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ABSTRACT Background and Aim Methods Results Conclusion We aimed to develop and validate a simple capsule endoscopy (CE) training assessment tool, the Capsule Endoscopy Training Assessment (CETA), and prospectively use it to analyze the learning progression achieved by participants in our CE training program.Over a 3‐year period, all participants in our CE training program completed pre‐training and post‐training CETA, ranging between 0% and 100%, and encompassing theoretical questions and interpretation of segmented CE videos. We compared the mean differences in overall, theoretical, and practical pre‐training and post‐training CETA, and assessed the influence of previous endoscopic experience (upper gastrointestinal endoscopy [UGE], colonoscopy, device‐assisted enteroscopy [DAE] and CE) using generalized linear models.Fifty‐seven participants were included. After training, there was a significant increase in participants' overall (mean difference, 26.3; 95% confidence interval [CI], 20.70 to 31.83), theoretical (mean difference, 27.2; 95% CI, 19.81 to 34.57), and practical (mean difference, 25.9; 95% CI, 20.09 to 31.63) CETA components. Compared to those without experience, participants with previous endoscopic experience demonstrated a smaller increase in overall CETA after training (UGE, rate ratio, 0.76; 95% CI, 0.63 to 0.91; colonoscopy (rate ratio, 0.80; 95% CI, 0.67 to 0.95; DAE (rate ratio, 0.84; 95% CI, 0.73 to 0.97; CE, rate ratio, 0.81; 95% CI, 0.72 to 0.92, respectively).CETA is a valid and useful tool in assessing the learning progression achieved by participants following the CE training program. We demonstrated a significant improvement in participants' CETA after training, being the least experienced participants in endoscopic procedures who benefited the most from CE training. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Aims Methods Results Conclusions Predose trough concentrations (Ctrough) of intravenous infliximab (IV‐IFX) during maintenance therapy are associated with therapeutic outcomes in patients with Crohn's disease (CD). A subcutaneous formulation of infliximab (SC‐IFX) has shown high Ctrough values due to its favourable pharmacokinetics.To evaluate the association of Ctrough of SC‐IFX with therapeutic outcomes and the threshold of SC‐IFX Ctrough for achieving mucosal healing (MH) and transmural healing (TH) in patients with CD.We performed this cross‐sectional study in patients with CD who had received SC‐IFX maintenance therapy for ≥ 6 months. We measured SC‐IFX Ctrough immediately before SC‐IFX injection. We performed ileocolonoscopy/single‐balloon enteroscopy and/or magnetic resonance enterography within 3 months of SC‐IFX Ctrough measurement. MH was defined as SES‐CD–ulcerated surface subscore of 0. TH was defined as simplified MaRIA score of 0.We enrolled 124 patients with MH in 77.9% (74/95) and TH in 36.3% (37/102). SC‐IFX Ctrough was significantly higher in patients with MH (24.1 vs.16.9 μg/mL; p = 0.001) and TH (26.0 vs. 20.5 μg/mL; p = 0.007) than in those without. ROC analysis identified that the threshold of SC‐IFX Ctrough for MH and TH were 17.5 and 30.3 μg/mL, respectively. Multivariate logistic regression showed that SC‐IFX Ctrough was significantly associated with MH (OR 1.16; 95% CI 1.05–1.27; p = 0.002) and TH (OR 1.08; 95% CI 1.02–1.14; p = 0.005).SC‐IFX Ctrough was positively associated with MH (≥ 18 μg/mL) and TH (≥ 30 μg/mL) in patients with CD, which may guide treatment decisions to optimise therapeutic response in the era of treat‐to‐target. [ABSTRACT FROM AUTHOR]

