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Background and Aims With an increasing number of women joining procedural fields, including gastroenterology, optimizing the work environment for learning, teaching, and clinical practice is essential to the well-being of both physicians and their patients. We queried female and male gastroenterologists on their beliefs toward the endoscopy suite environment, as well as their experiences in learning and teaching endoscopic skills. Methods We distributed a web-based survey to 403 gastroenterology fellows and practicing gastroenterologists at 12 academic institutions and 3 large private practices. We used univariate and multivariate analysis to compare the responses of female and male gastroenterologists. Results The overall response rate was 32% (n = 130); 54 women and 61 men completed the survey in its entirety and were included in the analysis (15 respondents did not meet the inclusion criteria). Baseline demographics were comparable between the groups. Overall, fewer women than men were trained using tactile instruction (41% vs 67%; P = .004). Of those trained using tactile instruction, 60.3%, with no gender differences, felt it was also important for endoscopic learning. More women reported experiencing gender bias toward themselves during training (57.4% vs 13.1%; P = .001) as well as in their current careers (50.0% vs 9.8%; P = .001). When queried on treatment of gastroenterologists by endoscopy staff, 75.9% of women reported that men were treated more favorably, whereas 70.5% of men felt that both male and female gastroenterologists were treated equally. Conclusions Inequities exist with regard to the experience of men and women in gastroenterology, and specific challenges for women may have an impact on their career choices and ability to safely and effectively learn, teach, and practice endoscopy.

Background and Aims: Consensus regarding an optimal algorithm for endoscopic treatment of papillary adenomas has not been established. We aimed to assess the existing degree of consensus among international experts and develop further concordance by means of a Delphi process. Methods: Fifty-two international experts in the field of endoscopic papillectomy were invited to participate. Data were collected between August and December 2019 using an online survey platform. Three rounds were conducted. Consensus was defined as >= 70% agreement. Results: Sixteen experts (31%) completed the full process, and consensus was achieved on 47 of the final 79 statements (59%). Diagnostic workup should include at least an upper endoscopy using a duodenoscope (100%) and biopsy sampling (94%). There should be selected use of additional abdominal imaging (75%-81%). Patients with (suspected) papillary malignancy or over 1 cm intraductal extension should be referred for surgical resection (76%). To prevent pancreatitis, rectal nonsteroidal anti-inflammatory drugs should be administered before resection (82%) and a pancreatic stent should be placed (100%). A biliary stent is indicated in case of ongoing bleeding from the papillary region (76%) or concerns for a (micro)perforation after resection (88%). Follow-up should be started 3 to 6 months after initial papillectomy and repeated every 6 to 12 months for at least 5 years (75%). Conclusions: This is the first step in developing an international consensus-based algorithm for endoscopic management of papillary adenomas. Surprisingly, in many areas consensus could not be achieved. These aspects should be the focus of future studies.

Background and Aims Gastric per-oral endoscopic myotomy (G-POEM) recently has been reported as minimally invasive therapy for gastroparesis. The aims of this study were to report on the first multicenter experience with G-POEM and to assess the efficacy and safety of this novel procedure for patients with gastroparesis with symptoms refractory to medical therapy. Methods All patients with gastroparesis who underwent endoscopic pyloromyotomy (G-POEM) at 5 medical centers were included. Procedures were performed following the same principles as esophageal POEM. Clinical response was defined as improvement in gastroparetic symptoms with absence of recurrent hospitalization. Adverse events were graded according to the American Society for Gastrointestinal Endoscopy lexicon. Results A total of 30 patients with refractory gastroparesis (11 diabetic, 12 postsurgical, 7 idiopathic) underwent G-POEM. Previous therapies included Botox injection in 12, transpyloric stenting in 3, and PEG with jejunal extension (PEGJ) in 1. Nausea/vomiting were the predominant symptoms in 25 patients. Weight loss was present in 27 patients with an average of 10% loss of body weight. G-POEM was completed successfully in all 30 (100%) patients with a mean procedure time of 72 minutes (range, 35–223 min). The mean myotomy length was 2.6 ± 2.3 cm. The mean length of hospital stay was 3.3 days (range, 1–12 days). Two adverse events occurred in 2 (6.7%) patients, including 1 capnoperitoneum and 1 prepyloric ulcer, rated as mild and severe, respectively. Clinical response was observed in 26 (86%) patients during a median follow-up of 5.5 months. Four patients (2 diabetic, 1 postsurgical, 1 idiopathic cause) did not respond to G-POEM. Repeat gastric emptying scan was obtained in 17 patients, normalized in 8 (47%), and improved in 6 (35%) patients. Conclusion G-POEM is a technically feasible procedure. This small non-randomized study suggests the effectiveness of G-POEM for the treatment of patients with gastroparesis refractory to medical therapy. It concomitantly results in normalization of GES in a significant proportion of treated patients.

