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Main RecommendationsThe European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in ERCP and EUS. This curriculum is set out in terms of the prerequisites prior to training; recommended steps of training to a defined syllabus; the quality of training; and how competence should be defined and evidenced before independent practice. 1 Trainees should be competent in gastroscopy prior to commencing training. Formal training courses and the use of simulation in training are recommended. 2 Trainees should keep a contemporaneous logbook of their procedures, including key performance indicators and the degree of independence. Structured formative assessment is encouraged to enhance feedback. There should be a summative assessment process prior to commencing independent practice to ensure there is robust evidence of competence. This evidence should include a review of a trainee’s procedure volume and current performance measures. A period of mentoring is strongly recommended in the early stages of independent practice. 3 Specifically for ERCP, all trainees should be competent up to Schutz level 2 complexity (management of distal biliary strictures and stones > 10 mm), with advanced ERCP requiring a further period of training. Prior to independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 300 cases, a native papilla cannulation rate of ≥ 80 % (90 % after a period of mentored independent practice), complete stones clearance of ≥ 85 %, and successful stenting of distal biliary strictures of ≥ 90 % (90 % and 95 % respectively after a mentored period of independent practice). 4 The progression of EUS training and competence attainment should start from diagnostic EUS and then proceed to basic therapeutic EUS, and finally to advanced therapeutic EUS. Before independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 250 cases (75 fine-needle aspirations/biopsies [FNA/FNBs]), satisfactory visualization of key anatomical landmarks in ≥ 90 % of cases, and an FNA/FNB accuracy rate of ≥ 85 %. ESGE recognizes the often inadequate quality of the evidence and the need for further studies pertaining to training in advanced endoscopy, particularly in relation to therapeutic EUS.

Background and study aims The etiology of idiopathic acute pancreatitis (IAP) should always be defined. Our aim was to compare the diagnostic value of endoscopic ultrasound (EUS) versus secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) in patients with IAP. Patients and Methods Patients admitted to a single tertiary care University hospital with IAP were invited to participate in the study. Enrolled patients underwent EUS and S-MRCP in a single-blinded comparative study. EUS and S-MRCP were performed no sooner than 4 weeks after discharge. The diagnostic yield of EUS and S-MRCP and demographic variables were included in the analysis. Additional follow-up, results of subsequent serology, radiographic exams, and relevant histological analysis were considered in determination of the final diagnosis. Results A total of 34 patients were enrolled; EUS was normal in six, cholelithiasis was defined in 15, choledocholithiasis in two, pancreas divisum in three, branch-type intraductal papillary mucinous tumor (IPMT) in three, and chronic pancreatitis in five. S-MRCP identified choledocholithiasis in one, divisum in four, branch-type IPMT in three, chronic pancreatitis in two; 24 subjects diagnosed as normal by S-MRCP. Diagnostic correlation between EUS and S-MRCP was slight (kappa = 0.236, 95 % confidence interval: 0.055–0.416). EUS provided a statistically significantly higher diagnostic yield than S-MRCP: 79.4 % (CI95 %: 65 %–94 %) vs 29.4 % (CI95 %: 13 %–46 %) (P = 0.0002). The sensitivity, specificity, and positive and negative predictive values of EUS and S-MRCP were 90 %, 80 %, 96 %, 57 % and 33 %, 100 %, 100 % and 16 %, respectively. Conclusion The diagnostic yield of EUS is higher than S-MRCP in patients with IAP.

Aims To assess the efficacy of a protocol based on two different levels of protective equipment (PE) to avoid Covid 19(C19) infections in the endoscopy unit. Methods To resume our endoscopic activity after the first wave of C19 infection, a protection protocol depending on C19reverse transcription polymerase chain reaction (PCR) test result and clinical triage before endoscopy was established. Twoprotection levels were defined: Low (negative PCR and triage), requiring basic protection (hat, gloves, permeable coat, surgical mask in lower and fpp2 in upper endoscopy);and high (positive PCR or symptoms), requiring advanced protection(hat, ocular protection, fpp2 mask, gloves and waterpro of coat). Non urgent endoscopies where cancelled if PCR waspositive. A prospective research evaluating the efficacy of this protocol was completed from april 27th to june 24th. Patientswhere contacted 2 weeks later to exclude a possible C19 infection. Results 2304 patients, 46.1 % women, were included with mean age of 59.88 ±15,547. 987 gastroscopies, 1084colonoscopies, 113 ERCP, 101 ecoendoscopies, 9 enteroscopies and 173 rectosigmoidoscopies were performed. PreviousPCR was made to 2302 patients and was positive in 10 (7 endoscopies were cancelled). We classiffied 2291 (99.7 %)patients as low risk and 13 as high. The PE used by the endoscopist was considered appropriate in 42.2 %, excessive in 41 % and insufficient in 16.7 % according to the protection protocol. This was influenced by the endoscopist (p < 0,01) and thetype of endoscopy: in 43.1 % of the colonoscopies the PE was excessive (p < 0,001). None of the endoscopists were infectedby C19 during the research period. We contacted 1744 patients (75.9 %) with no suspicion of C19 in any. Conclusions A protocol based on two protection levels according to the risk of patients to be infected and the type ofendoscopic procedure, seems to be useful to avoid C19 infections in the endoscopy unit.

