in a patient with initial failure of EUS-RFA. At 1-year follow-up, a significant response was seen in 70.5 % of 15 patients with PCNs. At the end of the follow-up, there was a significant response in 66.6 % with no mural nodules. Two cases of distant pancreatic adenocarcinoma unrelated to IPMN occurred. Conclusions  EUS-RFA results for pancreatic NETs or PCNs appear to be stable during 42 months of follow-up., Competing Interests: Competing interests Dr. Barthet received a research grant from Boston scientific (endoscopic gastrojejunal anastomosis). Dr. Napoleon is a consultant for Boston Scientific., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background and Study Aims: Large scale data on esophagogastroduodenoscopy (EGD) in Western countries are scarce. We conducted a prospective study on the diagnostic yield of upper gastrointestinal endoscopy in France., Patients and Methods: An online questionnaire was sent to all French gastroenterologists practicing endoscopy. Data from EGDs performed during one week were collected. A statistical extrapolation of the results to a whole year was performed., Results: 342 gastrointestinal endoscopists, representative of the population of French gastroenterologists, provided data on 2735 EGDs, corresponding to 1 006 316 (95%CI=937 080-1 075 552) procedures for the entire year. 1770 (64.7%) EGDs were performed under sedation or general anesthesia, and 930 (34%) were associated with a colonoscopy. 896 (32.8%) EGDs were normal. Hiatal hernia and esophagitis were the most frequent esophageal diagnoses, in 496 (18.1%) and 374 (13.7%) cases, respectively. Barrett's esophagus was diagnosed in 109 (4%) patients. Among gastric lesions, endoscopic gastritis was reported in 572 (20.9%) patients; ulcer, polyps, and suspected malignancy in 78 (2.9%), 62 (2.3%), and 19 (0.7%), respectively. 1597 (58.4%) EGDs included mucosal biopsies, and 141 (5.1%) were associated with a therapeutic procedure., Conclusions: We report nationwide prospective data on upper gastrointestinal endoscopy practice in France. Our data suggest that about 300 000 normal EGDs each year in France could potentially be avoided by a diagnostic strategy relying on upper GI capsule endoscopy, providing significant relief on healthcare practitioners., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objectives: Peroralcholangio-pancreatoscopy (POCP) is used for diagnosis and treatment of biliopancreatic disease when standard endoscopy (ERCP) or pre-operative imaging workup failed. We aimed to evaluate the diagnostic and therapeutic performance of POCP in complex biliary and pancreatic diseases., Materials and Methods: Patients with indeterminate biliary or pancreatic duct (PD) strictures, and patients with failure of complex biliary or pancreatic stones removal, were enrolled (six centers). The primary endpoint evaluated malignancy diagnostic performances (accuracy, sensitivity, specificity) and therapeutic performances (biliary or pancreatic stones extraction). Secondary endpoints evaluated: technical success in lesion visualization, ease of maneuvering, image quality and 30-days complications., Results: From November 2016 to March 2018, 66 patients were included: 29/37 women/men, median age (IQR): 73 (64-82). Fifty-three patients had diagnostic POCP and 13 patients therapeutic POCP. One endoscopist with one or two endoscopy nurses performed 94% of the POCP. The 'POCP visual impression' of malignancy showed 92.0% sensitivity, 92.9 % specificity and 92.5 % overall accuracy compared with the final diagnosis. 'POCP-guided samples histological analysis' showed 75.0 % sensitivity and 91.6% specificity. The technical success for lesion visualization was 98.5%. The median VAS scores for insertions in bile and PD were respectively 9.0 (8.1-9.6) and 9.0 (8.8-10.0). Median VAS score for access to the lesion and image quality were respectively 9.0 (7.7-9.6) and 9.0 (7.9-9.7). Only three 30-day minor complications occurred without any major complications., Conclusions: POCP was an effective, safe and easy-to-use tool in routine clinical practice for the management of complex diagnostic and therapeutic biliary and pancreatic diseases (NCT03190343).

Background: The aim of the study was to describe the clinical and endoscopic characteristics and management of severe acute gastrointestinal (GI) bleeding in patients treated with direct oral anticoagulants (DOACs)., Methods: Patients hospitalized for severe GI bleeding under DOAC therapy were identified in 36 centres between June 2013 and March 2016. Clinical outcomes including re-bleeding, major cerebral and cardiovascular events or all-cause mortality were assessed initially and 30 days after admission., Results: A total of 59 patients with anonymized detailed endoscopy reports for severe GI bleeding were considered. Mean age was 79.3 ± 10.0 years and 61.3% of patients were men. Patients had histories of hypertension (65.6%), heart failure (29.5%), coronary artery disease (27.9%), stroke (19.7%) and peripheral vascular disease (36.1%). Life-threatening bleeding was observed in 42.6%. Mean number of packed red blood cells transfused was 3.4 (range 1-31). Aetiology of bleeding (identified in 66.2% of cases) was peptic gastroduodenal ulcers (22%), diverticula (11.9%), angiodysplasia (8.5%), colorectal neoplasia (5.1%) and anorectal causes (5.1%). Endoscopic haemostasis was performed in 37.7% of patients. A low haemoglobin level was predictive of life-threatening bleeding and death in multivariate analysis. All-cause mortality rate at day 30 was 11.8%., Conclusions: In this cohort of elderly patients with multiple comorbidities treated with DOACs, the main cause of severe acute GI bleeding was peptic gastroduodenal ulcer and mortality was high., Competing Interests: Conflict of interest statement: CB has served as a speaker and a consultant for Bayer Healthcare and Boston Scientific. RB has served as a speaker and a consultant for Bayer Healthcare. PA has served as a speaker and a consultant for Aspen Pharmacare, Bayer Healthcare, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Leo Pharma, Novo Nordisk, Pfizer, Portola, Sanofi and Stago. DD, PA and J-MS had no conflict of interest.

