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Background: Achieving competence in endoscopic retrograde cholangiopancreatography (ERCP) requires extensive training. Recognizing the potential of simulator-based education for safe and effective skill development, we aimed to assess whether initial training with the Boškoski-Costamagna ERCP Trainer (BCT) is beneficial compared with conventional training alone (i.e. predictive validity)., Methods: A prospective multicenter randomized trial involving 16 novice ERCP trainees, randomly assigned to intervention or control groups, was performed. Both underwent hands-on training, with the intervention group receiving additional simulation training during the first 3 months. Each trainee was required to complete a minimum of 60 ERCPs in up to 1 year. The TEESAT score evaluated rates of global overall competence (primary outcome), biliary cannulation, and adverse events (AEs; secondary outcomes). Mixed-effect logistic regression models assessed differences in between-group ERCP procedure competence and success. Learning curves were generated cumulatively over the training period., Results: 1106 ERCPs (562 simulator group; 544 control group) were included. Although no statistically significant difference in global overall competence was observed between the groups, possibly owing to data heterogeneity, simulation training demonstrated higher success for native biliary cannulation (52% vs. 42%; P <0.001) and faster median (interquartile range) biliary cannulation times (3 [6] vs. 5 [8] minutes; P <0.001). The simulator group also showed faster improvements in overall performance, native biliary cannulation, and sphincterotomy. No statistical difference was found in overall AEs between the groups., Conclusion: Early simulation training with the BCT improved technical competence in native biliary cannulation and accelerated overall ERCP learning. This approach has the potential to enhance ERCP training programs., Competing Interests: I. Boskoski received a research grant from ERBE Elektromedizin and consultancy fees from Boston Scientific, Cook Medical, Pentax Medical, Siemens, Endotools, Nitinotes, and lecture fees from Microtech; he holds patents USA No. US D740,361 S (Endoscopy Training Apparatus) Oct. 6, 2015 and No. 0001426680, Class A61B1814 (Stent for electrothermal treatment) Feb. 7, 2017, and has stock options from Myka Labs. T. Voiosu has received fees for lectures from Boston Scientific and an educational event from Cook Medical. G. Costamagna has received consultancy fees from Olympus, Waldner Group, and AlfaSigma, as well as speaker's and writer's fees from Malesci. J. Devière’s received institutional support for IRB-approved studies and consultancy fees to his institution from Olympus and Cook Medical, as well as stocks from Endotools Therapeutics. M. Arvanitakis's has received consultancy fees from Olympus and honoraria from Pentax to her institution. J. van Hooft has received lecture fees from Cook Medical, Boston Scientific, Falk, and Fujifilm, and a consultancy fee from Olympus. G. Vanbiervliet has received lecture fees from Norgine, Tillots, Ambu, Fujifilm, and Pentax, and a consultancy fee from Boston Scientific. P. Fockens has provided consultancy for Cook Endoscopy and Olympus. R.P. Voermans received a research grant form Boston Scientific and Prion Medical, and his institution received consultancy fees from Boston Scientific and Cook Medical. J.-M. Gonzalez has received consultancy fees from Fujifilm and Boston Scientific. J.W. Poley has provided consultancy for MediGlobe GmbH, and Pentax Medical. M. Bruno has received consultancy fees from Boston Scientific, Cook Medical, Pentax, and AMBU, support for industry- and investigator-initiated studies from Boston Scientific and Cook Medical, and support for investigator-initiated studies from Pentax Medical, Mylan, AMBU, and ChiRoStim. P.J.F. de Jonge has received consultancy and lecture fees from Boston Scientific, Cook Medical, and Fujifilm. S.T. de Campos, M. Salmon, A. Langers, C. Gomercic, A. Lemmers, M. Barthet, W. Laleman, I. Tarantino, R. de Ridder, and JM Conchillo declare that they have no conflict of interests., (Thieme. All rights reserved.)

Competing Interests: M.J. Bruno received research support from Boston Scientific, Cook Medical, Pentax Medical, Mylan, ChiRoStim and acts as a consultant/lecturer for Boston Scientific, Cook Medical, Pentax Medical and AMBU. R.P. Voermans received research funding for investigator initiated studies from Boston Scientific and Prion Medical. He is a consultant with speakers fee for Boston Scientific. PJ.F. de Jonge received research support from FujiFilm. He received speakers fee for Boston Scientific and Cook Medical. D.M. de Jong, P.M.C. Stassen, I.G. Schoots and R.C. Verdonk declare that they have no conflicts of interest.

