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Background and study aims Bile cast syndrome (BCS) is a complication of orthotopic liver transplantation (OLT). It occurs in 4 % to 18 % of OLT recipients and can present as cholangitis and graft damage or loss. Twenty-two percent of patients with BCS require repeat OLT. The diagnosis and management of BCS can be challenging. Our aim is to share our experience with BCS and to briefly review the diagnosis and management of the condition.

Background and study aims The Bethesda ERCP Skill Assessment Tool (BESAT) is a video-based assessment tool of technical endoscopic retrograde cholangiopancreatography (ERCP) skill with previously established validity evidence. We aimed to assess the discriminative validity of the BESAT in differentiating ERCP skill levels. Methods Twelve experienced ERCP practitioners from tertiary academic centers were asked to blindly rate 43 ERCP videos using the BESAT. ERCP videos consisted of native biliary cannulation and sphincterotomy and were recorded from 10 unique endoscopists of various ERCP experience (from advanced endoscopy fellow to > 10 years of ERCP experience). Inter-rater reliability, discriminative validity, and internal structure validity were subsequently assessed. Results The BESAT was found to reliably differentiate between endoscopists of varying levels of ERCP experience with experienced ERCPists scoring higher than novice ERCPists in 11 of 13 (85%) instrument items. Inter-rater reliability for BESAT items ranged from good to excellent (intraclass correlation range: 0.86 to 0.93). Internal structure validity was assessed with item-total correlations ranging from 0.53 to 0.83. Conclusions Study findings demonstrate that the BESAT, a video-based ERCP skill assessment tool, has high inter-rater reliability and has discriminative validity in differentiating novice from expert ERCP skill. Further investigations are needed to determine the role of video-based assessment in improving trainee learning curves and patient outcomes., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest., (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/).)

The increasing global burden of obesity and its associated comorbidities has created an urgent need for additional treatment options to fight this pandemic. Endoscopic bariatric therapies (EBTs) provide an effective and minimally invasive treatment approach to obesity that would increase treatment options beyond surgery, medications, and lifestyle measures. This systematic review and meta-analysis were performed by the American Society for Gastrointestinal Endoscopy (ASGE) Bariatric Endoscopy Task Force comprising experts in the subject area and the ASGE Technology Committee Chair to specifically assess whether acceptable performance thresholds outlined by an ASGE Preservation and Incorporation of Valuable endoscopic Innovations (PIVI) document for clinical adoption of available EBTs have been met. After conducting a comprehensive search of several English-language databases, we performed direct meta-analyses by using random-effects models to assess whether the Orbera intragastric balloon (IGB) (Apollo Endosurgery, Austin, Tex) and the EndoBarrier duodenal-jejunal bypass sleeve (DJBS) (GI Dynamics, Lexington, Mass) have met the PIVI thresholds. The meta-analyses results indicate that the Orbera IGB meets the PIVI thresholds for both primary and nonprimary bridge obesity therapy. Based on a meta-analysis of 17 studies including 1683 patients, the percentage of excess weight loss (%EWL) with the Orbera IGB at 12 months was 25.44% (95% confidence interval [CI], 21.47%-29.41%) (random model) with a mean difference in %EWL over controls of 26.9% (95% CI, 15.66%-38.24%; P ≤ .01) in 3 randomized, controlled trials. Furthermore, the pooled percentage of total body weight loss (% TBWL) after Orbera IGB implantation was 12.3% (95% CI, 7.9%–16.73%), 13.16% (95% CI, 12.37%–13.95%), and 11.27% (95% CI, 8.17%–14.36%) at 3, 6, and 12 months after implantation, respectively, thus exceeding the PIVI threshold of 5% TBWL for nonprimary (bridge) obesity therapy. With the data available, the DJBS liner does appear to meet the %EWL PIVI threshold at 12 months, resulting in 35% EWL (95% CI, 24%-46%) but does not meet the 15% EWL over control required by the PIVI. We await review of the pivotal trial data on the efficacy and safety of this device. Data are insufficient to evaluate PIVI thresholds for any other EBT at this time. Both evaluated EBTs had ≤5% incidence of serious adverse events as set by the PIVI document to indicate acceptable safety profiles. Our task force consequently recognizes the Orbera IGB for meeting the PIVI criteria for the management of obesity. As additional data from the other EBTs become available, we will update our recommendations accordingly.