Background: The aim of this prospective multicenter study was to compare a flexible 19 G needle with nitinol shaft (19 G Flex) with a standard 22 G needle for transduodenal endoscopic ultrasound (EUS)-guided sampling of pancreatic head tumors., Methods: Patients with pancreatic head tumors requiring tissue diagnosis were randomized into two arms: puncture with either a 19 G Flex needle or a 22 G needle. The primary end point was diagnostic accuracy for malignancy. The secondary end points were ergonomic scores, sample cytohistological quality, and complications. A 6-month follow-up was performed., Results: 125 patients were randomized and 122 were analyzed: 59 patients in the 19 G Flex arm and 63 patients in the 22 G arm. The final diagnosis was malignancy in 111 patients and benign condition in 11. In intention-to-treat analysis, the diagnostic accuracy for malignancy of the 19 G Flex and 22 G needles was 69.5 % (95 % confidence interval [CI] 56.1 % - 80.8 %) vs. 87.3 % (95 %CI 76.5 % - 94.4 %), respectively ( P  = 0.02). In per-protocol analysis excluding eight technical failures in the 19 G Flex group, the diagnostic accuracy of the 19 G Flex and 22 G needles was not statistically different: 80.4 % (95 %CI 66.9 % - 90.2 %) vs. 87.3 % (95 %CI 76.5 % - 94.4 %; P  = 0.12). Technical success was higher in the 22 G arm than in the 19 G Flex arm: 100 % (95 %CI 94.3 % - 100 %) vs. 86.4 % (95 %CI 75.0 % - 94.0 %), respectively ( P  = 0.003). Transduodenal EUS-guided sampling was more difficult with the 19 G Flex (odds ratio 0.68, 95 %CI 0.47 - 0.97). CONCLUSION : The 19 G Flex needle was inferior to a standard 22 G needle in diagnosing pancreatic head cancer and more difficult to use in the transduodenal approach., Competing Interests: None, (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Gastrointestinal angiodysplasias (GIADs) could be responsible for recurrent bleeding and severe anemia. Somatostatin analogs could reduce transfusion requirements in these patients but no randomized controlled study is available. The main objective of the ANGIOPAS phase II double-blinded randomized, noncomparative study was to assess the effectiveness of pasireotide-LAR in reducing transfusion requirements in patients with refractory GIADs bleeding., Methods: A total of 22 patients with transfusion requirements ⩾6 units of packed red blood cells (pRBCs) during the 6 months prior to inclusion were randomized to receive pasireotide-LAR 60 mg ( n = 10) or placebo ( n = 12) every 28 days for 6 months. Patients were then followed for an additional 6 months after stopping treatment., Results: The pasireotide-LAR and placebo groups were equivalent for age, sex, comorbidities and transfusion requirement during the reference period (median 13 and 9.5 pRBCs). A 50 and 83% success rate (success defined as a decrease of at least 30% of transfused pRBCs) was observed in the pasireotide-LAR arm in the Intent to Treat (ITT) and per protocol (PP) analysis respectively. The need for transfusion during the intervention period was 3 pRBC units in the pasireotide-LAR group (range 0-26) and 11.5 pRBC units in the placebo group (range 0-23). Overall, three cases with glycemic control impairment were observed in the pasireotide-LAR group including one de novo diabetes., Conclusion: This double-blinded noncomparative randomized phase II study suggests, for the first time, the effectiveness of pasireotide-LAR 60 mg every 28 days to decrease the transfusion requirement in patients with recurrent bleeding due to GIADs., Competing Interests: Conflict of interest statement: RB: Alfa Wassermann Pharma, Mayoly Spindler, Medtronic and Norgine. MoB: None. JCS: Abbvie, Bouchara, Intromedic, Mayoly Spindler, Medtronic, MSD and Recordati. ChC: Abbvie, Aptalis, Gilead, MSD, Sciences Janssen and Vifor Pharma. RL: Abbvie and Boston Scientific. MV: None. CB: Boston Scientific, Cousin Endosurg, Norgine and Olympus. MaB: None. RG: Ipsen Pharma. ES: Amgen, Bayer, Ipsen Pharma, Novartis Oncology, Pierre Fabre, Pfizer, Roche, Sanofi and Vifor Pharma. PG: Abbvie, Boston Scientific, Cook Medical, Mayoly Spindler and Takeda. TA: Amgen, Novartis Oncology, Pfizer, Roche, Sanofi and Vifor Pharma. GA: None. BB: None. CB: None. JJR: None. VL: Amgen, GSK, Mundi Pharma, Octa Pharma and Roche DS: Boston Scientific.