Peroral endoscopic myotomy (POEM) has emerged as a promising treatment option for achalasia and other foregut dysmotility disorders. However, much of the current postprocedural care, such as mandatory admission and routine esophagrams, has been adapted from current surgical practices and may not in fact be necessary. Here, we describe our algorithm and outcomes for same-day discharge.Outcomes of 103 consecutive patients who underwent POEM for achalasia and other foregut dysmotility disorders from January 2015 to December 2018 were analyzed. Patients were discharged on the same day without esophagrams following a predetermined algorithm based on procedural adverse events and postprocedural pain. Patients were closely monitored after discharge for adverse events at 24 and 48 hours and then routinely in the office setting.Of the 103 POEMs, 101 were completed successfully. A total of 62.4% of patients were discharged safely on the same day, 29.7% were admitted for mild pain, and 7.9% were admitted for observation for other reasons. Overall, there were no serious adverse events at any time point. Univariate analysis identified duration of disease greater than 3 years, longer length of procedure (50.9 vs 68.5 min, P .0001), and longer length of myotomy (7.2 vs 8.5 cm, P .0068) as significant factors associated with postprocedural pain requiring admission.Although same-day discharge and foregoing routine esophagram have been suggested by many, this routine has not been systematically implemented. This series suggests that an algorithm for same-day discharge based on postprocedure chest pain and procedural complexity is both safe and feasible.

Background and Aims The need for transpapillary drainage (TPD) in patients undergoing transmural drainage (TMD) of pancreatic fluid collections (PFCs) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TMD versus combined (TMD and TPD) drainage (CD) and to identify predictors of symptomatic and radiologic resolution. Methods This is a retrospective review of 375 consecutive patients with PFCs who underwent EUS-guided TMD from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TMD and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression. Results A total of 375 patients underwent EUS-guided TMD of PFCs, of which 174 were pseudocysts. TMD alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success was as follows: TMD, 92 (97%) versus CD, 35 (44%) ( P = .0001). There was no difference in adverse events between the TMD (15%) and CD (14%) cohorts ( P = .23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TMD and 201 days (interquartile range, 150-493 days) ( P = .37). There was no difference in LT symptomatic resolution (TMD, 69% vs CD, 62%; P = .61) or LT radiologic resolution (TMD, 71% vs CD, 67%; P = .79). TPD attempt was negatively associated with LT radiologic resolution of pseudocyst (odds ratio, 0.11; 95% confidence interval, 0.02-0.8; P = .03). Conclusions TPD has no benefit on treatment outcomes in patients undergoing EUS-guided TMD of pancreatic pseudocysts and negatively affects LT resolution of PFCs.