Background & Aims: Obese patients rarely achieve long-term weight loss with only lifestyle interventions. We evaluated the use of endoscopic aspiration therapy for obesity. Aspiration therapy involves endoscopic placement of a gastrostomy tube (A-Tube) and the AspireAssist siphon assembly (Aspire Bariatrics, King of Prussia, PA) to aspirate gastric contents 20 minutes after meal consumption., Methods: We performed a pilot study of 18 obese subjects who were randomly assigned (2:1) to groups that underwent aspiration therapy for 1 year plus lifestyle therapy (n = 11; mean body mass index, 42.6 ± 1.4 kg/m(2)) or lifestyle therapy only (n = 7; mean body mass index, 43.4 ± 2.0 kg/m(2)). Lifestyle intervention comprised a 15-session diet and behavioral education program., Results: Ten of the 11 subjects who underwent aspiration therapy and 4 of the 7 subjects who underwent lifestyle therapy completed the first year of the study. After 1 year, subjects in the aspiration therapy group lost 18.6% ± 2.3% of their body weight (49.0% ± 7.7% of excess weight loss [EWL]) and those in the lifestyle therapy group lost 5.9% ± 5.0% (14.9% ± 12.2% of EWL) (P < .04). Seven of the 10 subjects in the aspiration therapy group completed an additional year of therapy and maintained a 20.1% ± 3.5% body weight loss (54.6% ± 12.0% of EWL). There were no adverse effects of aspiration therapy on eating behavior and no evidence of compensation for aspirated calories with increased food intake. No episodes of binge eating in the aspiration therapy group or serious adverse were reported., Conclusions: In a pilot study, aspiration therapy appears to be a safe and effective long-term weight loss therapy for obesity., (Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Investigators have proposed "predict, resect, and discard" strategies for diminutive (≤ 5 mm) or small (6-9 mm) polyps to reduce screening colonoscopy costs. Advanced histological features such as villous histology, high-grade dysplasia, and/or cancer in these polyps could deter adoption of these strategies., Objective: Determine the prevalence of advanced histological features in diminutive and small colon polyps., Design: Retrospective analysis of data from 3 prospective clinical trials., Setting: Two tertiary-care referral centers., Patients: This study involved patients undergoing screening or surveillance colonoscopy., Intervention: The location, size, and morphology of each polyp detected was documented. Each polyp was then resected, placed in a unique specimen jar, and sent for histopathological evaluation., Main Outcome Measurements: Rates of advanced histological features (villous histology, high-grade dysplasia, and cancer)., Results: A total of 2361 polyps were detected, removed, and retrieved. Both diminutive and small polyps had a lower frequency of any advanced histological features compared with large polyps (0.5% and 1.5%, respectively vs 15.0%; P < .001 for both comparisons). Polyps <10 mm in size had a lower frequency of advanced histology compared with polyps ≥ 10 mm (0.8% vs 15.0%; P < .001). During sensitivity analysis, the frequency of advanced histological features varied from 0.2% to 0.7% within diminutive polyps, 1.5% to 3.6% within small polyps, and 0.8% to 1.2% within polyps <10 mm., Limitations: Retrospective analysis from tertiary-care referral centers; predominantly white, male, veteran patient population resulting in limited generalizability of results., Conclusion: The prevalence of advanced histological features in colon polyps ≤ 5 mm is very low (0.5%). This has important implications for the potential practice of "predicting, resecting, and discarding" diminutive colon polyps., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: The American Society for Gastrointestinal Endoscopy (ASGE) recently developed thresholds for the performance characteristics of technologies for real-time assessment of histology of diminutive (≤ 5 mm) colon polyps. Narrow-band imaging (NBI) has been