The use of direct oral anticoagulants (DOACs) was an important step forward in the management of atrial fibrillation and venous thromboembolism (VTE). The DOACs, anti-IIa for dabigatran and anti-Xa for rivaroxaban, apixaban and edoxaban, all have a rapid onset of action and a short half life. There is no need for routine hemostasis testing for treatment monitoring of a DOAC. Compared with vitamin K antagonists (VKAs), DOACs may increase the risk of gastrointestinal bleeding (relative risk 1.25). Withholding the DOAC treatment, evaluating the time of the last intake and estimating the patient's renal function are the first steps in the management of gastrointestinal bleeding. For patients without impaired renal function, achieving low coagulation takes around 24 h after the last intake of a DOAC. The use of DOAC antagonists will be helpful in controlling bleeding in the most severe and urgent situations. Idarucizumab is available for clinical use for dabigatran and andexanet is currently being reviewed by drug agencies for rivaroxaban, apixaban and edoxaban. It is important to assess the bleeding risk associated with the planned procedure, and the patient's renal function before withholding DOAC therapy for a scheduled intervention. It is mandatory to strengthen the local hemostasis strategies in DOAC-treated patients undergoing a therapeutic endoscopic procedure. Resuming or not resuming anticoagulation with a DOAC after bleeding or a risky procedure depends on the thrombotic and bleeding risk as well as the procedure involved. This discussion should always involve the cardiologist and decisions should be taken by a pluridisciplinary team., Competing Interests: Conflict of interest statement: David Deutsch: none. Christian Boustière has served as a speaker and a consultant for Bayer Healthcare and Boston Scientific. Emile Ferrari has served as a speaker and a consultant for Bayer Healthcare, Boehringer Ingelheim, Bristol-Myers Squibb and Daichi Sankyo. Pierre Albaladejo has served as a speaker and a consultant for Aspen, Bayer Healthcare, Bristol-Myers Squibb, Nordic, Pfizer, Portola and Sanofi. Pierre-Emmanuel Morange has served as a speaker and a consultant for Bayer Healthcare, Boehringer Ingelheim, Bristol-Myers Squibb, Leo Pharma, Novo Nordisk, Pfizer, Sanofi and Stago. Robert Benamouzig has served as a speaker and a consultant for Bayer Healthcare.

Introduction: Self-expanding metal stents (SEMS) are commonly used in the palliation of dysphagia in patients with inoperable esophageal carcinoma. However, they predispose to gastroesophageal reflux when deployed across the gastroesophageal junction. The aims of this study were to: 1) assess the influence of the antireflux valve on trans-prosthetic reflux (primary outcome); and 2) compare the results of SEMS with and without antireflux valve in terms of reflux symptoms, quality of life (QOL), improvement of dysphagia and adverse events (secondary outcomes)., Patients and Methods: Thirty-eight patients were enrolled in nine centers. Carcinomas were locally advanced (47 %) or metastatic. After randomization, patients received either a covered SEMS with antireflux valve (n = 20) or a similar type of SEMS with no antireflux device but assigned to standard proton pump inhibitor therapy and postural advice (n = 18). Trans-prosthetic reflux was assessed at day 2 using a radiological score based on barium esophagography performed after Trendelenburg maneuver and graded from 0 (no reflux) to 12 (maximum). Monthly telephone interviews were conducted for Organisation Mondiale de la Santé (OMS) scoring from 0 (excellent) to 5 (poor), QOL assessment (based on the Reflux-Qual Simplifié scoring system) from 0 (poor) to 100 (excellent), dysphagia scoring from 0 (no dysphagia) to 5 (complete dysphagia) and regurgitation scoring from 0 (no regurgitation) to 16 (maximum)., Results: No difference was noted in terms of age, sex, size of lesion, prosthesis length or need for dilation prior to SEMS placement. No difficulty in placing SEMS nor complications were noted. Radiological scores of reflux were found to be significantly lower in patients with an antireflux stent compared to the conventional stent and associated measures. The regurgitation scores were significantly decreased in patients with antireflux stents during the first 2 months after stent placement and thereafter, they were similar in the two groups. QOL and dysphagia were improved in both groups. Survival rates were comparable in the two groups., Conclusions: No difference was observed between the two types of SEMS regarding the palliation of dysphagia and improvement of QOL. However, SEMS with an antireflux valve were more effective in preventing trans-prosthetic gastroesophageal reflux but at the cost of an increased likehood of minor adverse events (migrations and/or obstruction of the SEMS).