Objectives: Single‐balloon enteroscopy (SBE) is an effective tool for the detection of small intestine lesions. Because it is conventionally performed by two operators, the efficacy of single‐operator SBE method has not yet been elucidated. We aimed to evaluate the diagnostic yield, total enteroscopy rate, procedure time, and complications of single‐operator SBE for small intestinal disease. Methods: This was a single‐center, retrospective study including consecutive patients who underwent single‐operator SBE for suspicious small intestinal disorders or required therapeutic interventions between December 2014 and January 2019. The SBE procedures were performed by four endoscopists. Diagnostic yield, total enteroscopy rate, procedure time, incubation depth, and complications were analyzed, and stratification analysis was performed. Results: Altogether 922 patients with 1422 SBE procedures were included for analysis, among whom 250, 172, and 500 patients underwent SBE via the oral route, the anal route and a combined route, respectively. The overall diagnostic yield was 78.52% (724/922). And 253 patients achieved total enteroscopy, with a total enteroscopy rate of 56.10%. The average procedure time for the oral and anal routes were 69.28 ± 14.72 min and 64.95 ± 13.87 min, respectively. While the incubation depth was 389.95 ± 131.42 cm and 191.81 ± 83.67 cm, respectively. Jejunal perforation was observed in one patient, which was managed by endoclips. Stratification analysis showed that the diagnostic yield and total enteroscopy rate significantly increased with operation experience together with decreased procedure time. Conclusion: Single‐operator SBE is effective and safe for the detection of small intestinal lesions, and is easy to master. [ABSTRACT FROM AUTHOR]

Background and Aim: The study aims to evaluate the feasibility of body mass index (BMI)‐based individualized small bowel preparation for computed tomography enterography (CTE). Methods: In this prospective randomized controlled study, patients undergoing CTE were randomly assigned to the individualized group or standardized group. Those in individualized group were given different volumes of mannitol solution based on BMI (1000 mL for patients with BMI < 18.5 kg/m2, 1500 mL for patients with 18.5 kg/m2 ≤ BMI < 25 kg/m2 and 2000 mL for patients with BMI ≥ 25 kg/m2) while patients in the standardized group were all asked to consume 1500‐mL mannitol solution. CTE images were reviewed by two experienced radiologists blindly. Each segment of the small bowel was assessed for small bowel image quality and disease detection rates. Patients were invited to record a diary regarding adverse events and acceptance. Results: A total of 203 patients were enrolled and randomly divided into two groups. For patients with BMI < 18.5 kg/m2, 1000‐mL mannitol solution permitted a significantly lower rate of flatulence (P = 0.045) and defecating frequency (P = 0.011) as well as higher acceptance score (P = 0.015), but did not affect bowel image quality and diseases detection compared with conventional dosage. For patients with BMI ≥ 25 kg/m2, 2000‐mL mannitol solution provided better overall image quality (P = 0.033) but comparable rates of adverse events and patients' acceptance compared with conventional dosage. Conclusions: Individualized bowel preparation could achieve both satisfactory image quality and patients' acceptance thus might be an acceptable alternative in CTE. [ABSTRACT FROM AUTHOR]

Aim: Preoperative frailty has been associated with adverse postoperative outcomes in various populations, but of its use in patients with inflammatory bowel disease (IBD) remains sparse. The present study aimed to characterize the impact of frailty, as measured by the modified frailty index (mFI), on postoperative clinical and resource utilization outcomes in patients with IBD. Methods: This retrospective population‐based cohort study assessed patients from the National Inpatient Sample database from 1 September 2015 to 31 December 2019. Corresponding International Classification of Diseases 10th Revision Clinical Modification codes were used to identify adult patients (>18 years of age) with IBD, undergoing either small bowel resection, colectomy or proctectomy. Patient demographics and institutional data were collected for each patient to calculate the 11‐point mFI. Patients were categorized as either frail or robust using a cut‐off of 0.27. Primary outcomes were postoperative in‐hospital morbidity and mortality, whilst secondary outcomes included system‐specific morbidity, length of stay, in‐hospital healthcare costs and discharge disposition. Logistic and linear regression models were used for primary and secondary outcomes. Results: Overall, 7144 patients with IBD undergoing small bowel resection, colectomy or proctectomy were identified, 337 of whom were classified as frail (i.e., mFI < 0.27). Frail patients were more likely to be women, older, have lower income and a greater number of comorbidities. After adjusting for relevant covariates, frail patients were at greater odds of in‐hospital mortality (adjusted odds ratio [aOR] 5.42, 95% CI 2.31–12.77, P < 0.001), overall morbidity (aOR 1.72, 95% CI 1.30–2.28, P < 0.001), increased length of stay (adjusted mean difference 1.3 days, 95% CI 0.09–2.50, P = 0.035) and less likely to be discharged to home (aOR 0.59, 95% CI 0.45–0.77, P < 0.001) compared to their robust counterparts. Conclusions: Frail IBD patients are at greater risk of postoperative mortality and morbidity, and reduced likelihood of discharge to home, following surgery. This has implications for clinicians designing care pathways for IBD patients following surgery. [ABSTRACT FROM AUTHOR]