shown to predict polyp histology with moderate to high accuracy in several studies., Objective: To determine whether in vivo optical diagnosis of polyp histology by using NBI can reach the 2 benchmarks set forth by the ASGE., Design: Retrospective analysis of data from 3 prospective clinical trials., Setting: Two tertiary referral centers., Patients: Subjects undergoing screening or surveillance colonoscopy., Interventions: In vivo optical diagnosis of polyp histology by using NBI., Main Outcome Measurement: Accuracy in predicting colonoscopy surveillance intervals, negative predictive value (NPV) for diagnosing adenomatous histology in the rectosigmoid., Results: A total of 410 patients met the inclusion/exclusion criteria and had at least 1 polyp seen and resected during colonoscopy. Using in vivo optical diagnosis instead of histopathology for all diminutive polyps predicted the correct colonoscopy surveillance interval in 86% to 94% patients. When optical diagnosis was limited to diminutive polyps in the rectosigmoid only, the NPV for diagnosing adenomatous histology with NBI was 95%., Limitations: Retrospective analysis from tertiary referral centers., Conclusions: The threshold NPV for diagnosing adenomatous histology in diminutive rectosigmoid polyps recently set forth by the ASGE can be achieved by using NBI. The threshold accuracy rate for predicting surveillance interval recommendations can be reached by using NBI, but only if patients with 1 to 2 small adenomas without advanced features have a repeat colonoscopy in 10 years., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: There are conflicting data on the risk of post-ERCP pancreatitis (PEP) related to self-expandable metallic stents (SEMSs)., Objective: To compare rates of PEP in patients who undergo biliary drainage with SEMSs or polyethylene stents (PSs)., Design: Retrospective, cohort study., Setting: Tertiary-care medical center., Patients: This study involved patients undergoing ERCP for malignant biliary obstruction between January 2005 and October 2008., Intervention: First-time placement of a SEMS or PS for biliary decompression., Main Outcome Measurements: Early post-ERCP complications, particularly PEP., Results: We identified 544 eligible patients, 248 SEMSs (102 covered), and 296 PSs. The etiology of malignant biliary obstruction was similar between groups, with 55% from pancreatic cancer. The frequency of PEP was significantly higher in the SEMS group (7.3%) versus the PS group (1.3%) (OR 5.7 [95% CI, 1.9-17.1]). On univariate analysis, patient age of <40 years, a history of PEP, and at least 1 pancreatic duct injection were also significant predictors of PEP, whereas female sex and having pancreatic cancer were not. When significant variables were added to a multiple-predictor regression model, the odds of PEP from SEMS placement increased to 6.8 (95% CI, 2.2, 21.4). However, the frequency of PEP was similar between covered (6.9%) and uncovered (7.5%) SEMSs (OR 0.9 [CI, 0.3-2.4]). Purported SEMS-specific risk factors, including the use of cSEMSs, overlapping SEMSs, or having a biliary sphincterotomy were not found to be significant contributors to the higher risk., Limitations: Retrospective design., Conclusion: After we controlled for confounding variables, the frequency of PEP was significantly higher with placement of a SEMS compared with a PS. Rates of PEP were comparable with use of covered and uncovered SEMSs., (Copyright © 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Colonoscopy may fail to detect neoplasia located on the proximal sides of haustral folds and flexures. The Third Eye Retroscope (TER) provides a simultaneous retrograde view that complements the forward view of a standard colonoscope., Objective: To evaluate the added benefit for polyp detection during colonoscopy of a retrograde-viewing device., Design: Open-label, prospective, multicenter study evaluating colonoscopy by using a TER in combination with a standard colonoscope., Setting: Eight U.S. sites, including university medical centers, ambulatory surgery centers, a community hospital, and a physician's office., Patients: A total of 249 patients (age range 55-80 years) presenting for screening or surveillance colonoscopy., Interventions: After cecal intubation, the disposable TER was inserted through the instrument channel of the colonoscope. During withdrawal, the forward and retrograde video images were observed simultaneously on a wide-screen monitor., Main Outcome Measurements: The number and sizes of lesions (adenomas and all polyps) detected with the standard colonoscope and the number and sizes of lesions found only because they were first detected with the TER., Results: In the 249 subjects, 257 polyps (including 136 adenomas) were identified with the colonoscope alone. The TER allowed detection of 34 additional polyps (a 13.2% increase; P < .0001) including 15 additional adenomas (an 11.0% increase; P < .0001). For lesions 6 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 18.2% and 25.0%, respectively. For lesions 10 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 30.8% and 33.3%, respectively. In 28 (11.2%) individuals, at least 1 additional polyp was found with the TER. In 8 (3.2%) patients, the polyp detected with the TER was the only one found. Every polyp that was detected with the TER was subsequently located with the colonoscope and removed. For all polyps and for adenomas, the additional detection rates for the TER were 9.7%/4.1% in the left colon (the splenic flexure to the rectum) and 16.5%/14.9% in the right colon (the cecum to the transverse colon), respectively., Limitations: There was no randomization or comparison with a separate control group., Conclusions: A retrograde-viewing device revealed areas that were hidden from the forward-viewing colonoscope and allowed detection of 13.2% additional polyps, including 11.0% additional adenomas. Additional detection rates with the TER for adenomas 6 mm or larger and 10 mm or larger were 25.0% and 33.3%, respectively. (, Clinical Trial Registration Number: NCT00657371.)., (2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Because of greater recognition and improved imaging capabilities, intraductal papillary mucinous neoplasms (IPMNs) are being diagnosed with increasing frequency. IPMNs of the main pancreatic duct cause symptoms and lead to pancreatitis. Side-branch (SB) IPMNs are thought to cause symptoms less frequently, and their association with pancreatitis is not well defined., Objective: Our purpose was to ascertain whether an association exists between SB-IPMN and pancreatitis., Design: Single-center, retrospective study., Setting: Academic medical center., Patients: A total of 305 patients underwent EUS examinations between October 2002 and October 2006 for pancreatic cystic lesions., Main Outcome Measurement: The main outcome measure was the frequency of acute or chronic pancreatitis that was not procedurally related., Results: Thirty-two patients had SB-IPMNs, and 11 (34%) had pancreatitis. Three patients reported a single episode, and 8 patients reported having recurrent episodes of pancreatitis. Overall, 17 (53%) patients had symptoms possibly attributable to SB-IPMN. Female sex (73% vs 38%) and multiple pancreatic lesions (54% vs 24%) were more commonly seen in those with pancreatitis, but were not statistically significant factors. Larger cyst size or cyst fluid marker levels did not appear associated with pancreatitis occurrence. EUS-FNA demonstrated communication with the pancreatic duct in 94% and thick, mucinous fluid in 84%., Limitations: Single-center, retrospective study., Conclusions: Pancreatitis was frequently associated with the presence of SB-IPMNs in our referral practice. SB-IPMNs should be considered in the differential diagnosis of patients with recurrent pancreatitis with cystic lesions seen on imaging studies. EUS-FNA was the most useful modality in helping to differentiate SB-IPMNs from other lesions.