Background: Biliary bipolar radiofrequency ablation (RFA) is a new treatment for extrahepatic cholangiocarcinoma (CCA) currently under evaluation. The purpose of this study was to evaluate the safety, particularly biliary fistula occurrence, and the feasibility of biliary RFA in a homogeneous group of patients treated using the same RFA protocol., Methods: Twelve patients with inoperable or unresectable CCA were included in a bicentric case series study. After removal of biliary plastic stents, a radiofrequency treatment with a new bipolar probe (Habib™ EndoHBP) was applied. The energy was delivered by a RFA generator (VIO 200 D), supplying electrical energy at 350 kHz and 10 W for 90 s. At the end of the procedure, one or more biliary stents were left in place. Adverse events were assessed per-procedure and during follow-up visits., Results: CCA was confirmed in all patients by histology (66%), locoregional evolution or metastatic evolution. The types of CCA were Bismuth I stage (N = 4), Bismuth II stage (N = 3), Bismuth III stage (N = 2) and Bismuth IV stage (N = 3). No serious adverse events occurred within 30 days following endoscopic treatment: One patient had a sepsis due to bacterial translocation on day 1 and another had an acute cholangitis on day 12 due to early stent migration. No immediate or delayed biliary fistula was reported. The ergonomics of the probe made treatment easy in 100 % of cases. Mean survival was 12.3 months., Conclusion: Endoscopic radiofrequency treatment of inoperable CCA appears without major risks and is feasible. No major adverse events or biliary fistula were identified.

Background: Dual-Knife(®) (Olympus) and Hydride-Knife(®) are new needle knives frequently used for submucosal dissection because of their safety and precision. In this study we aimed to evaluate the efficacy and safety of such devices in the diverticulopexy by flexible endoscopy., Methods: From February 2009 to March 2013, 42 patients (25 men), mean age 74.5, with symptomatic Zenker's diverticulum, were included in a non-randomized prospective multicenter study. The symptoms described by all patients include dysphagia, regurgitation and/or swallowing disorders. The diverticulopexy was performed with the Dual-Knife(®) or Hydrid-Knife(®), after septum exposure with the diverticuloscope, and terminated with distal tip clips positioning. All complications were noted. Patients' symptoms were regularly assessed during follow-up visits or telephone interviews., Results: The first endoscopy treatment was successful for all patients. Thirty-seven patients (88%) had symptoms improvement after the first treatment. The recurrence rate was 14% (6 patients); a second endoscopic treatment was required 12 months on average after the first treatment, with 100% efficiency. Mid-term (16 months) efficiency was 91.67% after 1 to 3 endoscopic treatments. A total of 55 procedures were performed without perforation or significant bleeding and 3 patients underwent surgery. In multivariate analysis, the diverticulum size and the type of dissection knife were not risks factors for recurrence., Conclusions: Endoscopic diverticuloscope-assisted diverticulotomy with submucosal dissection knives is a safe and effective alternative treatment for patients with a symptomatic Zenker's diverticulum measuring between 2 and 10 cm.

Background: Data on the current management of inflammatory bowel disease are scarce., Methods: This was a nationwide survey among 65 private gastroenterologists treating patients with inflammatory bowel disease in France in 2012., Results: A total of 375 inflammatory bowel disease patients were analysed: 48% had ulcerative colitis. One third of inflammatory bowel disease patients had a history of hospitalisation, and 40% of Crohn's disease patients had prior surgery. Two thirds of inflammatory bowel disease patients had active disease. Significantly fewer ulcerative colitis patients were treated with anti-tumour necrosis factor therapy than Crohn's disease patients (18.9% vs. 38.9%; p<0.0001). Among patients treated with anti-tumour necrosis factor, only 4.5% were receiving concomitant immunomodulators. Half of inflammatory bowel disease patients had undergone a colonoscopy within the past year. For colorectal cancer screening, random biopsies and chromoendoscopy were performed in 75% and 40% of cases, respectively. An endoscopic score was used for only 10% of inflammatory bowel disease patients. About one third of inflammatory bowel disease patients had imaging studies within the past year (magnetic resonance enterography in 65%). An abdominal computed tomography scan was prescribed for 12% of inflammatory bowel disease patients., Conclusions: Many patients still have active disease in the biologics era, and the number of patients receiving combination therapy is low in private practice. Chromoendoscopy and endoscopy scores are not often used., (Copyright © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background and Study Aims: Endoscopic submucosal dissection (ESD) provides a high en bloc resection rate for superficial colorectal tumors. The aims of this study were to assess the feasibility of ESD in France and to evaluate the complete resection rate at 1 year., Patients and Methods: Patients with superficial rectal tumors ≥ 10 mm in size were prospectively included in the study at nine French expert centers between February 2010 and June 2012. The study was stopped temporarily because of a high complication rate. Study recruitment resumed following remedial action., Results: A total of 45 patients were included (mean age 67 years; 24 males). The immediate perforation rate was 18 % (n = 8), and salvage surgery was not required. Six patients (13 %) had late bleeding, which was treated endoscopically in five patients and surgically in one patient who had required blood transfusion. The mortality rate was zero. The en bloc resection rate was 64 % (29/45), and the curative R0 resection rate was 53 % (24/45). Three patients (7 %) had an invasive tumor (two sm1, one T2). At 1-year follow-up, endoscopic examinations showed complete resection in 38 /43 patients (88 %). At the end of the study, after the remedial action, the en bloc resection rate had increased from 52 % to 82 %, and the perforation rate had decreased significantly from 34 % to 0 %., Conclusions: The study reflects the initial prospective experience of ESD in France, and suggests that curative R0 resection rates should increase and complication rates should decrease with experience and corrective actions., (© Georg Thieme Verlag KG Stuttgart · New York.)