Background: Endoscopic transmural drainage (ETD) using double-pigtail stents (DPSs) is a well-established treatment for walled-off pancreatic necrosis (WON). This study aimed to compare outcomes in patients undergoing ETD with DPSs left indwelling versus those where stents were removed or migrated., Methods: This retrospective multicenter cohort study included patients with WON who underwent ETD using DPSs between July 2001 and December 2019. The primary outcome was recurrence of a pancreatic fluid collection (PFC). Secondary outcomes were long-term complications and recurrence-associated factors. Competing risk regression analysis considered DPS removal or migration as time-varying covariates., Results: Among 320 patients (median age 58; 36% women), DPSs were removed in 153 (47.8%), migrated spontaneously in 27 (8.4%), and remained indwelling in 140 (43.8%). PFC recurrence was observed in 57 patients (17.8%): after removal (n = 39; 25.5%); after migration (n = 4; 14.8%); in patients with indwelling DPSs (n = 14; 10.0%). In 25 patients (7.8%), drainage of recurrent PFC was indicated. Risk factors for recurrence were DPS removal or migration (hazard ratio [HR] 3.45, 95%CI 1.37-8.70) and presence of a disconnected pancreatic duct (HR 5.08, 95%CI 1.84-14.0)., Conclusions: Among patients who undergo ETD of WON, leaving DPSs in situ seems to lower the risk of recurrent fluid collections, without any long-term DPS-related complications. These results suggest that DPSs should not be routinely removed and can be safely left indwelling indefinitely., Competing Interests: M.J. Bruno received research support from Boston Scientific, Cook Medical, Pentax Medical, Mylan, ChiRoStim and acts as a consultant/lecturer for Boston Scientific, Cook Medical, Pentax Medical and AMBU. R.P. Voermans received research funding for investigator initiated studies from Boston Scientific and Prion Medical. He is a consultant with speakers fee for Boston Scientific. PJ.F. de Jonge received research support from FujiFilm. He received speakers fee for Boston Scientific and Cook Medical. D.M. de Jong, P.M.C. Stassen, I.G. Schoots and R.C. Verdonk declare that they have no conflicts of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Background: Current duodenoscope reprocessing protocols are insufficient to prevent contamination and require adaptations to prevent endoscopy-associated infections (EAIs). This study aimed to investigate the effect of a new endoscope cleaning brush on the contamination rate of ready-to-use duodenoscopes., Methods: This retrospective before-and-after intervention study collected duodenoscope surveillance culture results from March 2018 to June 2022. Contamination was defined as ≥1 colony-forming unit of a microorganism of gut or oral origin (MGO). In December 2020, an endoscope cleaning brush with a sweeper design was introduced as an intervention in the manual cleaning of duodenoscopes. A logistic mixed-effects model was used to study the effects of this intervention., Results: Data were collected from 176 culture sets before the new brush's introduction and 81 culture sets afterwards. Pre-introduction, culture sets positive with an MGO comprised 45.5% (95%CI 38.3%-52.8%; 80/176), decreasing to 17.3% (95%CI 10.6%-26.9%; 14/81) after implementation of the new brush. Compared with the former brush, duodenoscopes cleaned with the new brush had lower odds of contamination with MGOs (adjusted odds ratio 0.25, 95%CI 0.11-0.58; P =0.001) CONCLUSIONS: Use of the new brush in manual cleaning reduced contamination with MGOs and is expected to prevent EAIs. These findings should be confirmed in future prospective randomized studies., Competing Interests: M.C. Vos has received research support from Boston Scientific, 3M, and Pentax Medical. M.J. Bruno has received research support from Boston Scientific, Cook Medical, Pentax Medical, Mylan, and ChiRoStim, and has acted as a consultant/lecturer for Boston Scientific, Cook Medical, Pentax Medical, and AMBU. K. van der Ploeg, C.P. Haanappel, A.F. Voor in ’t holt, W. de Groot, A.J.C. Bulkmans, N.S. Erler, B.C.G.C. Mason-Slingerland, and J.A. Severin declare that they have no conflict of interest. The authors declare that the Endoss firm had no relation with the study authors and was not involved in this research financially or otherwise., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Background: Patients with head and neck squamous cell carcinoma (HNSCC) can develop second primary tumors (SPTs) in the esophagus. Endoscopic screening could lead to detection of SPTs at early stages and improve survival., Methods: We performed a prospective endoscopic screening study in patients with curably treated HNSCC diagnosed between January 2017-July 2021 in a Western country. Screening was performed synchronously (< 6 months) or metachronously (≥ 6 months) after HNSCC diagnosis. Routine imaging for HNSCC consisted of flexible transnasal endoscopy with positron emission tomography/computed tomography or magnetic resonance imaging, depending on primary HNSCC location. The primary outcome was prevalence of SPTs, defined as presence of esophageal high grade dysplasia or squamous cell carcinoma., Results: 202 patients (mean age 65 years, 80.7 % male) underwent 250 screening endoscopies. HNSCC was located in the oropharynx (31.9 %), hypopharynx (26.9 %), larynx (22.2 %), and oral cavity (18.5 %). Endoscopic screening was performed within 6 months (34.0 %), 6 months to 1 year (8.0 %), 1-2 years (33.6 %), and 2-5 years (24.4 %) after HNSCC diagnosis. We detected 11 SPTs in 10 patients (5.0 %, 95 %CI 2.4 %-8.9 %) during synchronous (6/85) and metachronous (5/165) screening. Most patients had early stage SPTs (90 %) and were treated with curative intent with endoscopic resection (80 %). No SPTs in screened patients were detected with routine imaging for HNSCC before endoscopic screening., Conclusion: In 5 % of patients with HNSCC, an SPT was detected with endoscopic screening. Endoscopic screening should be considered in selected HNSCC patients to detect early stage SPTs, based on highest SPT risk and life expectancy according to HNSCC and comorbidities., Competing Interests: 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 License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Background: Confirming the diagnosis, invasiveness, and disease extent of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas is challenging. The aim of this study was to summarize the literature on the efficacy and safety of peroral pancreatoscopy (POP) in