Background: Abdominal pain after ERCP is common, and although it is frequently nonspecific and self-limited, it may provoke concern for complications and thus distress both patients and physicians. Carbon dioxide (CO(2)) insufflation during ERCP may reduce abdominal distension in comparison to insufflation of air, resulting in less pain., Objective: To compare the incidence and severity of post-ERCP pain in patients receiving CO(2) versus air insufflation during ERCP., Design: Randomized, double-blind, controlled trial., Setting: University medical center., Patients: This study involved consecutive patients presenting for ERCP, excluding those with significant preprocedure pain or obstructive lung disease., Intervention: Randomization to insufflation with air or CO(2); all other care was identical., Main Outcome Measurements: Pre-ERCP and post-ERCP pain and nausea were assessed by using a 0 to 10 visual analogue scale. Patient waist circumferences were measured before and after procedures., Results: One hundred patients (82 outpatients, 51 women, mean age 54.4 years, 50 randomized to CO(2)) completed the study. The CO(2) and air groups were similar in regard to demographics, indication for ERCP, and procedure duration. The mean pain score 1 hour post-ERCP was higher with air than with CO(2) insufflation (1.9 vs 0.7, P = .01). Similarly, the incidence of any pain at 1 hour post-ERCP was higher with air than with CO(2) (48% vs 28%, P = .04). The mean increase in waist circumference was greater with air than with CO(2) (2.1 cm vs 0.3 cm, P = .003). Adverse events were infrequent and did not differ by group. No serious cardiopulmonary complications occurred., Limitations: Single-center, selected patient population., Conclusion: Insufflation of CO(2) during ERCP reduces postprocedure pain and abdominal distension in comparison to insufflation of air. The use of CO(2) in deeply sedated, prone patients appears to be safe.

Background: In many centers, on-site cytopathologists are not available during EUS-guided FNA (EUS-FNA) examinations. Often, endosonographers request that technologists assess the adequacy of FNA by gross inspection of the slides. To date, there has not been a study that assessed the accuracy of experienced technologists in predicting tissue sampling adequacy by gross inspection before cytologic staining., Objectives: To assess a grading system used by cytotechnologists and EUS technologists during gross inspection of FNA slides in reliably predicting specimen adequacy compared with the final cytologic diagnoses., Design: Prospective, double-blind, controlled study., Setting: Academic tertiary-referral center with a high-volume EUS practice., Patients: Fifty-one patients with a suspected solid pancreatic mass who were undergoing planned EUS-FNA., Main Outcome Measurements: The degree of correlation in the assessment of specimen adequacy as exhibited by a weighted kappa statistic between 2 groups of technologists and a board-certified cytopathologist., Results: FNA was performed in 37 cases with 234 individual slide specimens available for analysis. Only fair agreement was observed between cytotechnologists and EUS technologists versus final cytopathologic assessment of adequacy (kappa 0.20 and 0.19, respectively). The routine practice of 6 to 7 FNA passes yielded adequate tissue for assessment in 36 of 37 patients (97%)., Limitations: Interobserver variability, single center, and findings applicable only to solid pancreatic lesions., Conclusions: Neither trained EUS technologists nor cytotechnologists were able to provide a reliable assessment of pancreatic-mass FNA adequacy by using gross visual inspection of the specimen on a slide. Rapid on-site cytopathology reduced the number of passes, ensured specimen adequacy, provided definitive diagnosis, and should be used in centers where available.

Background: Internal drainage of pancreatic pseudocysts can be accomplished by traditional open or minimally invasive laparoscopic or endoscopic approaches. This study aimed to evaluate the primary and overall success rates and clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts., Methods: Records of 83 patients undergoing laparoscopic (n = 16), endoscopic (n = 45), and open (n = 22) pancreatic cystgastrostomy were analyzed on an intention-to-treat basis., Results: There were no significant differences (p < 0.05) in the mean patient age (years), gender, body mass index (BMI) (kg/m(2)), etiology of pancreatitis (% gallstone), or size (cm) of pancreatic pseudocyst between the groups. Grade 2 or greater complications occurred within 30 days of the primary procedure for 31.5% of the laparoscopic patients, 15.6% of the endoscopic patients, and 22.7% of the open patients (nonsignificant differences). The follow-up evaluation for 75 patients (90.4%) was performed at a mean interval of 9.5 months (range, 1-40 months). The primary compared with the overall success rate, defined as cyst resolution, was 51.1% vs. 84.6% for the endoscopic group, 87.5% vs. 93.8% for the laparoscopic group, and 81.2% vs. 90.9% for the open group. The primary success rate was significantly higher (p < 0.01) for laparoscopic and open groups than for the endoscopic group, but the overall success rate was equivalent across the groups (nonsignificant differences). Primary endoscopic failures were salvaged by open pancreatic cystgastrostomy (n = 13), percutaneous drainage (n = 3), and repeat endoscopic drainage (n = 6)., Conclusions: Laparoscopic and open pancreatic cystgastrostomy both have a higher primary success rate than endoscopic internal drainage, although repeat endoscopic cystgastrostomy provides overall success for selected patients.