Endoscopic evaluation after chemoradiotherapy (CR) is impossible with an esophageal stent in place. The main study objective was to evaluate self-expanding plastic stent (SEPS) removal post-CR. Secondary end-points were the improvement of dysphagia and patients' quality of life. From October 2008 to March 2011, 20 dysphagic patients who suffered from advanced esophageal cancer were enrolled in a multicenter, prospective study. SEPS was inserted prior to CR and then removed endoscopically. SEPS efficiency (dysphagia score) and tolerance, as well as the patients' quality of life (European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire validated for the esophagus), were monitored. Continuous variables were compared using a paired t-test analysis for matched data. A P-value of less than 0.05 was considered statistically significant. Twenty patients (15 men and 5 women), aged 61.5 years (±9.88) (range 43-82 years), with adenocarcinoma (n = 12) and squamous cell carcinoma (n = 8), were enrolled. SEPS were successfully inserted in all patients (100%). There was one perforation and three episodes of migration. All of these complications were medically treated. The mean dysphagia score at the time of stent placement was 2.79 (0.6). Mean dysphagia scores obtained on day 1 and day 30 post-SEPS placement were 0.7 (0.9) (P < 0.0001) and 0.45 (0.8) (P < 0.0001), respectively. Quality of Life Questionnaire validated for the esophagus score showed an improvement in dysphagia (P = 0.01) and quality of oral feeding (P = 0.003). All SEPS were removed endoscopically without complications. In two patients, the stent was left in place due to metastatic disease. SEPS are extractable after CR of esophageal cancer. Early stenting by SEPS prior to and during CR may reduce dysphagia and improve quality of oral alimentation., (© 2013 Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.)

Background: Patient acceptability of the preparation is a key factor in the success of colonoscopy, yet standard polyethylene glycol solutions are poorly tolerated owing to their high volume (4L) and low palatability. This study compared the efficacy, safety and acceptability of a 2L polyethylene glycol+ascorbate solution with a standard 4-L polyethylene glycol solution., Methods: Adults referred for colonoscopy were randomised to 2-L polyethylene glycol+ascorbate (n=202) or 4-L polyethylene glycol solution (n=198). Colon cleansing success was assessed using the Harefield Cleansing Scale(©) and the Aronchick scale. Safety and acceptability were also assessed., Results: Successful cleansing was achieved in 94.1% and 90.9% of subjects with the 2-L and 4-L solutions respectively using the Harefield Cleansing Scale(©) and 94.6% and 90.0% using the Aronchick scale (non significant). Despite better acceptability and tolerability, no superiority over the standard 4-L preparation was demonstrated. Fewer treatment-related adverse events were reported with the 2-L solution (80.2% versus 89.9%, p=0.011). More subjects were willing to take the 2L PEG+ascorbate solution again (87% versus 51%, p<0.001), found it easier to drink (80% versus 70%, p=0.025), with a better taste (p=0.01)., Conclusions: Two-litre polyethylene glycol+ascorbate solution, with a similar high degree of cleansing and superior acceptability and tolerability, presents an alternative to 4-L polyethylene glycol when compliance is an issue., (Copyright © 2013 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

This article is the second of a two-part publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic ultrasound (EUS)-guided sampling, including EUS-guided fine needle aspiration (EUS-FNA) and EUS-guided Trucut biopsy. The first part (the Clinical Guideline) focused on the results obtained with EUS-guided sampling, and the role of this technique in patient management, and made recommendations on circumstances that warrant its use. The current Technical Guideline discusses issues related to learning, techniques, and complications of EUS-guided sampling, and to processing of specimens. Technical issues related to maximizing the diagnostic yield (e.g., rapid on-site cytopathological evaluation, needle diameter, microcore isolation for histopathological examination, and adequate number of needle passes) are discussed and recommendations are made for various settings, including solid and cystic pancreatic lesions, submucosal tumors, and lymph nodes. The target readership for the Clinical Guideline mostly includes gastroenterologists, oncologists, internists, and surgeons while the Technical Guideline should be most useful to endoscopists who perform EUS-guided sampling. A two-page executive summary of evidence statements and recommendations is provided., (© Georg Thieme Verlag KG Stuttgart · New York.)