Background: Endoscopic resection (ER) for jejunoileal lesions (JILs) has been technically challenging. We aimed to characterize the clinicopathologic characteristics, feasibility, and safety of ER for JILs. Method: We retrospectively investigated 52 patients with JILs who underwent ER from January 2012 to February 2022. We collected and analyzed clinicopathological characteristics, procedure‐related parameters, outcomes, and follow‐up data. Results: The mean age was 49.4 years. Of the 52 JILs, 33 ileal tumors within 20 cm from the ileocecal valve were resected with colonoscopy, while 19 tumors in the jejunum or the ileum over 20 cm from the ileocecal valve received enteroscopy resection. The mean procedure duration was 49.0 min. The en bloc resection and en bloc with R0 resection rates were 86.5% and 84.6%, respectively. Adverse events (AEs) included one (1.9%) major AE (delayed bleeding) and five (9.6%) minor AEs. During a median follow‐up of 36.5 months, two patients had local recurrence (3.8%), while none had metastases. The 5‐year recurrence‐free survival (RFS) and disease‐specific survival (DSS) were 92.9% and 94.1%, respectively. Compared with the enteroscopy group, overall AEs were significantly lower in the colonoscopy group (P < 0.05), but no statistical differences were observed in RFS (P = 0.412) and DSS (P = 0.579). There were no significant differences in AEs, RFS, and DSS between the endoscopic submucosal dissection (ESD) and the endoscopic mucosal resection (EMR) group. Conclusions: ER of JILs has favorable short‐term and long‐term outcomes. Both ESD and EMR can safely and effectively resect JILs in appropriately selected cases. [ABSTRACT FROM AUTHOR]

Objectives: Blue rubber bleb nevus syndrome (BRBNS) is a rare challenging cause of gastrointestinal bleeding. We performed a systematic review of case reports and case series on BRBNS to gather information on the treatment options currently available. Methods: All studies reporting a case of BRBNS in humans were evaluated. Papers were ruled out if CARE criteria and explanations on patient's selection, ascertainment, causality, and reporting were not respected or identified. PROSPERO 2021 CRD 42021286982. Results: Blue rubber bleb nevus syndrome was treated in 106 cases from 76 reports. 57.5% of the population was under 18 years old, and up to 50% of the cases reported a previous treatment. Clinical success was achieved in 98 patients (92.4%). Three main types of interventions were identified: systemic drug therapy, endoscopy, and surgery. After BRBNS recurrence or previous therapy failure, systemic drug therapy emerged as a preferred second‐line treatment over endoscopy (P = 0.01), but with a higher rate of reported adverse events when compared with surgery and endoscopy (P < 0.001). Endoscopic treatment was associated with a higher number of required sessions to achieve complete eradication when compared with surgery (P < 0.001). No differences between the three main areas were found in the overall follow‐up time (P = 0.19) or in the recurrence rate (P = 0.45). Conclusion: Endoscopy, surgery, and systemic drug therapy are feasible treatment options for BRBNS. Systemic drug therapy was the favorite second‐line treatment after endoscopic failure or recurrence of BRBNS, but adverse events were more frequently reported. [ABSTRACT FROM AUTHOR]