Background: Recommended techniques for minor papilla sphincterotomy include performing a standard pull-type sphincterotomy (PTS) or using a needle-knife over a stent. A wire-assisted access sphincterotomy (WAAS) technique may hold some technical advantages over these accepted methods, but has not been robustly described., Objective: To describe the safety and efficacy of WAAS compared with PTS in a series of patients from our institution., Design: Retrospective audit of initial minor papilla sphincterotomies over a 6-year period. Demographic and procedural data were abstracted, and the medical record was reviewed for clinical follow-up., Setting: A large tertiary referral center., Patients: One hundred twenty-eight consecutive patients with pancreas divisum who underwent ERCPs between April 2001 and April 2007, 64 of whom underwent an initial minor papilla sphincterotomy., Interventions: WAAS was performed by deeply cannulating the dorsal duct with a guidewire and then passing a needle-knife sphincterotome alongside the wire and cutting the minor papilla by inserting the needle-knife beside the wire and cutting away from the wire., Main Outcome Measurements: Clinical procedural success and reported adverse events., Results: Thirty-two patients had recurrent acute pancreatitis, 15 had pain only, and 13 had chronic pancreatitis. Thirty-two underwent WAAS, 24 had PTS, and 8 had other types of sphincterotomies. Patients undergoing WAAS (32) versus PTS (24) were similar in age, sex, and procedural indication. Mild post-ERCP pancreatitis and mild intraprocedural bleeding occurred more commonly in the WAAS group, although the differences were not statistically significant., Limitations: Retrospective, nonrandomized study., Conclusions: WAAS is an effective technique that may be used either to begin a minor papilla sphincterotomy or to perform the entire sphincterotomy. Complications appear similar to those seen with conventional methods but require a larger patient sample to fully evaluate.

Introduction: The purpose of this study is to determine the incidence of residual common bile duct (CBD) stones after preoperative ERCP for choledocholithiasis and to evaluate the utility of routine intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) in this patient population., Methods: All patients who underwent preoperative ERCP and interval LC with IOC from 5/96 to 12/05 were reviewed under an Institutional Review Board (IRB)-approved protocol. Data collected included all radiologic imaging, laboratory values, clinical and pathologic diagnoses, and results of preoperative ERCP and LC with IOC. Standard statistical analyses were used with significance set at p < 0.05., Results: A total of 227 patients (male:female 72:155, mean age 51.9 years) underwent preoperative ERCP for suspicion of choledocholithiasis. One hundred and eighteen patients were found to have CBD stones on preoperative ERCP, and of these, 22 had choledocholithiasis diagnosed on IOC during LC. However, two patients had residual stones on completion cholangiogram after ERCP and were considered to have retained stones. Therefore, 20 patients overall were diagnosed with either interval passage of stones into the CBD or a false-negative preoperative ERCP. In the 109 patients without CBD stones on preoperative ERCP, nine patients had CBD stones on IOC during LC, an 8.3% incidence of interval passage of stones or false-negative preoperative ERCP. In both groups, there was no correlation (p > 0.05) between an increased incidence of CBD stones on IOC and a longer time interval between ERCP and LC, performance of sphincterotomy, incidence of cystic duct stones, or pathologic diagnosis of cholelithiasis., Conclusions: The overall incidence of retained or newly passed CBD stones on IOC during LC after a preoperative ERCP is 12.9%. Although the natural history of residual CBD stones after preoperative ERCP is not known, the routine use of IOC should be considered in patients with CBD stones on preoperative ERCP undergoing an interval LC.