A number of guidelines on the management of gastro-intestinal stromal tumours (GISTs) have been published, mostly based on expert consensus. However, these guidelines have generally failed to address the specific problem of GISTs of limited size (i.e. those measuring a few centimetres in diameter) with which gastroenterologists are increasingly confronted. The aim of the present work was to draw up proposals for the diagnosis and treatment of GISTs measuring less than 5 cm in diameter. For this purpose, a number of practical questions were put to a panel of French experts., (Copyright © 2011 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

With the increasing use of antiplatelet agents (APA), their management during the periendoscopic period has become a more common and more difficult problem. The increase in use is due to the availability of new drugs and the widespread use of drug-eluting coronary stents. Acute coronary syndromes can occur when APA therapy is withheld for noncardiovascular interventions. Guidelines about APA management during the periendoscopic period are traditionally based on assessments of the procedure-related risk of bleeding and the risk of thrombosis if APA are stopped. New data allow better assessment of these risks, of the necessary duration of APA discontinuation before endoscopy, of the use of alternative procedures (mostly for endoscopic retrograde cholangiopancreatography [ERCP]), and of endoscopic methods that can be used to prevent bleeding (following colonic polypectomy). This guideline makes graded, evidence-based, recommendations for the management of APA for all currently performed endoscopic procedures. A short summary and two tables are included for quick reference., (© Georg Thieme Verlag KG Stuttgart · New York.)

Worldwide diagnoses of bowel cancer approximate an estimated one million new cases per year, comprising 9% of all cancer cases, and this has continued to increase over the last 25 years. With the association between cancer risk and increasing age, together with the suggestion that by 2015 there will be a 22% increase in the proportion of the population aged over 65 years and a 50% increase in the proportion of people aged over 80 years, there is likely to be a significant increase in the demand on cancer services throughout Europe and the rest of the world. This article discusses the current state of bowel cancer screening within Europe.

The complications of gastrointestinal (GI) endoscopy have become very rare, due to technical advances but also the use of good practices by all gastroenterologists. The overall rate of complications is 1 percent per year for more than 2 millions of lower and upper GI endoscopies, all indications included. The most common complication, though with a frequency inferior to 1/1,000 per year, is still perforation during colonoscopy, most often induced by a fragile intestine or a healing abdomen. Other complications are often the consequence of diathesis or comorbidities, especially if this procedure is performed under anesthesia. Thus in patients with severe cardiovascular or respiratory diseases, or simply depending on the age of patients, risks should be carefully assessed so that the endoscopic procedure can be adapted or even postponed. Being aware of and especially taking into account any risk factor before performing a diagnostic endoscopic examination should thus allow gastroenterologists to avoid complications.

Background and Study Aim: Polyp miss rates during colonoscopy have been calculated in a few tandem or back-to-back colonoscopy studies. Our objective was to assess the adenoma miss rate while limiting technique or operator expertise biases, i. e. by performing a large multicenter study, with same-day back-to-back video colonoscopy, done by two different operators in randomized order and blinded to the other examination., Patients and Methods: 294 patients at 11 centers were included. Among the 286 analyzable tandem colonoscopies, miss rates were calculated in both a lesion- and patient-based analysis. Each of these rates was determined for polyps overall, for adenomas, and then for lesions larger than 5 mm, and for advanced adenomas. Univariate and logistic regression analysis were performed to define independent variables associated with missed polyps or adenomas., Results: The miss rates for polyps, adenomas, polyps > or = 5 mm, adenomas > or = 5 mm, and advanced adenomas were, respectively, 28 %, 20 %, 12 %, 9 % and 11 %. None of the masses with a carcinomatous (n = 3) or carcinoid component (n = 1) was missed. The specific lesion miss rates for patients with polyps and adenomas were respectively 36 % and 26 % but the corresponding rates were 23 % and 9.4 % when calculated for all 286 patients. The diameter (1-mm increments) and number of polyps (> or = 3) were independently associated with a lower polyp miss rate, whereas sessile or flat shape and left location were significantly associated with a higher miss rate. Adequacy of cleansing, presence of diverticula, and duration of withdrawal for the first procedure were not associated with adenoma miss rate., Conclusions: We confirm a significant miss rate for polyps or adenoma during colonoscopy. Detection of flat polyps is an issue that must be focused on to improve the quality of colonoscopy.

One side effect of the immunomodulatory effect of interferon is the possible triggering or exacerbation of systemic or cutaneous sarcoidosis. We report two new cases and offer an exhaustive review of the literature. A 39-year-old man with type C chronic active hepatitis developed new respiratory symptoms and pulmonary infiltrates with hilar and mediastinal adenopathy after 7 months of treatment with pegylated interferon. The evolution was favourable after stopping treatment. The second patient developed cutaneous lesions after 6 months of treatment. Resolution occurred after the discontinuation of the treatment. In these two cases ribavirin was stopped before the first signs of sarcoidosis.