Background Endoscopic decompression of symptomatic main pancreatic duct (MPD) dilation in Whipple patients is often difficult because of stenosis of the pancreaticojejunal (PJ) anastomosis. Objective To evaluate the feasibility and procedural safety of the pancreatic antegrade needle-knife (PANK) technique, with the goal of restoring antegrade MPD flow, when endoscopic retrograde pancreatography (ERP) and EUS-guided rendezvous fail. Setting Tertiary care center. Design Retrospective series. Patients Three patients with symptomatic MPD dilation refractory to ERP and EUS-guided rendezvous. Interventions Under EUS guidance, a 19-gauge echo-needle was used to gain access to the dilated MPD and a Jagwire advanced. After failed attempts at antegrade guidewire passage across the PJ stenosis, deep transgastric MPD access was achieved via a Soehendra stent retriever and balloon dilation. Careful antegrade needle-knife of the stenotic site was performed. A long pancreatic stent spanning the jejunum, MPD, and gastric access site was placed. Four to 8 weeks later, this stent was upsized and converted to a PJ stent, which in turn was removed 4 weeks thereafter. Main Outcome Measurements Technical feasibility and complications. Results All 3 patients successfully underwent the PANK procedure. Pre- and post-MRCP studies showed the mean MPD diameter decreased 60% from 8.3 mm to 3.6 mm (mean follow-up 8 months). At 24-month follow-up, all 3 patients experienced decreased or resolved pain without further need for MPD intervention. Limitations Retrospective study with small numbers. Conclusions When ERP and EUS rendezvous fail, the PANK procedure using a staged stent strategy seems to be an effective means of MPD decompression.

Background The most common complication of uncovered biliary self-expandable metal stents (SEMSs) is tumor ingrowth. The addition of an impenetrable covering may prolong stent patency. Objective To compare stent patency between uncovered and partially covered SEMSs in malignant biliary obstruction. Design Multicenter randomized trial. Setting Four teaching hospitals. Patients Adults with inoperable distal malignant biliary obstruction. Interventions Uncovered or partially covered SEMS insertion. Main outcome measures Time to recurrent biliary obstruction, patient survival, serious adverse events, and mechanism of recurrent biliary obstruction. Results From October 2002 to May 2008, 129 patients were randomized. Recurrent biliary obstruction was observed in 11 of 61 uncovered SEMSs (18%) and 20 of 68 partially covered SEMSs (29%). The median times to recurrent biliary obstruction were 711 days and 357 days for the uncovered and partially covered SEMS groups, respectively ( P = .530). Median patient survival was 239 days for the uncovered SEMS and 227 days for the partially covered SEMS groups ( P = .997). Serious adverse events occurred in 27 (44%) and 42 (62%) patients in the uncovered and partially covered SEMS groups, respectively ( P = .046). None of the uncovered and 8 (12%) of the partially covered SEMSs migrated ( P = .0061). Limitations Intended sample size was not reached. Allocation to treatment groups was unequal. Conclusions There was no significant difference in time to recurrent biliary obstruction or patient survival between the partially covered and uncovered SEMS groups. Partially covered SEMSs were associated with more serious adverse events, particularly migration. (Clinical trial registration number: NCT01047332.)

Background Endoscopic submucosal dissection requires a high degree of endoscopic skill and specifically designed dissecting instruments. Objective To describe the technique for endoscopic submucosal dissection when using the ERBE Hybrid Knife, which combines an ultrafine high-pressure water jet with an electrocautery needle. Design Descriptive study (ex vivo and in vivo porcine esophagus, stomach, and colon). Interventions The only instrument used for the dissection was the ERBE Hybrid Knife. The high-pressure water jet was used at a pressure between 45 and 60 bar for creating submucosal fluid elevation. After this, circumferential mucosal incisions and submucosal dissection were performed with the FORCED COAG and ENDOCUT D modes of the same device. The water jet was used intermittently during the dissection process. Main Outcome Measurements At the end of the in vivo experiments, animals were killed and the organs removed for evaluation. Results Multiple endoscopic submucosal dissection procedures were successfully performed. It was possible to create submucosal fluid cushions rapidly. Repeated fluid injections during dissection were easily facilitated with the same device. All ex vivo gastric endoscopic submucosal dissections of 50 × 40-mm lesions were completed within 10 minutes. In the in vivo studies, the mean size of the gastric and colonic specimens was 3.7 ± 2.1 × 2.3 ± 1 cm, and the dissections were completed within 8 minutes. No thermal injury was observed on the serosa, and no perforations were detected. Conclusions Endoscopic submucosal dissection can be safely and effectively achieved in a porcine model with the ERBE Hybrid Knife and should be considered a suitable device for this procedure in humans.