This article discusses the feasibility, safety, and benefits of laparoscopic intracorporeal Kono-S anastomosis for Crohn's disease. Crohn's disease is a chronic inflammatory disease that often requires surgical intervention, which can lead to complications such as anastomotic leak and recurrence. The Kono-S anastomosis is a novel technique that has been shown to have lower rates of recurrence and reoperation compared to standard anastomosis methods. The article presents a case study of a patient who underwent laparoscopic intracorporeal Kono-S anastomosis with successful outcomes. The authors conclude that this technique is safe and effective, avoiding the need for larger incisions and reducing the risk of complications. [Extracted from the article]

Background and Aims. Intestinal ultrasound (IUS) is considered a nonirradiating, noninvasive, well-tolerated, and valuable tool for objectively assessing Crohn's disease (CD) activity. However, there is no widely accepted intestinal ultrasound scoring system. This study is aimed at evaluating the efficacy of IUS key parameters, the International Bowel Ultrasound Activity Score (IBUS-SAS), and IBUS-SAS combined with blood inflammatory markers in assessing CD activity. Methods. 40 CD patients were reviewed in this retrospective study and were divided into the moderate-severe group (n = 25) and nonmoderate-severe group (n = 15) based on a simplified endoscopic score of Crohn's disease (SES-CD). Double-balloon enteroscopy/colonoscopy were reviewed by three gastroenterologists. A transabdominal ultrasound was performed by two ultrasound specialists. Blood inflammatory markers were measured from morning samples. Results. In evaluating moderate to severe CD patients, (1) IBUS-SAS had a good predictive effect with an area-under-the-curve (AUC) of 0.855 (P < 0.001); (2) IUS key parameters (including BWT, CDS, BWS, and I-fat) yielded good predictive effects with AUC of 0.811, 0.731, 0.724, and 0.747, respectively (P < 0.001); (3) blood inflammatory markers (including ESR, CRP, PLR, MLR, and NLR) also had good predictive effects with AUC of 0.771, 0.837, 0.728, 0.743, and 0.775, respectively (P < 0.001); (4) IBUS-SAS combined with ESR and CRP exerted the best predictive effect with the highest AUC of 0.912 (95% CI: 0.823-1.000), and the sensitivity and specificity were 88.0% and 80.0%, respectively (P < 0.001). Conclusion. IBUS-SAS combined with ESR and CRP is a more efficient tool than IBUS-SAS alone or inflammatory markers alone in evaluating CD patients with moderate to severe disease activity. [ABSTRACT FROM AUTHOR]

Introduction: The number and invasion depth of endometriotic bowel lesions, total length of bowel affected by endometriosis, lesion‐to‐anal verge distance, and extent of pouch of Douglas obliteration are important factors in preoperatively determining risk and complexity of endometriosis surgery. The intra‐ and interobserver reproducibility of transvaginal ultrasound in the evaluation of many of these parameters has not yet been investigated. Our study aimed to assess the intra‐ and interobserver reproducibility of transvaginal ultrasound between an experienced and less experienced examiner for all of these parameters. Material and methods: This prospective observational cross‐sectional study was conducted between July 2019 and November 2020. Fifty consecutive premenopausal women who underwent transvaginal ultrasound examination in our clinic for the first time, were examined by the same two operators during the same attendance. Outcomes of interest were the inter‐rater reproducibility of transvaginal ultrasound for detecting the presence, number, depth and size of bowel endometriotic nodules, lesion‐to‐anal‐verge distance, total length of bowel affected, and pouch of Douglas obliteration. The intraobserver reproducibility was assessed for the continuous parameters. Cohen's kappa (κ) statistic, Cohen's weighted kappa (κ), proportions of agreement, intraclass correlation coefficient (ICC) and Bland–Altman limits of agreement were used to assess the reproducibility of the parameters. Results: The inter‐rater agreement and reliability were very good for identifying bowel endometriosis, the number and invasion depth of bowel nodules, determining whether the maximum nodule length was <3 cm, and lesion‐to‐anal‐verge distance <8 cm (proportion of agreement 0.92, 0.94, 0.97, 0.94, 0.96; κ 0.92, 0.91, 0.92, 0.82, 0.89). The inter‐rater agreement and reliability were good for assessing pouch of Douglas obliteration (proportion of agreement 0.86, κ 0.80). The intra‐rater reliability for the mean nodule diameter (ICC 0.93 and 0.97) and total length of bowel affected (ICC 0.94 and 0.91) were excellent for operators A and B, respectively. The inter‐rater reliability for the mean nodule diameter was good (ICC 0.80), and moderate for the total length of bowel affected (ICC 0.70). The Bland–Altman limits of agreement demonstrated clinically acceptable ranges for these two parameters. Conclusions: This study demonstrated a high intra‐ and inter‐rater reproducibility of transvaginal ultrasound in the diagnosis of bowel endometriosis and measurement of its various components. [ABSTRACT FROM AUTHOR]