Background and study aims Interventional endoscopic treatments including the application of glue are becoming more frequently used for the treatment of esophageal fistulas. However, there are no prospective studies of endoscopic treatment for esophageal fistulas. This prospective study aims to investigate the efficacy and safety of endoscopic injection of alpha-cyanoacrylate monomer for intractable esophageal fistulas. Patients and methods This single-center prospective phase II trial included patients with more than 1 wk of conservative medical treatment for intractable esophageal fistulas after esophagectomy. In the image-guided therapy suite, a mixture of alpha-cyanoacrylate monomer and oily contrast agent in a ratio of 0.3 to 1.7 mL was endoscopically injected through the fistula. Results Twenty-five patients who underwent esophagectomy at Wakayama Medical University Hospital were enrolled in this study. The primary disease was esophageal cancer in 16 patients (64 %) and gastric cancer in the remaining 9 patients (36 %). Complete closure of the esophageal fistula was performed in 22 patients after endoscopic injection of alpha-cyanoacrylate monomer. The overall success rate was 88 %. There was no fistula recurrence in any successful closure cases. Three patients with failed esophageal fistula closure had esophageal cancer with cervical esophageal fistulas and required reoperation of the fistulectomy under general anesthesia. No complications associated with this endoscopic treatment were detected. Conclusions Endoscopic treatment with injection of alpha-cyanoacrylate monomer facilitated healing of post-esophagectomy fistula in 88 % of patients without complications. This suggests that the treatment is effective and safe for patients with esophageal fistulas.

Introduccion: La pancreaticogastrostomia (PG) y pancreaticoduodenostomia (PD) guiadas por ecoendoscopia permiten el drenaje transparietal del conducto pancreatico cuando no es posible por via transpapilar. Objetivo: evaluar resultados tecnicos y clinicos obtenidos con la PG/PD en nuestro medio. Identificar variantes tecnicas asociadas al exito tecnico y clinico. Metodo: Analisis retrospectivo incluyendo la experiencia en PG/PD de 6 anos en 5 hospitales terciarios. Variables: epidemiologicas, indicacion, evolucion clinica posterior, complicaciones precoces (primer mes) y tardias (tras el primer mes). En el seguimiento distinguimos un grupo al que se hizo recambio programado de las protesis (Grupo A), y otro con recambio segun clinica (Grupo B). Resultados: 27 PG/PD (edad media: 53,6 anos). La indicacion fue: estenosis (23); desconexion ductal (3), fistula pancreaticocutanea (1). El 92% presentaban dolor de semiologia pancreatica. Exito tecnico en 85% realizando 20 PG y 3 PD. Complicaciones precoces (15%): dolor (2), pancreatitis (1) y coleccion (1). Complicaciones tardias (19%): obstruccion de protesis (1), pancreatolitiasis (1), migracion de protesis (2), neumatosis cistoide (1). Hubo complicaciones tardias en 100% de PD vs. 10% de PG. Exito clinico en 95% de pacientes con exito tecnico, resolviendose el dolor en el 95%. Seguimiento medio: 21,8 meses. El 39% de los pacientes pertenecian al Grupo A, en todos se hizo recambio programado de la protesis mientras el 14% del Grupo B lo requirio (p 0,05), ni evolucion clinica (Exito clinico: 89%vs100%, p > 0,05) entre ambos grupos. Conclusiones: El exito tecnico de la PG/PD ecoendoscopica alcanza el 85% con exito clinico del 95%, destacando una excelente respuesta del dolor. Nuestros datos orientan a que no es necesario programar recambios de las protesis y a un mayor indice de complicaciones en relacion a la PD.