the diagnosis of IPMN, including the impact of pre- and intraoperative POP on the management of IPMN., Methods: The EMBASE, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar databases were systematically searched for articles. Eligible articles investigated cohorts of patients who underwent POP for (suspected) IPMN., Results: 25 articles were identified and included in this review; with 22 of these reporting on the diagnostic yield of POP in IPMN and 11 reporting on the effect of pre- or intraoperative POP on clinical decision-making. Cannulation and observation rates, and overall diagnostic accuracy were high across all studies. Frequently reported visual characteristics of IPMN were intraductal fish-egg-like lesions, hypervascularity, and granular mucosa. Overall, the adverse event rate was 12 %, primarily consisting of post-endoscopic retrograde cholangiopancreatography pancreatitis, with a pooled rate of 10 %, mostly of mild severity. Regarding the impact of POP on clinical decision-making, POP findings altered the surgical approach in 13 %-62 % of patients., Conclusion: POP is technically successful in the vast majority of patients with (suspected) IPMN, has a consistently high diagnostic accuracy, but an adverse event rate of 12 %. Data on intraoperative pancreatoscopy are scarce, but small studies suggest its use can alter surgical management. Future studies are needed to better define the role of POP in the diagnostic work-up of IPMN., Competing Interests: M.J. Bruno received research funding from Boston Scientific, Cook Medical, Pentax Medical, InterScope, and Mylan; he is a consultant to Boston Scientific, Cook Medical, and Pentax Medical. M. Ellrichmann received research funding from Boston Scientific and is a consultant to Boston Scientific. L. Kylänpää is a speaker and consultant for Boston Scientific, Cook Medical, and Olympus. A. Anderloni is a consultant for Boston Scientific. George Webster is a consultant and invited speaker for Boston Scientific, Cook Endoscopy, and Pentax Medical. The remaining 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 License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Introduction: Duodenal stent placement is a palliative option for management of malignant gastric outlet obstruction (GOO). In the last 20 years, management of gastrointestinal cancers has considerably changed. It is unknown if these changes have affected clinical outcome of duodenal stent placement., Methods: Retrospective cohort study conducted in a tertiary referral center. Patients who underwent duodenal stent placement for GOO-symptoms due to a malignant stricture were included. Primary outcome was GOO-symptom free survival. Secondary outcomes included stent-related adverse event rates. Potential explanatory parameters such as period of stent placement (1998-2009 vs 2010-2019), prior treatments, peritoneal deposits, and stricture length were evaluated using multivariable Cox regression analysis., Results: A total of 147 patients (62 % male; median age 64 years) were included. After a median of 28 days after stent placement, 82 patients (57 %) had recurrent GOO-symptoms. GOO-symptom free survival was significantly lower in 2010-2019 (P < 0.01). Time period was the only independent predictor for reduced GOO-symptom free survival (HR 1.76, P < 0.01). Stent-related adverse event rates increased over time (1998-2009: 31 % vs 2010-2019: 37 %). Prior treatment with chemotherapy and/or radiotherapy was significantly associated with an increased risk of adverse events (OR 2.53, P = 0.02)., Conclusions: Clinical outcome of duodenal stent placement did not improve over time. The decreased GOO-symptom free survival and increased adverse event rate in more recent years are probably related to the chemo- and/or radiotherapy treatment provided prior to duodenal stent placement., Competing Interests: M. C. W. Spaander has received research support from Medtronic, Norgine, and Boston Scientific. P. D. Siersema has recieved research support from Pentax, The E-Nose company, Lucid Diagnostics, MicroTech, Motus GI, Magentiq Eye and Endo Tools Therapeutics. M. J. Bruno has recieved research support from Boston Scientific, Cook Medical, Pentax Medical, Mylan, Interscope and ChiRoStim., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Background: To mitigate duodenoscope contamination, recent design enhancements have primarily focused on the distal tip. However, the working channels remain unchanged, which may be linked to biofilm formation. We assessed the persistence of microorganisms, indicative of biofilm formation, in reprocessed duodenoscopes in a non-clinical endoscopic retrograde cholangiopancreatography (ERCP) simulation setting., Methods: Three new duodenoscopes were over-soiled in non-clinical ERCP simulations followed by reprocessing. After 40 tests, the Pseudomonas aeruginosa strain in the soil (Pa-type 1) was switched to a different P. aeruginosa strain (Pa-type 2) for 20 subsequent tests. Cultures of the tip and working channel were acquired after high level disinfection and overnight storage., Results: One duodenoscope showed persistent growth of P. aeruginosa from the fifth test until the end of the study. Pa-type 1 remained present until the end of the study in the cultures of this duodenoscope, even after discontinuation of exposure to that specific strain. The other two duodenoscopes only showed incidental contamination., Conclusion: Persistent contamination by Pa-type 1 was seen in one out of three duodenoscopes after exposure to supraphysiological levels of gut microorganisms. No clear explanation was found for this persistent contamination as exposure and handling were identical and no abnormalities of this particular duodenoscope were identified by borescope inspection., Competing Interests: JA Kwakman has received grants from Pentax Medical and Boston Scientific. MJ Bruno has received grants from 3M, Pentax Medical, Boston Scientific, Mylan, and Interscope, and is a consultant for Boston Scientific and Cook Medical. MC Vos has received grants from 3M, Pentax Medical, and Boston Scientific. The remaining author declares that he has no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: In 2018, the European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology (UEG) published quality performance measures for endoscopic retrograde cholangiopancreatography (ERCP). Since January 2016, all endoscopists in the Netherlands have been required to register all ERCP procedures in a nationwide quality registry. This study aimed to evaluate