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Background and study aims Endoscopic drainage of benign biliary and pancreatic strictures can be challenging, especially when tightness of the stenosis does not allow passage of mechanical and pneumatic dilation catheters. Electroincision of benign biliopancreatic can be considered in selected cases.Patients and methods Three male patients (mean age 33 years, range 9-60) underwent endoscopic retrograde cholangiopancreatography to drain anastomotic biliary stricture (ABS) following orthotopic liver transplantation (n =2) and pancreatic duct stenosis due to abdominal trauma (n= 1). The biliopancreatic strictures could be passed only with a thin 0.020-inch hydrophilic guidewire. Conventional mechanical and pneumatic dilators failed to pass the strictures due to weakness of the guidewire. Therefore, electrosurgical incision by over-the-wire 6Fr cystotome or needle-knife was attempted using pure cut current.Results The two cases of ABS were approached also by cholangioscopy and the 6Fr cystotome easily passed the strictures, allowing subsequent pneumatic dilatation and insertion of multiple plastic stents. The patient with a pancreatic duct stricture underwent electrosurgical incision using a thin needle knife over-the-wire, resulting in insertion of a 7Fr pancreatic stent. No adverse events occurred; all the patients were discharged within 24 to 48 hours.

Background and study aims The aim of this study was to assess long-term clinical outcomes beyond 6 years in patients who underwent per-oral endoscopic myotomy (POEM) for the treatment of achalasia.Patients and methods Patients with achalasia who underwent POEM between 2010 and 2012 and had follow-up of at least 6 years were retrospectively identified at eight tertiary care centers. The primary outcome evaluated was clinical success defined by an Eckardt symptom score (ESS) <= 3 for the duration of the follow-up period. The clinical success cohort was compared to failure (ESS >3 at any time during follow-up) in order to identify characteristics associated with symptom relapse. The incidence of patient-reported gastroesophageal reflux (GER) was also evaluated.Results Seventy-three patients with 6-year follow-up data were identified. Sustained clinical remission was noted in 89% (65/73) at 6-years. Mean ESS decreased from 7.1 +/- 2.3 pre-procedure to 1.1 +/- 1.1 at 6 years (P<0.001). Symptomatic reflux was reported by 27 of 72 patients (37.5%). Type I achalasia (OR 10.8, P=0.04) was found to be associated with clinical failure on logistic regression analysis.Conclusions In patients with achalasia, POEM provides high initial clinical success with excellent long-term outcomes. There are high rates of patient-reported gastro-esophageal reflux post-procedure which persist at long-term follow-up.

Background and study aims The need for hospital beds during the COVID-19 pandemic almost overwhelmed the health care systems all over the world. Therefore, elective non-life-saving procedures were postponed. We decided to perform all colorectal endoscopic mucosal dissections (ESDs) for challenging lesions as outpatient procedures, organizing an ad hoc path to management of any delayed post-procedural complications. The aim of the present study was to retrospectively evaluate the feasibility and safety of outpatient ESD for colorectal tumors. Patients and methods From March 2020 to May 2020, outpatient colorectal ESDs were performed for 15 challenging lesions. We retrospectively investigated feasibility and safety of the procedures, rates of en bloc resection, and complications rates. Results The mean age of the patients was 66.5 years and 40% of the them were on antiplatelet/anticoagulation therapy. Median size of removed lesions was 45mm (range 32-77) and 38mm (range 24 to 55) Five patients (33%) had rectal tumors extending to the dentate line and four (26.6%) were recurrences on a scar of previous endoscopic or surgical local resections. All complications, such as bleeding or visible microperforation, were managed endoscopically and no delayed perforations occurred. One patient had fever (37.5 degrees C), while three patients complained of anal pain after ESD for a rectal tumor that extended to the dentate line (RTDL); all patients were managed conservatively. Conclusion Outpatient colorectal ESD is feasible and safe for challenging lesions. It reduces costs of hospitalization but direct access to the endoscopy service to manage potential post-ESD complications should always be guaranteed.