The article in the ANZ Journal of Surgery discusses the addition of a proximal duodenojejunostomy to Roux‐en‐Y reconstruction following total gastrectomy to enable future endoscopic surveillance of the duodenum. This technique was developed to address challenges in accessing the duodenum for surveillance in clinical scenarios such as familial adenomatous polyposis syndrome or post-gastric resection for cancer. The study describes the surgical procedure in detail and highlights the feasibility and safety of incorporating a proximal duodenojejunostomy for endoscopic surveillance post-total gastrectomy. [Extracted from the article]

Background: Laparoscopic postoperatives outcomes in adhesiolysis are promising but conversion and morbidity remains high. The objective of our study was to determine preoperative factors to individualize and select the most appropriate approach for each patient. Methods: Patients ≥18 years old undergoing emergent surgery for adhesive small bowel obstruction and internal hernias were evaluated. Bivariate and multivariate analysis were performed to investigate factors related to conversion to open surgery and to the type of adhesions. Results: Of 333 patients, 224 were operated by laparotomy and 109 by laparoscopy (conversion rate: 40%). Previous abdominal wall mesh, type of adhesions, bowel lesion, need for intestinal resection and laparoscopic skills were statistically related to conversion. In the multivariate analysis, complex adhesions (OR 4.3, 95% CI 1.5–12.2; P = 0.006), the need for intestinal resection (OR 14.16, 95% CI 2.55–78.68; P = 0.002), and non‐advanced laparoscopy surgeons (OR 4.31, 95% CI 1.56–11.94; P = 0.005) were independent factors for conversion to open surgery. ASA III–IV, previous surgeries, previous abdominal mesh and previous adhesiolysis were related to complex adhesions. Previous laparoscopic surgery and internal hernia or closed loop in computed tomography were associated with simple adhesions as a cause of the obstruction. In the multivariate, previous adhesiolysis (OR 4.76, 95% CI 1.23–18.3; P = 0.023) and the findings on computed tomography were significantly related with the type of adhesion. Conclusion: Some preoperative factors allow to individualize the surgical approach in the adhesive small bowel obstruction improving surgical outcomes. [ABSTRACT FROM AUTHOR]