the procedural success rates of ERCP after the implementation of mandatory national registration and to compare these with the ESGE quality performance measures., Methods: This study was conducted with data from a multicenter endoscopy database. Data from 2019 and 2020 were analyzed. The primary outcome was ERCP procedural outcome. ESGE performance measures that could be evaluated were the percentage of successful bile duct cannulations in patients with virgin papillary anatomy; successful stent placement for a biliary obstruction located below the liver hilum; and complete removal of bile duct stones (< 10 mm)., Result: In total, 5295 ERCPs performed in 11 centers were included for analysis. The overall procedural success rate was 89.1 %. Successful biliary cannulation in patients with a virgin papilla was 90.3 % in nonacademic and 92.4 % in academic centers. The rates of successful stent placement in patients with a biliary obstruction located below the liver hilum were 97.0 % in nonacademic and 98.2 % in academic centers, and of successful bile duct stone extraction were 97.9 % in both nonacademic and academic centers., Conclusions: The quality of ERCPs performed met five of the six evaluated ESGE performance measures. The 95 % target for successful biliary cannulation in patients with virgin papillary anatomy in academic centers was not met. Mandatory registration provides valuable insight into ERCP performance rates., Competing Interests: M.J. Bruno has provided consultancy for and has received support for industry- and investigator-initiated studies from Boston Scientific and Cook Medical; and has received support for investigator-initiated studies from Pentax Medical, Mylan, and ChiRoStim. R.J.T. Ouwendijk has received research grants from Janssen Netherlands, and the Coolsingel Foundation. P.D. Siersema has received research grants from Norgine, Pentax, MicroTech, Yakult and Motus GI; and is on the advisory board of Motus GI and Boston Scientific. The remaining authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: The risk of exogenous infections from endoscopic procedures is often cited as almost negligible (1 infection in 1.8 million procedures); however, this risk is based on older literature and does not seem to match the number of infectious outbreaks due to contaminated duodenoscopes reported after endoscopic retrograde cholangiopancreatography (ERCP). Using Dutch data, we aimed to estimate the minimum risk of duodenoscope-associated infection (DAI) and colonization (DAC) in patients undergoing ERCP., Methods: A systematic literature search identified all DAI outbreaks in the Netherlands reported between 2008 and 2019. Included cases were confirmed by molecular matching of patient and duodenoscope cultures. Risk ratios were calculated based on the total number of ERCPs performed during the study period., Results: Three outbreaks were reported and published between 2008 and 2018, including 21 confirmed DAI cases and 52 confirmed DAC cases. The estimated number of ERCPs performed during the same period was 181 209-227 006. The calculated minimum estimated DAI risk was approximately 0.01 % and the minimum estimated DAC risk was 0.023 %-0.029 %., Conclusions: The estimated risk of DAI in Dutch ERCP practice was at least 180 times higher than previously published risk estimates. The actual risk is likely to be (much) higher due to underreporting of infections caused by multidrug-resistant organisms and sensitive bacteria. Greater awareness by healthcare personnel involved in endoscopy and endoscope cleaning is required, as well as innovative technical solutions to contain and ultimately eliminate DAIs., Competing Interests: J.A. Kwakman has received grant funding from Pentax Medical and Boston Scientific. M.C. Vos has received grant funding from 3 M, Pentax Medical, and Boston Scientific (development of disposable duodenoscopes). M.J. Bruno is a consultant for Boston Scientific (development of disposable duodenoscopes) and Cook Medical, and has received grant funding from Boston Scientific (development of disposable duodenoscopes), Cook Medical, Pentax Medical, 3 M, Mylan, and InterScope. N.S. Erler has no conflicts of interest., (Thieme. All rights reserved.)

Background: Lymph node metastasis (LNM) is possible after endoscopic resection of early esophageal adenocarcinoma (EAC). This study aimed to develop and internally validate a prediction model that estimates the individual risk of metastases in patients with pT1b EAC., Methods: A nationwide, retrospective, multicenter cohort study was conducted in patients with pT1b EAC treated with endoscopic resection and/or surgery between 1989 and 2016. The primary end point was presence of LNM in surgical resection specimens or detection of metastases during follow-up. All resection specimens were histologically reassessed by specialist gastrointestinal pathologists. Subdistribution hazard regression analysis was used to develop the prediction model. The discriminative ability of this model was assessed using the c-statistic., Results: 248 patients with pT1b EAC were included. Metastases were seen in 78 patients, and the 5-year cumulative incidence was 30.9 % (95 % confidence interval [CI] 25.1 %-36.8 %). The risk of metastases increased with submucosal invasion depth (subdistribution hazard ratio [SHR] 1.08, 95 %CI 1.02-1.14, for every increase of 500 μm), lymphovascular invasion (SHR 2.95, 95 %CI 1.95-4.45), and for larger tumors (SHR 1.23, 95 %CI 1.10-1.37, for every increase of 10 mm). The model demonstrated good discriminative ability (c-statistic 0.81, 95 %CI 0.75-0.86)., Conclusions: A third of patients with pT1b EAC experienced metastases within 5 years. The probability of developing post-resection metastases was estimated with a personalized predicted risk score incorporating tumor invasion depth, tumor size, and lymphovascular invasion. This model requires external validation before implementation into clinical practice., Competing Interests: A. D. Koch has received consultancy fee from ERBE Elektromedizin and Pentax Medical. He has received research support from Dr Falk Pharma. M. J. Bruno is a consultant for Boston Scientific, Cook Medical and Pentax Medical. He has received support for industry and investigator initiated studies from Boston Scientific, Cook Medical, Pentax Medical, Mylan, ChiRoStim and 3M. M. I van Berge Henegouwen is consultant for Mylan, Johnson & Johnson, Alesi Surgical and Medtronic, and received research grants from Olympus and Stryker., (Thieme. All rights reserved.)