Background Endoluminal gastroplication has been shown to reduce symptoms of gastroesophageal reflux disease and to induce focal hypertrophy of the gastroesophageal junction (GEJ) muscularis propria. Despite suture loss, some patients have persistent symptomatic resolution. Objective This study was designed to examine the durability of smooth muscle hypertrophy after suture removal. Design Seven pigs underwent upper endoscopy with endoscopic ultrasonography (EGD/EUS) at baseline to evaluate GEJ muscularis propria layer. Endoluminal gastroplication was performed at week 1 with placement of 2 sutures at the GEJ. Repeat EGD/EUS was performed at week 3 and week 5. Three of the 7 pigs were killed for histologic analysis. The remaining 4 pigs had sutures removed and survived for 9, 11, and 13 weeks; serial weekly EGD/EUS was performed until the animal was killed. Results The GEJ muscularis propria thickness by EUS was 1.1 ± 0.1 mm at baseline, 4.7 ± 1.9 mm at week 3, and 4.4 ± 1.1 mm at week 5. The muscularis propria thickness by histologic examination in the 3 animals with sutures intact were 6.2 ± 0.3 mm near the suture site and 4.7 ± 0.5 mm at the opposing wall to the suture site. For the 4 animals with sutures removed, the measurements were 6.9 ± 0.2 mm (suture site) and 4.7 ± 0.5 mm (opposing wall), respectively. Conclusions The GEJ smooth muscle cell hypertrophy induced by endoluminal gastroplication persisted after removal of mucosal sutures. These changes may be responsible for persistent symptomatic response despite suture loss in patients.

Background Endoluminal gastroplication has shown promise for the treatment of GERD in short-term studies. Until now, long-term outcome data have been lacking. Methods A prospective, multicenter trial enrolled 85 patients with GERD to be treated with endoluminal gastroplication. Inclusion criteria were 3 or more heartburn or regurgitation episodes per week, >4.2% time in 24 hours with esophageal pH Results At 1- and 2-year follow-up, patients had significant reductions in median heartburn symptom scores (72 at baseline [interquartile range (IQR) 90-48] vs. 4 at 12 months [IQR 43-0] and 16 at 24 months [IQR 53-3.5]; p Conclusions Endoscopic gastroplication is safe and effective, and is associated with symptom reductions in patients with GERD for at least 24 months.

As the fourth decade of ERCP and its related techniques is entered and all that has been achieved in its evolution is reflected upon, a number of technological, clinical, and research milestones can be identified along with the experts who developed them. They showed the clinical gastroenterologist how to learn, perfect, and apply the wide range of therapeutic modalities encompassed by the ERCP umbrella. ERCP has grown from a limited esoteric procedure, performed by a few, to a mainstream modality for diagnosis and treatment of a wide variety of benign and malignant ampullary, biliary, and pancreatic disorders. It has taken surprisingly long to subject some of the applications of endoscopic therapy of biliary and pancreatic disease to the same scientific evaluation as alternative treatments, define patient populations and their associated risk profiles, and to understand how positive, negative, and unplanned treatment outcomes are determined by patient, technical, and physician influences. Training requirements for physicians wishing to acquire and maintain the necessary skills needed to perform high-quality ERCP have been defined but remain a contentious area in endoscopic practice and education. ERCP is currently used for the management of bile duct stones, benign and malignant biliary obstruction, benign and malignant pancreatic neoplasms and diseases of the major and minor papilla, acute and chronic pancreatitis, bile duct injuries, pancreatic duct disruption and pseudocysts, pain syndromes considered to be of pancreatic, biliary, or sphincter of Oddi origin, certain congenital and acquired hepatic conditions affecting the biliary tract, and bleeding or infection suspected of being of hepatic, biliary, or pancreatic origin. This wide range of indications has grown with clinical experience based on empirical judgment, case reports, case series, prospective studies, and randomized controlled trials. The precise role of ERCP in these varied clinical settings has not, however, always been well characterized in terms of difficulty, success, risk of associated morbidity, overall outcome, and patient satisfaction in comparison with the most suitable alternatives, which are often surgical. Past research has allowed us to reach the current level of ERCP usage with considerable benefit to our patients but definition of risk-benefit has been lacking and is desirable in all of the settings in which ERCP is applicable. Future research, whether carefully performed prospective or retrospective analyses of databases, cohort studies, or randomized controlled trials, must concentrate on precise definition of patient populations, cost-benefit, and risk-benefit in order to clarify the role of ERCP in the setting being tested.