Background and study aims Current data show that traditional training methods in endoscopic retrograde cholangiopancreatography (ERCP) fall short of producing competent trainees. We aimed to evaluate whether a novel approach to simulator-based training might improve the learning curve for novice endoscopists training in ERCP.Methods We conducted a multicenter, randomized controlled trial using a validated mechanical simulator (the Bokoski-Costamagna trainer). Trainees with no experience in ERCP received either standard cannulation training or motion training before undergoing standard cannulation training on the mechanical simulator. Trainees were timed and graded on their performance in selective cannulation of four different papilla configurations.Results Thirty-six trainees (16 in the motion training group, 20 in the standard group) performed 720 timed attempts at cannulating the bile duct on the simulator. Successful cannulation was achieved in 698 of 720 attempts (96.9%), with no significant difference between the two study groups ( P =0.37). Trainees in the motion training group had significantly lower median cannulation times compared to the standard group (36 vs. 48 seconds, P =0.001) and better technical performance on the first papilla type ( P =0.013).Conclusions Our findings suggest that motion training could be an innovative method aimed at accelerating the learning curve of novice trainees in the early phase of their training. Future studies are needed to establish its role in ERCP training programs.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure with a relatively high rate of adverse events. Data on training of operators and fulfillment of quality indicators in Italy are scarce. The goal of this study was to assess the overall quality of ERCP in Italy compared to international standards.Patients and methods This was a prospective, observational study from different Italian centers performing ERCP. Operators answered a questionnaire, then recorded data on ERCPs over a 1-to 3-month period.Results Nineteen Italian centers participated in the study. The most common concern of operators about training was the lack of structured programs. Seven/19 centers routinely used conscious sedation for ERCP. Forty-one experienced operators and 21 trainees performed 766 ERCPs: a successful deep biliary cannulation in native-papilla patients was achieved in 95.1% of cases; the post-ERCP pancreatitis (PEP) rate was 5.4% in native-papilla patients; cholangitis rate was 1.0%; bleeding and perforation occurred in 2.7% and 0.4% of the patients, respectively.Conclusions This study revealed that, overall, ERCP is performed in the participating Italian centers meeting good quality standards, but structured training and sedation practice are still subpar. The bleeding and perforation rate slightly exceeded the American Society of Gastrointestinal Endoscopy indicator targets but they are comparable to the reported rates from other international surveys.

Laparoscopic sleeve gastrectomy (LSG) is the current standard for bariatric surgery, but it is affected by several postoperative complications. Endoscopic sleeve gastroplasty (ESG) was created as a less invasive alternative to LSG. However, its efficacy and safety compared with LSG is unclear.

Background and study aims Laparoscopic sleeve gastrectomy (LSG) is the current standard for bariatric surgery, but it is affected by several postoperative complications. Endoscopic sleeve gastroplasty (ESG) was created as a less invasive alternative to LSG. However, its efficacy and safety compared with LSG is unclear.Materials and methods Relevant publications were identified in MEDLINE/Cochrane/EMBASE/OVID/ PROSPERO and NIH up to January 2020. Studies were selected that included obese patients with a baseline body mass index (BMI) between 30 and 40kg/m(2) with a minimum of 12 months of follow-up and with reported incidence of complications. The mean difference in percentage of excess weight loss (%EWL) at 12 months between LSG and ESG represented the primary endpoint. We also assessed the difference in pooled rate of adverse events. The quality of the studies and heterogeneity among them was analyzed.Results Sixteen studies were selected for a total of 2188 patients (LSG: 1429; ESG: 759) with a mean BMI 34.34 and 34.72 kg/m(2) for LSG and ESG, respectively. Mean %EWL was 80.32% (+/- 12.20; 95% CI; P = 0.001; I-2 = 98.88) and 62.20% (+/- 4.38; 95% CI; P = 0.005; I-2 = 65.52) for the LSG and ESG groups, respectively, corresponding to an absolute difference of 18.12% (+/- 0.89; 95% CI, P = 0.0001). The difference in terms of mean rate of adverse events was 0.19% (+/- 0.37; 95 %CI;. 2 = 1.602; P = 0.2056).Conclusions Our analysis showed a moderate superiority of LSG versus ESG. No difference in terms of safety was shown between the two groups. ESG is a less-invasive, repeatable and reversable and acceptable option for mild-moderate obese patients.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) requires extensive hands-on training. Currently in ERCP training there are two very important problems that need attention: lack of standardized commands for communication, and misunderstanding between the trainee and the trainer. Methods A method of "blind-eye" cannulation was developed with two paired trainees using the Boskoski-Costamagna ERCP Trainer. The trainee who was holding the duodenoscope was blind-folded and the other trainee gave instructions on what maneuvers were necessary to achieve cannulation, under the supervision of a trainer. Before starting cannulation, a standard list of commands was agreed by the operators. Results The blind-eye method of cannulation teaches the operator trainee to listen and the assistant trainee to teach. Trainees use standardized commands. During the training session the two trainees swapped roles. Conclusions Currently, we do not have proof that this type of training is useful, therefore, scientific studies are needed for confirmation. However, we believe that this ERCP model may provide an entirely safe means of improving communication and technical proficiency.

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