Background: Endoscopic ultrasound (EUS)-guided tissue acquisition is extensively used, but the optimal sampling device is still a matter of debate. We performed meta-analyses on studies comparing fine-needle aspiration (FNA) with fine-needle biopsy (FNB) needles, and studies comparing different FNB needles., Methods: Online databases were searched for randomized controlled trials (RCTs) of at least 50 cases with a suspected solid pancreatic or nonpancreatic lesion that compared FNA with FNB needles. Outcome measures included diagnostic accuracy, adequacy, number of passes, presence of tissue cores, and adverse events. We also performed meta-regression analysis on the effect of FNB design on diagnostic accuracy. Quality was assessed using the QUADAS-2 tool., Results: 18 RCTs comparing FNA with FNB needles were included. FNB provided a higher pooled diagnostic accuracy (87 % vs. 80 %; P  = 0.02) and tissue core rate (80 % vs. 62 %; P  = 0.002), and allowed diagnosis with fewer passes ( P  = 0.03), in both pancreatic and nonpancreatic lesions. A total of 93 studies were included comparing different FNB devices. Pooled diagnostic accuracy was higher for forward-facing bevel needles than for the reverse bevel needle. In this analysis, study quality was low and heterogeneity was high ( I2  = 80 %)., Conclusion: FNB outperformed FNA when sampling pancreatic and nonpancreatic lesions. Forward-facing bevel FNB needles seemed to outperform the reverse bevel FNB needle, but the low quality of evidence prevents us from making strong recommendations on the optimal FNB design., Competing Interests: Dr. van Riet is a consultant for Cook Medical Devices. Dr. Bruno is a consultant and lectures for Cook Medical and Boston Scientific. All other authors declare that they have no conflicts of interest., (Thieme. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background:  COVID-19 has dramatically affected gastrointestinal endoscopy practice. We aimed to investigate its impact on procedure types, indications, and findings., Methods:  We retrospectively analyzed endoscopies performed in 15 Dutch hospitals by comparing periods 15 March to 25 June of 2019 and 2020 using the prospective Trans.IT database., Results:  During lockdown in 2020, 9776 patients underwent endoscopy compared with 19 296 in 2019. Gastroscopies decreased by 57 % (from 7846 to 4467) and colonoscopies by 45 % (from 12219 to 5609), whereas endoscopic retrograde cholangiopancreatography volumes remained comparable (from 578 to 522). Although endoscopy results indicative of cancer decreased (from 524 to 340), the likelihood of detecting cancer during endoscopy increased (2.7 % [95 % confidence interval (CI) 2.5 - 3.0] in 2019 versus 3.5 % [95 %CI 3.1 - 3.9] in 2020; P  < 0.001). After lifting of lockdown, endoscopy volumes started to return to normal, except for colorectal cancer screening., Conclusions:  Fewer endoscopies were performed during the COVID-19 lockdown, leading to a significant reduction in the absolute detection of cancer. Endoscopies increased rapidly after lockdown, except for colorectal cancer screening., Competing Interests: Prof. Bruno is a consultant for and has received support for industry- and investigator-initiated studies from Boston Scientific and Cook Medical. He has also received support for investigator-initiated studies from Pentax Medical, Mylan, and ChiRoStim. Dr. Ouwendijk has received research grants from Janssen Netherlands, Olympus, and the Coolsingel Foundation. Prof. Siersema has received research grants from Norgine, Pentax, Microtech, Yakult, and Motus GI (ongoing), and is an advisory board member for Motus GI. All other authors declare that they have no conflicts of interest., (Thieme. All rights reserved.)

Background: The majority of patients with symptomatic sterile walled-off necrosis (WON) can be treated conservatively. Although endoscopic transluminal drainage (ETD) is often performed in cases of persistent symptoms, post-procedural iatrogenic infection may occur. This study aimed to evaluate clinical outcomes after ETD of symptomatic sterile WON., Methods: This was a retrospective, multicenter, open-label case series of 56 patients with necrotizing pancreatitis who underwent ETD for symptomatic sterile WON between July 2001 and August 2018 at two tertiary referral hospitals. Primary end point was clinically relevant post-procedural iatrogenic infection, defined as need for endoscopic transluminal necrosectomy. Secondary end points included mortality, total number of interventions, hospital stay, and resolution of symptoms at 1-year follow-up.  RESULTS : ETD of sterile WON was performed in 56 patients (median age 55 years, 57 % male), who presented with abdominal pain (71 %), gastric outlet obstruction (45 %), jaundice (20 %), and failure to thrive (27 %). A total of 41 patients (73 %) developed clinically relevant post-procedural iatrogenic infection, resulting in a median of 3 (interquartile range [IQR] 2 - 4) endoscopic, radiological, and/or surgical interventions. Mortality rate was 2 %. Median total hospital stay was 12 days (IQR 6 - 17). Resolution of symptoms was reported in 40 of 46 patients (87 %) for whom long-term follow-up data were available (median follow-up 13 months, IQR 6 - 29)., Conclusions: ETD of symptomatic sterile WON resulted in high clinical success. Nonetheless, the majority of patients required additional reinterventions for clinically relevant post-procedural iatrogenic infection., Competing Interests: Dr. Fockens has received research support from Boston Scientific and personal fees from Cook Medical, Ethicon Endo-Surgery, and Olympus. Dr. Poley has received speaker fees and has acted as a consultant for Cook Medical, Boston Scientific, and Pentax. Dr. van Hooft has received research support from Cook Medical and Mylan, and has acted as a consultant for Metronics and Boston Scientific. Dr. Bruno has received research support from Boston Scientific, Cook Medical, Pentax, and 3 M, and has acted as a consultant for Boston Scientific, Cook Medical, Pentax, and Mylan. Dr. Voermans has received research support from Boston Scientific and has acted as a consultant for Boston Scientific. Drs. Boxhoorn, Drs. Fritzsche, and Dr. de Jonge declare that they have no conflicts of interest., (Thieme. All rights reserved.)