Therapeutic ERCP was born with the introduction of endoscopic sphincterotomy (ES) in 1973, which transformed the therapeutic approach to biliary disease, especially the management of common bile duct (CBD) stones. Today, more than 150,000 endoscopic biliary sphincterotomies are performed annually in the United States. Patients with bile duct stones present with a variety of clinical problems, alone or in combination, including cholestasis, pain, cholangitis, pancreatitis, or as asymptomatic demonstration on imaging or operative cholangiography. It has become increasingly feasible, acceptable, and supportable to treat patients in all these categories endoscopically. In its infancy, endoscopic therapy was initially considered justifiable only in elderly patients after cholecystectomy who had recurrent or retained CBD stones and who were at high risk of serious complications from open surgical CBD exploration or reexploration at a time when few endoscopy centers could offer the techniques. Adolescence witnessed the impressive successes of ES and stone extraction methods in high-risk groups. With an expansion of units offering endoscopic therapy, a low level of associated complications, and a strong patient preference, many centers were persuaded to widen their indications for the procedure to include younger patients after cholecystectomy, and later, a range of patients in whom the gallbladder was still in place but in whom CBD stones were the principal clinical problem. Much of this occurred in the absence of any comparative trial data to aid decision-making and, indeed, there was such enthusiasm for endoscopic therapy that the establishment of randomized trials became difficult. Nevertheless, the wisdom of maturity dictated that, because they are essential to settle arguments about relative morbidity and mortality risks in different patient populations and the bias of selection for treatment by endoscopic or surgical means, such prospective studies were forthcoming and have provided a sound basis on which to triage patients. Concomitant with the developments of wider clinical application has been the evolution of endoscopic techniques to reduce stone size and facilitate endoscopic removal. These comprise mechanical lithotripsy, laser lithotripsy, and electrohydraulic lithotripsy (EHL). There was a growing appreciation that maintaining biliary drainage was imperative after any endoscopic intervention and could be achieved by nasobiliary tube or endoprosthesis. Many lithotripsy techniques can also be applied by means of percutaneous choledochoscopy, which may be the only endoscopic option if the peroral route is denied or fails. The endoscopist is now faced with the referral of a number of clearly defined groups of patients with confirmed or suspected bile duct stones for whom endoscopic therapy may be optimal compared with these alternatives: 1. Severe cholangitis with or without cholelithiasis; 2. Severe gallstone pancreatitis

Background: The aim of this study was to identify predictors of outcome after pancreatic duct stent placement for duct disruption. Methods: Patients were identified from endoscopy databases. Disruption was defined by extravasation of contrast from the pancreatic duct during endoscopic retrograde pancreatography. Data collected included demographic information, imaging studies, management before and outcome after stent placement. Success was defined as resolution of the disruption clinically, on radiologic imaging, and/or at endoscopic retrograde pancreatography. Results: Forty-three patients (23 women, 20 men; mean age 57 years, [SD] 15.2 years) were studied. The etiology of pancreatic duct disruption was acute pancreatitis in 24, chronic pancreatitis in 9, operative injury in 7, and trauma in 3 patients. In 25 patients there was resolution of the disruption, whereas stent therapy was unsuccessful in 16 and the outcome was indeterminate in 2 patients. On univariate analysis, stent positioned to bridge the disruption ( p = 0.04) and longer duration of stent therapy ( p = 0.002) were associated with a successful outcome. Female gender ( p = 0.05) and acute pancreatitis ( p = 0.05) were associated with a lack of success. On multivariate analysis, only the bridging stent position remained correlated to outcome. Complications occurred in 4 patients. Conclusions: A bridging stent is associated with a successful outcome after pancreatic duct stent placement for duct disruption. (Gastrointest Endosc 2002;56:18-24.)