Introduction. Balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) is a useful therapeutic procedure that provides promising results in patients with surgically altered anatomy. However, biliary cannulation in BE-ERCP remains challenging. Therefore, in patients with Roux-en-Y gastrectomy, this study aimed to evaluate a BE-ERCP cannulation strategy that includes the newly developed alpha-retroflex scope position. Methods. This was a retrospective review of 52 patients with Roux-en-Y gastrectomy who underwent BE-ERCP at two centers between April 2017 and December 2022. In these patients, three types of scope position had been used for biliary cannulation: straight (S-position), J-retroflex (J-position), and alpha-retroflex (A-position). First, the S-position was used for biliary cannulation. Then, if biliary cannulation was difficult with this position, the J-position was used, followed by the A-position, if necessary. Results. The biliary cannulation success rate was 96.6% (50/52). The S-, J-, and A-positions achieved successful biliary cannulation in 24 (48%), 14 (28%), and 12 patients (24%), respectively. No adverse events, including post-ERCP pancreatitis and perforation, occurred. Conclusion. This was the first study of a cannulation strategy that included the A-position in addition to the S- and J-positions. The study showed that the A-position is feasible and safe in BE-ERCP in patients with Roux-en-Y gastrectomy. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ultrasound‐guided antegrade treatment (EUS‐AG) and balloon endoscopy‐assisted endoscopic retrograde cholangiopancreatography (BE‐ERCP) have emerged as useful procedures for managing bile duct stones (BDS) in patients with surgically altered anatomy. However, the comparison between these two procedures has not been well studied. The aim of our study was to compare the clinical outcomes of EUS‐AG and BE‐ERCP for managing BDS in patients with surgically altered anatomy. Methods: The database was retrospectively evaluated at two tertiary care centers to identify patients with surgically altered anatomy who underwent either EUS‐AG or BE‐ERCP for BDS. Clinical outcomes were compared between the procedures. The success rate of each procedure was evaluated in three steps: endoscopic approach, biliary access, and stone extraction. Results: Among the 119 identified patients, 23 had EUS‐AG, and 96 had BE‐ERCP. The overall technical success rates of EUS‐AG and BE‐ERCP were 65.2% (15/23) and 69.8% (67/96), respectively (P =.80). The comparison of each step between the procedures EUS‐AG versus BE‐ERCP was as follows: endoscopic approach, 100% (23/23) versus 88.5% (85/96) (P =.11); biliary access, 73.9% (17/23) versus 80.0% (68/85) (P =.57); stone extraction, 88.2% (15/17) versus 98.5% (67/68) (P =.10). The overall adverse event rate was 17.4% (4/23) versus 7.3% (7/96) (P =.22). Conclusions: Both EUS‐AG and BE‐ERCP are effective and relatively safe procedures in the management of BDS in patients with surgically altered anatomy. The challenging steps of each procedure might be different, which could help decide which one to use to manage BDS in patients with surgically altered anatomy. [ABSTRACT FROM AUTHOR]

Capsule endoscopy (CE) and balloon‐assisted enteroscopy (BAE) have become indispensable techniques for the diagnosis and management of small bowel disease in both adult and pediatric cases. However, relevant differences exist in the indications between these cohorts, with body weight and age having particular relevance in decisions for the latter. Both CE and BAE are designed for adult physique and they were not widely used among children. In addition, the types of small intestinal diseases differ between adults and children, and consequently, the indications also differ between them. This review focuses on the issues relevant to pediatric cases and describes the practical application of endoscopy in clinical practice. In conclusion, although there are age and weight restrictions, both CE and BAE are safe and useful devices for use in children, and their indications for use in children are likely to expand in the future. [ABSTRACT FROM AUTHOR]

Background and Aim: Overt obscure gastrointestinal bleeding (OOGIB) is defined as continued bleeding with unknown source despite esophagogastroduodenoscopy (EGD) and colonoscopy evaluation. Small bowel evaluation through video capsule endoscopy (VCE) or double balloon enteroscopy (DBE) is often warranted. We studied the timing of DBE in hospitalized OOGIB patients regarding diagnostic yield, therapeutic yield, and GI rebleeding. Methods: We performed a retrospective review of DBEs performed at a tertiary medical center between November 2012 and December 2020. The inclusion criterion was first admission for OOGIB undergoing DBE. Those without previous EGD or colonoscopy were excluded. Patients were stratified into two groups: DBE performed within 72 h of OOGIB (emergent) and beyond 72 h of OOGIB (nonemergent). Propensity score matching was used to adjust for the difference in patients in the two groups. Logistic regression analysis was used to assess factors associated with diagnostic and therapeutic yield. Kaplan–Meir survival curve showed GI bleed‐free survival following initial bleed and was compared using the log rank test. Results: A total of 154 patients met the inclusion criterion, of which 62 had emergent DBE and 92 had nonemergent DBE. The propensity‐score‐matched sample consisted of 112 patients, with 56 patients each in the emergent and nonemergent groups. Univariate and multivariable logistic regression analysis showed a significant association between VCE and emergent DBE and diagnostic and therapeutic yield (P < 0.05). Emergent DBE patients had increased GI bleed‐free survival compared to those in the nonemergent group (P = 0.009). Conclusion: Our data demonstrate that emergent DBE during inpatient OOGIB can impact the overall diagnostic yield, therapeutic yield, and GI rebleeding post DBE. [ABSTRACT FROM AUTHOR]