Hepatitis C virus (HCV) genotypes are distributed differently depending on geography and route of infection. We characterized the distribution of genotypes in a large cohort of patients with chronic hepatitis C in the South-east of France and evaluated the relative prevalence according to time of acquisition. One thousand, one hundred-and-eighty-three patients who were anti-HCV-positive were studied. HCV genotype distribution has changed significantly from the 1960s to 2000. The prevalence of genotype 1b decreased from 47% before 1978 to 18.8% in the 1990s while the prevalence of genotype 1a and 3a increased during the same period from 18% and 15.3% to 28.8% and 26.3%, respectively. The logistic regression model showed that genotype 1a was significantly more common in patients infected through intravenous drug injection odds ratio ((OR): 2.08, P < 0.01) and after 1990 (OR: 1.98, P < 0.05). Genotype 1b was significantly less frequent in patients infected through intravenous drug injection (OR: 0.17, P < 0.001) and has decreased since 1978 (OR: 0.27, P < 0.001). Genotype 3a was independently associated with intravenous drug injection (OR: 6.1, P < 0.001) and tattooing (OR: 8.01, P < 0.001) and was more frequent in the 1979-90 period (OR: 2.05 and 1.74, P < 0.001 and P < 0.05). Our results show a modification of HCV genotypes distribution over the last four decades due to an increase of intravenous drug use (IVDU) contamination and an evolution of HCV genotypes distribution only in IVDU population characterized by a decrease of genotype 1b, an increase of genotype 3a from 1970 to 1990 and a higher increase of genotype 1a which is currently the predominant genotype in our population.

Hepatitis C virus (HCV) is transmitted primarily through direct percutaneous exposure to infected blood. Sporadic HCV cases exist and may represent more than 10% of HCV transmission. We report the first case of documented transmission of HCV during a fight from a person who unknowingly had chronic HCV infection to a person who subsequently contracted acute hepatitis C. Patient-to-patient transmission was ascertained by sequence analysis of part of the NS5B genome and phylogenetic analysis. This case report suggests that sporadic HCV infection may be a result of blood exposure. This example of transmission could have a major impact in sports such as boxing or rugby. We suggest that in any fight, single use or nondisposable material should be used to dry blood to avoid such contamination.

Background: The existence of endosonographic abnormalities of the oesophagus in achalasia is discussed. The place of endoscopic ultrasonography (EUS) needs to be clarified., Patients: Thirty five untreated patients suffering from achalasia and 28 controls without oesophageal disease were prospectively enrolled since 1993. Pseudoachalasia was diagnosed in two patients., Methods: EUS measurements were performed at two opposite sites at the level of the cardia, and 5 cm and 10 cm proximally, avoiding compression by the water filled balloon., Results: The oesophageal wall and the fourth hypoechoic layer were significantly thicker at the level of the cardia and 5 cm above, with mean differences between patients and controls of 0.37/0.42 mm and 0.16/0.23 mm respectively. No statistically significant correlation could be demonstrated between the thickness of the oesophageal wall or of the fourth hypoechoic layer and weight loss, or the average pressure of the lower oesophageal sphincter. However, a significant inverse relationship was demonstrated between the duration of symptoms and the thickness of the fourth hypoechoic layer. The thickness of the fourth hypoechoic layer was also increased in patients who required only one pneumatic dilatation (P < 0.01)., Conclusion: The thickness of the oesophageal wall and of the fourth hypoechoic layer appeared to be significantly increased in achalasia patients. However, the slight increase of the mean size (< 0.5 mm) of the muscularis propria suggests that EUS is not helpful in the diagnosis of achalasia. The physiopathological basis of advanced achalasia has to be reconsidered as we demonstrated an inverse relationship between the duration of symptoms and the thickness of the muscularis propria.

Endoscopic ultrasonography was performed in 80 cirrhotic patients and 50 control subjects. The aim of the study was to describe and classify the vascular abnormalities of the gastric wall as observed on echoendoscopy in cirrhotic patients and to compare the data with endoscopy. The size of gastric varices was classified into 3 grades: grade 0 (none), grade 1 (small or non-confluent varices < 5 mm), grade 2 (large or confluent varices > or = 5 mm). The abnormalities of the gastric wall were classified into 3 grades: 0 (none), grade 1 (thickening and brilliance of the third hyperechogenic layer with or without fine internal anechogenic structures), grade 2 (visible vessels in the third layer which deform the entire wall, with penetrating varices). Endoscopy provides better visualization of esophageal varices than echoendoscopy but does not detect gastric varices and the first signs of portal hypertension as well. In conclusion echoendoscopy should be a routine examination for screening portal hypertension in cirrhotic patients and could be used in therapeutic follow-up.

From January to December 1991, the portal venous system was evaluated by Doppler ultrasonography in 72 patients with liver cirrhosis. The objectives of this study were to evaluate the prevalence of spontaneous reversal of blood flow in the portal vein and to assess the relationship between Doppler ultrasound investigation and clinical, biochemical, endoscopic (70 patients), and endosonographic (44 patients) features. Reversed flow was quite frequent (alternating: 17%, permanent: 22%) and its prevalence did not differ in relation to age, sex, serum gammaglobulin concentration and Child-Pugh class. In patients with reversed portal venous flow, the prevalence of hepatic encephalopathy was higher (39% vs 13.5%, P < 0.05), but the prevalence of esophageal or gastric varices was not related to that pattern. Endosonography detected gastric wall abnormalities in a higher proportion of patients with reversed portal flow than in patients without it (P < 0.05). This study suggests that reversal of flow in the portal vein could play a role in the development of the gastric wall abnormalities in liver cirrhosis, which are detected by endosonography but not by endoscopy.