Background: Premature stent clogging is the major limitation with plastic stents used in the treatment of malignant biliary structures. A pilot study suggested improved duration of patency of the Tannenbaum stent compared with polyethylene stents. The aim of this prospective, multicenter randomized trial was to compare the Tannenbaum Teflon stent with a conventional polyethylene endoprosthesis (Cotton-Leung biliary stent set) for the treatment of malignant biliary strictures. Methods: Patients over age 18 years with symptoms caused by nonhilar malignant biliary strictures were enrolled. Patients were randomized to receive a 10F Tannenbaum or polyethylene stent after a guidewire was passed beyond the stricture. One hundred six patients (mean age 72 years and 71 years, respectively) were enrolled (54 Tannenbaum, mean age 72 years; 52 polyethylene, mean age 71 years). Results: Tannenbaum and polyethylene stent placement was successful in, respectively, 100% and 96% of procedures without complications. The mean (SD) 90-day stent patency of the Tannenbaum stent was 67% (7%) compared with 73% (7%) for the polyethylene stents. Conclusions: The present study demonstrated no difference in ease of implantation or stent patency between Tannenbaum and polyethylene stents. (Gastrointest Endosc 2002;55:354-8.)

Background: The endoscopically placed enteral stent has emerged as a reasonable alternative to palliative surgery for malignant intestinal obstruction. This is a report of our experience with the use of enteral stents for nonesophageal malignant upper GI obstruction. Methods: Data on all patients who had undergone enteral stent placement were reviewed. Those with a diagnosis of pancreatic cancer were compared with another similar cohort of patients who underwent palliative gastrojejunostomy. Results: Thirty-one procedures were performed on 29 patients (mean age 67.7 years). Thirteen (45%) were men and 16 (55%) women. The diagnoses were gastric (13.8%), duodenal (10.3%), pancreatic (41.4%), metastatic (27.6%), and other malignancies (6.9%). Malignant obstruction occurred at the pylorus (20.7%), first part of duodenum (37.9%), second part of duodenum (27.6%), third part of duodenum (3.5%), and anastomotic sites (10.3%). Twenty-nine (93.5%) procedures were successful and good clinical outcome was achieved in 25 (80.6%). Re-obstruction by tumor ingrowth occurred in 2 patients after a mean of 183 days. The median survival time for patients with pancreatic cancer who underwent enteral stent placement compared with those who underwent surgical gastrojejunostomy was 94 and 92 days, charges were $9921 and $28,173, and duration of hospitalization was 4 and 14 days, respectively (latter 2 differences with p value Conclusion: Endoscopic enteral stent placement of nonesophageal malignant upper GI obstruction is a safe, efficacious, and cost-effective procedure with good clinical outcome, lower charges, and shorter hospitalization period than the surgical alternative. (Gastrointest Endosc 2001;53:329-32.)

Background: Recurrent bleeding after successful primary endoscopic hemostasis of acutely bleeding ulcers is a significant problem.This study evaluates endoscopic Doppler ultrasound (US) in assessing risk of recurrent bleeding in patients presenting with acute peptic ulcer hemorrhage. Methods: In this prospective, double-blind, nonrandomized trial, patients were enrolled from a single academic institution. Only patients with endoscopically confirmed gastric, duodenal, pyloric, or anastomotic ulcers were enrolled. The therapeutic endoscopist was blinded to the Doppler US signal from the ulcer and based treatment decisions on standard guidelines. A 16 MHz pulsed-wave, linear scanning, US probe was used through the accessory channel of an endoscope to assess for the presence of a Doppler signal. Results: Fifty-two of 139 screened patients entered the trial (55 Doppler sessions). Endoscopic therapy was performed in 42% (30-day recurrent bleeding rate of 17%). Ulcers that remained persistently Doppler positive immediately after endoscopic therapy had a significantly higher rate of recurrent bleeding than ulcers where the Doppler signal was abolished: 100% versus 11% ( p = 0.003). There were no bleeding-related deaths. Conclusions: A persistently positive Doppler US signal appears to be a marker of inadequate endoscopic therapy in patients with acutely bleeding peptic ulcers. (Gastrointest Endosc 2000;52:315–21.)