Background: Endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) are potential tools for the detection of residual disease after neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer. This study investigated yield of EUS and FNA for detection of malignant lymph nodes (LNs) after nCRT., Methods: This was a post hoc analysis of the preSANO trial. EUS was performed 10 - 12 weeks after nCRT. 18F-fluorodeoxyglucose positron emission tomography - computed tomography ( 18 F-FDG PET-CT) was used to guide targeting of suspicious LNs. Consecutive FNA sampling was performed for suspicious LNs identified on EUS and/or PET-CT. EUS nodal staging was compared with histopathological examination of the resection specimen. The primary outcome was the proportion of correctly identified patients with malignant LNs by radial EUS., Results: 101 consecutive patients were included: 79 patients had no malignant LNs, of whom 62 were classified correctly by EUS (specificity 78 %); 22 patients had malignant LNs, of whom 11 were identified (sensitivity 50 %). Six of these patients had ≥ 1 suspicious LN not fulfilling EUS criteria (round, hypoechogenic, > 5 mm). Malignant LNs in falsely negative patients were predominantly located at distal LN stations. Specificity and sensitivity of conclusive FNA outcomes were 100 % (7/7) and 75 % (3/4), respectively. FNA outcome was uncertain in eight patients, half of whom appeared to have malignant LNs., Conclusions: EUS only detected 50 % of patients with malignant LNs 10 - 12 weeks after nCRT. To optimize sensitivity and minimize the risk of missing residual disease, FNA of LNs should be performed even in cases of low endosonographic suspicion., Competing Interests: The authors declare that they have no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Instead of choosing one endoscopic ultrasound (EUS) needle over the other, some advocate the use of fine-needle aspiration (FNA) and fine-needle biopsy (FNB) consecutively. We explored the yield of combined use of 20 G FNB and 25 G FNA needles in patients with a suspicious solid gastrointestinal lesion., Methods: Patients from the ASPRO study who were sampled with both needles during the same procedure were included. The incremental yield of dual sampling compared with the yield of single needle use on the diagnostic accuracy for malignancy was assessed for both dual sampling approaches - FNA followed by FNB, and vice versa., Results: 73 patients were included. There were 39 (53 %) pancreatic lesions, 18 (25 %) submucosal masses, and 16 (22 %) lymph nodes. FNA was used first in 24 patients (33 %) and FNB was used first in 49 (67 %). Generally, FNB was performed after FNA to collect tissue for ancillary testing (75 %), whereas FNA was used after FNB to allow for on-site pathological assessment (76 %). Diagnostic accuracy for malignancy of single needle use increased from 78 % to 92 % with dual sampling ( P  = 0.002). FNA followed by FNB improved the diagnostic accuracy for malignancy ( P  = 0.03), whereas FNB followed by FNA did not ( P  = 0.13)., Conclusion: Dual sampling only improved diagnostic accuracy when 25 G FNA was followed by 20 G FNB and not vice versa. As the diagnostic benefit of the 20 G FNB over the 25 G FNA needle has recently been proven, sampling with the FNB needle seems a logical first choice., Competing Interests: Dr. van Riet was a consultant for Cook Medical Devices during the UEGW in 2016. Dr. Bruno is a consultant and lectures for Cook Medical and Boston Scientific., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Guidelines aim to reduce treatment variation and improve quality of care. In the literature there is large variation in the reported rates of adherence to recommendations of surveillance for Barrett's esophagus (BE). The aim of this systematic review was to identify explanatory parameters determining these differences in adherence rates., Methods: Embase, Medline Epub, and Web of Science were searched. Studies reporting adherence in at least one of five domains were selected: general domain, surveillance interval, biopsy protocol, landmark identification, and histopathological information. Adherence was expressed as the proportion of endoscopies or endoscopists being in accordance with guideline recommendations. Variation in adherence was evaluated by 1) meta-regression of adherence rates in random effects meta-analysis to define subgroups, and 2) compiling an overview of the most reported explanatory parameters for (non)adherence., Results: 56 studies, including 14 002 BE patients and 4932 endoscopists, were included. Subgroup analysis showed that variation in rates of adherences to surveillance interval recommendations ( I 2  = 98 % - 99 %) was explained by difference in country (43 %), by practice type (90 %), and by year of publication (11 %). Variation in adherence to the Seattle protocol was explained by difference in country (14 %). Factors most frequently reported to be associated with better adherence were shorter BE length, salaried employment, surveillance in university hospitals, and dedicated programs., Conclusions: This study provides insight into the variability of rates of adherence to BE surveillance recommendations between studies. Better adherence in university hospitals and dedicated programs indicate that persistent alertness of guidelines is important., Competing Interests: None, (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Self-expandable metal stents (SEMSs) are effective for improving dysphagia in patients with incurable esophageal cancer but are also associated with recurrent dysphagia and adverse events. In the past decades, new SEMSs have been introduced, but also patients' risk profiles have altered. It is unknown if these changes have affected SEMS outcomes., Methods: This retrospective cohort study was conducted in a tertiary referral center in the Netherlands. Patients who underwent palliative esophageal SEMS placement for malignant dysphagia