In 19 patients, extraction of bile duct stones through the papilla using a Dormia basket or a mechanical lithotripter was not possible following endoscopic sphincterotomy. After the insertion of a nasobiliary drain, extracorporeal lithotripsy was performed with intravenous sedation using an ultrasonographic stone localization system. The number and location of stones were first determined by retrograde cholangiography. At the time of lithotripsy, saline was injected in the bile ducts to modify the acoustic impedance of tissues surrounding the stones, and subsequent ultrasonography was effective in localizing all stones present in 4 of 5 (80%) patients with intrahepatic stones, and 13 of 14 (93%) with common bile duct stones. In 10 patients (53%), fragmentation was satisfactory and the bile ducts were cleared completely. The mean single stone diameter was significantly smaller in successful cases of fragmentation compared with failures (22.8 +/- 6.6 mm vs. 40 +/- 10 mm). The results in patients with multiple stones were significantly worse than those in patients with single stones of similar size (25% vs. 100% successful fragmentation). Reasons for this difference in results included the small size of the focal area and the reduced ability of ultrasonography (1) to adequately visualize multiple calculi individually and (2) to assess the degree of stone destruction. Care was taken to first await the resolution of infection or the correction of coagulation abnormalities when present; no morbidity following extracorporeal lithotripsy was observed. Despite its 3-step approach (endoscopic sphincterotomy, lithotripsy, and endoscopic extraction), the need for only intravenous sedation and the absence of patient immersion in water render this technique attractive for elderly and frail patients.

Non-alcoholic steatosis of the liver is a common condition. It usually consists of triglyceride drop deposits in macro- or microvacuoles of the hepatocytes and may result from various disturbances of lipid metabolism, notably accumulation of fatty acids in the liver and decrease in the secretion or synthesis of lipoproteins. The causes of steatosis are numerous. It is important to distinguish between severe steatosis (acute steatosis of pregnancy, toxic steatosis, Reye's syndrome), where most of the deposits are in microvacuoles, and incidental or moderate steatosis of nutritional or hormonal origin, or developed during idiopathic enterocolitis or various liver diseases. Treatment, sometimes intensive, essentially depends upon the cause of steatosis.

Ultrasonography allowed to diagnose in emergency an acute intraperitoneal bleeding complicating a percutaneous needle liver biopsy in a woman suffering from diffuse steatosis and to demonstrate the mechanism of bleeding by the visualization of the probable injury of a sus-hepatic vein.

This study was carried out in order to assess the value of ultrasonography in the diagnosis of cirrhosis. One hundred patients were studied within 2 weeks of the histological diagnosis of the liver disease (cirrhosis 49, acute or chronic hepatitis: 23, fatty liver: 16, normal liver: 12). Ultrasonic patterns were classified by a second examiner according to 5 hepatic criteria (volume, outline, echogenicity, attenuation of the ultrasound beam, enlargement of caudate lobe) and 3 extrahepatic criteria (dilatation of the portal vein, ascites, splenomegaly), leading to a ultrasonic diagnosis. Cirrhosis was diagnosed in 36 out of 49 patients (73 p. 100) by the echographist whereas clinical and biological data lead to diagnosis in only 27 out of these 49 patients (P = 0.057). Hepatocellular carcinoma was diagnosed only in 2 out of 5 patients. Splenomegaly (0.60) and caudate lobe enlargement (0.59) were the signs whose predictive value was the best for this group of patients. The ratio thickness of caudate lobe/global hepatic thickness (as measured on a sagittal cut through the inferior vena cava) allowed for easy assessment of caudate lobe size. The mean value of this ratio was significantly different (P less than 0.001) in the cirrhotic group (0.38 +/- 0.07) when compared to the non-cirrhotic one (0.28 +/- 0.06). Ratios greater than 0.35 were not seen in subjects with normal livers, nor were ratios greater than 0.40 seen in non-cirrhotic patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Citrate, calcium and protein have been estimated in pure pancreatic juice after a secretin and a CCK injection in 4 patients presenting with alcoholic calcified pancreatitis (ACP), 10 controls without evidence of pancreatic disease, drinking more than 130 g alcohol/day, and 10 controls without evidence of pancreatic disease, drinking less than 20 g alcohol/day. Citrate is normally secreted in the pancreatic juice and this secretion increases in parallel with protein after CCK injection. Citrate secretion is significantly decreased in the two alcoholic groups. Calcium secretion is increased in the ACP, and reasons are presented to suggest that this may be due to lesions of the ducts. These modifications could play a role in the formation of pancreatic stones which are mostly built up of calcium carbonate.