Introduccion: La valoracion ductal pancreatica en pacientes con colecciones pancreaticas drenadas por via transmural es beneficiosa pero controvertida y autores recomiendan no retirar las protesis transmurales. Objetivo: Analizar resultados de valoracion ductal pancreatica mediante CPRE en pacientes con colecciones drenadas via transmural. Material y Metodo: Estudio retrospectivo incluyendo CPRE realizadas en los ultimos 4 anos para valoracion ductal pancreatica en pacientes sometidos a drenaje endoscopico transmural de colecciones pancreaticas. Incluimos: pacientes > 18 anos con consentimiento informado. Excluimos: drenaje transpapilar de colecciones como unica terapeutica. Todas las CPRE fueron realizadas por un endoscopista. Variables: patologia ductal, tratamiento realizado, resolucion de patologia ductal, complicaciones de CPRE, resolucion y recurrencia de coleccion pancreatica. Aprobado por CEIC de nuestro centro. Resultados: Incluimos 48 drenajes endoscopicos de colecciones pancreaticas. En 17 no se realizo CPRE por falta de consentimiento informado, mala evolucion clinica u otros. En 14 de los 31 restantes solo se realizo drenaje transpapilar. Finalmente analizamos 17 pacientes. En 10 la coleccion fue por pancreatitis aguda y en 7 por pancreatitis cronica. Encontramos patologia ductal en 15 de estos 17 pacientes (88%): disrupcion parcial (4), completa (2) con desconexion ductal (otros 2), estenosis (3) y asociada a disrupcion parcial (otros 2) y pancreatolitiasis (1). La relacion con pancreatitis aguda o cronica no influyo en la presencia de patologia ductal (p < 0,05). En los 15 pacientes con patologia ductal se realizo tratamiento endoscopico (eficaz en 11). Se consiguio resolucion de las colecciones en 88% y no hubo ninguna recidiva ni complicaciones en este grupo de 17 pacientes. Conclusiones: La prevalencia de patologia ductal pancreatica en pacientes con colecciones pancreaticas drenadas endoscopicamente se acerca al 90%. El tratamiento endoscopico de esta patologia es eficaz en el 73% de los casos. En nuestra serie no hemos tenido complicaciones secundarias ni recurrencia de la coleccion.

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Introduccion: El tratamiento de la disrupcion ductal pancreatica (DDP) mediante protesis pancreaticas transpapilares (PT) resuelve la DDP en el 44 – 92% de los casos, especialmente si la PT puentea la DDP, lo cual es tecnicamente muy complejo. Objetivo: Analizar los resultados del tratamiento de DDP mediante PT e influencia de diversos factores en el exito terapeutico. Material y Metodo: Analizamos retrospectivamente una base de datos prospectiva identificando pacientes sometidos a tratamiento endoscopico de DDP entre enero/09-junio/14. Analizamos tipo de DDP (parcial/completa), pancreatopatia (estenosis/pancreatolitiasis/coleccion), localizacion de PT (“en puente” cuando la PT conecto el conducto proximal y distal a DDP; “intradisrupcion” cuando la PT se coloco dentro de la DDP; “distal” cuando la PT quedo por debajo de la DDP) y resultado terapeutico. Obtuvimos aprobacion por CEIC local. Resultados: Incluimos 29 pacientes: 21 con DDP parcial y 8 completa. Asociada: pancreatolitiasis (2 casos), estenosis (17) y coleccion (27). En todos los pacientes se coloco PT: en puente (13 pacientes: 11 con DDP parcial y 2 completa), intradisrupcion (8 pacientes: 4 parcial, 4 completa) y distal (8 pacientes: 6 parcial, 2 completa). Asociamos esfinterotomia pancreatica mayor (19 pacientes) y minor (3). En dos pacientes no pudimos analizar el resultado terapeutico por cirugia y exitus. En los 27 restantes comprobamos resolucion de la disrupcion en 20 (74,1%): 14/19 parciales, 6/8 completas. La PT en puente resolvio la DDP en el 100%, la intradisrupcion en 75% y la distal en 28%. La colocacion en puente o intradisrupcion fueron significativamente mas resolutivas que la distal (90% vs. 28%; p = 0,005). El resto de variables no influyeron en el resultado. Conclusiones: El tratamiento mediante PT resuelve la DDP en el 74% de los casos. Las PT en puente o intradisrupcion son la mejor opcion subiendo el exito terapeutico al 90%.