between 1994 and 2017 were included. The primary outcome was to assess shifts over time with respect to recurrent dysphagia and adverse events after SEMS placement., Results: 997 patients who underwent SEMS placement were included. Recurrent dysphagia occurred in 309 patients (31 %) and remained stable, although with a trend towards an increase over time (hazard ratio [HR] 1.02 per 1-year increase; P  = 0.05). Migration rate significantly increased over time (HR 1.04 per 1-year increase; P  = 0.01). SEMS-related complications occurred in 461 patients (46.2 %), with 207 (20.7 %) major and 336 (33.7 %) minor complications. Prior chemoradiotherapy was significantly associated with major complications (HR 1.69; P  < 0.001). Pain was the most common adverse event and showed a significant increase over time ( P  < 0.01). Factors associated with pain were prior chemoradiotherapy, absence of a fistula, axial and radial forces, and squamous cell carcinoma., Conclusions: Despite the introduction of novel esophageal SEMS designs, recurrent dysphagia has not declined over the years. Stent-related complications have increased in recent years, which seems to be mainly associated with more frequent use of chemoradiotherapy prior to SEMS placement., Competing Interests: Prof. Bruno has received personal fees as lecturer and consultant. Reports having received institutional financial support for industry and investigator initiated studies from Boston Scientific, Cook Medical, Pentax Medical and 3M. Prof. Siersema has received research support from Ella-CS, Boston Scientific USA and Cook Medical Ireland. Dr. Spaander has received institutional financial support for investigator initiated studies from Boston Scientific. The remaining authors have no competing interests to report., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Covered esophageal self-expandable metal stents (SEMSs) are currently used for palliation of malignant dysphagia. The optimal extent of the covering to prevent recurrent obstruction is unknown. Therefore, we aimed to compare fully covered (FC) versus partially covered (PC) SEMSs in patients with incurable malignant esophageal stenosis., Methods: In this multicenter randomized controlled trial, 98 incurable patients with dysphagia caused by a malignant stricture of the esophagus or cardia were randomized 1:1 to an FC-SEMS or PC-SEMS. The primary outcome was recurrent obstruction after endoscopic SEMS placement. Secondary outcomes were technical and clinical success, adverse events, and health-related quality of life (HRQoL). Patients were followed until 6 months after SEMS placement or to SEMS removal, second SEMS insertion, or death, whichever came first., Results: Recurrent obstruction after SEMS placement was similar for both types of stents: 19 % for FC-SEMSs and 22 % for PC-SEMSs ( P  = 0.65). The times to recurrent obstruction did not differ. The frequency of adverse events was similar between the two groups, with major adverse events occurring in 38 % and 47 % of patients for FC-SEMSs and PC-SEMSs, respectively ( P  = 0.34). No significant differences were seen in technical success, improvement of dysphagia, and HRQoL. Proximal esophageal stenosis and female sex were independently associated with recurrent obstruction and/or major adverse events., Conclusions: Esophageal FC-SEMSs did not reveal a lower recurrent obstruction rate compared with PC-SEMSs in the palliative management of malignant dysphagia., Competing Interests: Manon C. W. Spaander has received funding for reserach from Scientific. Marco J. Bruno is a consultant and lecturer for Boston Scientific and Cook Medical., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Marco J. Bruno received consultant and lecturer fees for: Boston Scientific group, Cook Medical and 3M. He also received industry and investigator initiated grants for: Boston Scientific group, Cook Medical and 3M.J. W. Poley received: consultancy, travel and speaker’s fees for: Boston Scientific group, Cook Medical and Pentax.

Background and study aims  Treatment strategies for clinical (c)T2N0M0 esophageal adenocarcinoma (EAC) are subject to debate owing to the relative inaccuracy of tumor staging by endoscopic ultrasound (EUS), with profound implications in overstaged patients. We aimed to evaluate the final histological diagnosis of patients initially staged as having a cT2 tumor by EUS, and to assess the value of endoscopic reassessment by an interventional endoscopist, followed by an endoscopic resection when deemed feasible. Patients and methods  Two distinct cohorts of patients with cT2 EAC as determined by EUS were included: a retrospective surgical cohort of patients treated by primary esophagectomy, and a prospective cohort of patients who underwent an endoscopic reassessment by an interventional endoscopist. The main outcome measure was the final pathological (p)T stage. Results  We identified 134 patients with stage T2 EAC from the surgical cohort. In 72 patients treated by primary esophagectomy, 32/72 (44 %) were downstaged to a pT1 tumor. In 12/72 (17 %), the surgical resection specimen showed tumor characteristics that fulfilled the current criteria for a curative endoscopic resection. In 13 prospectively identified patients with cT2N0M0 EAC, an expert endoscopic reassessment was done. In 11/13 (85 %) the lesion appeared endoscopically resectable and a complete endoscopic resection was performed. Histology revealed a pT1 tumor in all 11 patients, with 5/13 (38 %) fulfilling current criteria for a curative endoscopic resection. Conclusions  In this study, 44 % of cT2 EACs were in fact pT1 tumors. Curative treatment by endoscopic resection was achieved in more than a third of these cases. To avoid an unnecessary esophagectomy, an endoscopic reassessment by an interventional endoscopist is recommended for all patients with cT2N0M0 EAC., Competing Interests: Competing interests: None, (© Georg Thieme Verlag KG Stuttgart · New York.)