Background: Roux-en-Y gastric bypass is the most frequently performed bariatric surgery for morbid obesity. Gastrojejunal anastomotic strictures are a relatively frequent postoperative complication., Objective: To evaluate the clinical outcomes and therapeutic response to through-the-scope balloon dilation performed to treat anastomotic strictures after Roux-en-Y gastric bypass surgery., Design: Single-center, retrospective study., Setting: Academic medical center., Patients: Between 1997 and 2005, 801 patients with morbid obesity underwent Roux-en-Y gastric bypass surgery at our institution., Main Outcome Measurements: The development of an anastomotic stricture after Roux-en-Y gastric bypass surgery. The response to through-the-scope balloon dilation after diagnosis., Results: Forty-three of 801 patients (5.4%) developed an anastomotic stricture (26 of 294 open surgeries [8.8%]; 17 of 507 laparoscopic surgeries [3.4%]; P < .001). Strictures were dilated to 15.5 +/- 0.4 mm. There were no perforations or clinically significant bleeding after dilation; 93% of the strictures were successfully managed with 1 or 2 endoscopic sessions. Dilation to at least 15 mm did not affect weight loss at 1 year when compared with the group without a stricture (percentage excess weight loss: stricture group, 76%; no stricture group, 74%)., Limitations: Single-center, retrospective study., Conclusions: Endoscopic balloon dilation is a safe and effective method for the management of gastrojejunostomy strictures after Roux-en-Y gastric bypass. Dilation to at least 15 mm is safe and decreases the need for further endoscopic dilation.

Context: Atypical antipsychotic agents (clozapine, olanzapine) have been linked to metabolic effects and acute pancreatitis., Case Report: We reviewed the inpatient and outpatient records of three patients who developed acute pancreatitis while being treated with olanzapine. The mean age of the patients was 37.7 years (range 18-54 years, 2 female, 1 male). No alternative cause of acute pancreatitis was found in two of the three patients. In the remaining patient, olanzapine may have contributed to acute pancreatitis in the setting of hypertriglyceridemia. Olanzapine was discontinued in all instances. Over a mean follow-up of 14 months, one patient has had a relapsing course, but the remaining two patients have been symptom free without recurrence of acute pancreatitis., Conclusions: Our case series adds further support to the potential link between olanzapine use and acute pancreatitis. Close monitoring of metabolic parameters is suggested in patients treated with olanzapine. Alternative antipsychotic agents should be considered in patients at high risk for pancreatitis.

Background: Few patients have significant symptoms during wireless esophageal pH monitoring, and the capsule typically sloughs spontaneously. Severe discomfort during monitoring can occur that requires endoscopic dislodgement of the capsule., Objective: To determine the frequency with which endoscopic capsule dislodgement is required and the outcomes of the intervention., Design: Chart review., Setting: University-based outpatient endoscopy facility., Patients: A total of 452 consecutive patients undergoing wireless pH monitoring over a 3.5-year period., Interventions: Endoscopic dislodgement of the capsule by using nudging with the endoscope tip and cold snare techniques., Results: Eight subjects (1.8%) required endoscopic capsule dislodgement because of severe chest pain or odynophagia (n = 7) or severe foreign-body sensation (n = 1). Chest pain was the initial indication for pH monitoring in 5 (62.5%) of the subjects. Initial nudging with the endoscope tip successfully dislodged 2 capsules; continued nudging produced mucosal stripping in 3 subjects, which required hemostasis in 1. A cold snare was used successfully, without complication, to separate the capsule from stripped mucosa and as a primary removal method in the remainder of subjects. Capsule removal uniformly resulted in marked improvement of discomfort., Conclusions: Endoscopic removal of the capsule was required in <2% of subjects who underwent wireless pH monitoring. Separation of the capsule from the mucosa with a cold snare may be the preferred method of accomplishing uncomplicated removal.