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE), endorsed by the European Society for Radiotherapy and Oncology (ESTRO), the European Society of Digestive Endoscopy (ESDO), and the European Society for Clinical Nutrition and Metabolism (ESPEN). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations for malignant disease 1 ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliative treatment of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass (strong recommendation, high quality evidence). 2 For patients with longer life expectancy, ESGE recommends brachytherapy as a valid alternative or in addition to stenting in esophageal cancer patients with malignant dysphagia. Brachytherapy may provide a survival advantage and possibly a better quality of life compared to SEMS placement alone. (Strong recommendation, high quality evidence.) 3 ESGE recommends esophageal SEMS placement as the preferred treatment for sealing malignant tracheoesophageal or bronchoesophageal fistula (strong recommendation, low quality evidence). 4 ESGE does not recommend the use of concurrent external radiotherapy and esophageal stent treatment. SEMS placement is also not recommended as a bridge to surgery or prior to preoperative chemoradiotherapy. It is associated with a high incidence of adverse events and alternative satisfactory options such as placement of a feeding tube are available. (Strong recommendation, low quality evidence.) Main recommendations for benign disease 1 ESGE recommends against the use of self-expandable stents (SEMSs) as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and costs (strong recommendation, low quality evidence). 2 ESGE suggests consideration of temporary placement of SEMSs as therapy for refractory benign esophageal strictures (weak recommendation, moderate evidence). Stents should usually be removed at a maximum of 3 months (strong recommendation, weak quality evidence). 3 ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures, because of their lack of embedment and ease of removability (weak recommendation, low quality evidence). 4 For the removal of partially covered esophageal SEMSs that are embedded, ESGE recommends the stent-in-stent technique (strong recommendation, low quality evidence). 5 ESGE recommends that temporary stent placement can be considered for treating esophageal leaks, fistulas, and perforations. The optimal stenting duration remains unclear and should be individualized. (Strong recommendation, low quality evidence.) 6 ESGE recommends placement of a SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive esophageal variceal bleeding (strong recommendation, moderate quality evidence)., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: Infections are a recognized risk of endoscopic retrograde cholangiopancreatography (ERCP). This paper reports on a large outbreak of VIM-2-producing Pseudomonas aeruginosa that was linked to the use of a recently introduced duodenoscope with a specific modified design (Olympus TJF-Q180V)., Methods: Epidemiological investigations and molecular typing were executed in order to identify the source of the outbreak. Audits on implementation of infection control measures were performed. Additional infection control strategies were implemented to prevent further transmission. The design and the ability to clean and disinfect the duodenoscope were evaluated, and the distal tip was dismantled., Results: From January to April 2012, 30 patients with a VIM-2-positive P. aeruginosa were identified, of whom 22 had undergone an ERCP using a specific duodenoscope, the TJF-Q180V. This was a significant increase compared with the hospital-wide baseline level of 2 - 3 cases per month. Clonal relatedness of the VIM-2 P. aeruginosa was confirmed for all 22 cases and for the VIM-2 strain isolated from the recess under the forceps elevator of the duodenoscope. An investigational study of the new modified design, including the dismantling of the duodenoscope tip, revealed that the fixed distal cap hampered cleaning and disinfection, and that the O-ring might not seal the forceps elevator axis sufficiently. The high monthly number of cases decreased below the pre-existing baseline level following withdrawal of the TJF-Q180V device from clinical use., Conclusions: Duodenoscope design modifications may compromise microbiological safety as illustrated by this outbreak. Extensive pre-marketing validation of the reprocessability of any new endoscope design and stringent post-marketing surveillance are therefore mandatory., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: Despite significant interest from health care authorities, patient organizations, and insurance companies, data on procedural outcome and quality of endoscopic retrograde cholangiopancreatography (ERCP) in general and academic practice are sparse. The aims of this study were to assess procedural outcome of ERCP within a large prospective registry in The Netherlands, and to evaluate associations between endoscopist-related factors and procedural outcome., Methods: All endoscopists performing ERCP in The Netherlands were invited to register their ERCPs over a 1-year period using the Rotterdam Assessment Form for ERCP (RAF-E). The primary outcome measure was procedural success. A priori difficulty level of the procedure was classified according to Schutz. Baseline characteristics of the endoscopist (e. g. previous experience) were recorded at study entry. Regression analysis was performed to identify predictors of procedural outcome., Results: A total of 8575 ERCPs were registered by 171 endoscopists from 61 centers, constituting about 50 % of all ERCPs performed nationally during the study period. Overall procedural success was 85.8 %. Intact papillary anatomy was present in 5106 patients (59.5 %): procedural success in this subgroup of patients was 83.4 % vs. 89.4 % after sphincterotomy (P < 0.001). Multivariate logistic regression identified "degree of difficulty," "intact papillary anatomy," and "previous ERCP failure" to be independently associated with procedural failure. "Yearly volume of ERCPs" and "trainee involvement" were independently associated with success., Conclusions: The nationwide prospective RAF-E registry proved to be a valuable tool to gain insight into procedural outcome of ERCPs., (© Georg Thieme Verlag KG Stuttgart · New York.)