Objective: To explore the factors associated with small intestinal bacterial overgrowth (SIBO), and to further evaluate the impact of SIBO on irritable bowel syndrome (IBS) in terms of symptom severity and health‐related quality of life (HRQoL). Methods: A cross‐sectional study of consecutive adult patients who underwent glucose hydrogen breath test was conducted. Factors associated with SIBO were evaluated. Symptom severity and HRQoL of IBS patients with and without SIBO were compared. The independent factors associated with severe IBS were explored. Results: A total of 160 patients were included (median age 40 years, males 31.3%). IBS was present among 53.8% of subjects, with 33.8% having diarrhea‐predominant IBS (IBS‐D). SIBO was diagnosed in 22.5% of the study population. Patients with SIBO were more commonly diagnosed with IBS‐D than those without (50.0% vs 29.0%, P = 0.019). Severe IBS was associated with SIBO (36.4% vs 15.6%, P = 0.043). SIBO was associated with poorer HRQoL (Euroqol five‐dimensional utility score: 0.73 vs 0.80, P = 0.024). SIBO (44.4% vs 20.6%, P = 0.043), anxiety (77.8% vs. 39.7%, P = 0.004), and depression (50.0% vs 19.1%, P = 0.011) were associated with severe IBS in the univariate analysis. However, SIBO was the only independent factor associated with severe IBS in the multivariate analysis (adjusted odds ratio 3.83, 95% confidence interval CI 1.02–14.34, P = 0.046). Conclusions: There was a significant association between IBS‐D and SIBO. The coexistence of SIBO had a significant negative impact on IBS patients. [ABSTRACT FROM AUTHOR]

We report a case of hepatolithiasis 30 years after congenital biliary dilatation (CBD) surgery. A 31‐year‐old woman presented with fever and epigastric pain. She had a history of radical surgery for type I CBD at the age of 1 year and had no significant symptoms for approximately 30 years after surgery. Laboratory and imaging results showed hepatolithiasis at the common trunk of segments II and III with cholangitis. She was admitted to our hospital for antibiotics and underwent double‐balloon endoscopic retrograde cholangiography (DBERC) to treat the hepatolithiasis. Roux‐limb jejunum was perforated during DBERC; hence, emergent laparoscopic perforation site closure and simultaneous endoscopic lithotomy through the Roux‐limb jejunum with exteriorization via umbilical incision were performed. The postoperative course was uneventful, and the patient was discharged without any complications. [ABSTRACT FROM AUTHOR]

Background and Aim: We aim to evaluate the efficacy and safety of endoscopic radial incision (ERI) versus endoscopic balloon dilation (EBD) treatment of naïve, recurrent, and refractory benign esophageal anastomotic strictures. Methods: One hundred and one ERI, 145 EBD, and 42 ERI combined with EBD sessions were performed in 136 consecutive patients with benign esophageal anastomotic stricture after esophagectomy at Zhongshan Hospital from January 2016 to August 2021. Baseline characteristics, operational procedures, and clinical outcomes data were retrospectively evaluated. Parameters and recurrence‐free survival (RFS) were compared between ERI and EBD in patients with naïve or recurrent or refractory strictures. Risk factors for re‐stricture after ERI were identified using univariate and multivariate analyses. Results: Twenty‐nine ERI versus 68 EBD sessions were performed for naïve stricture, 26 ERI versus 60 EBD for recurrent strictures, and 46 ERI versus 17 EBD for refractory stricture. With comparable baseline characteristics, RFS was greater in the ERI than the EBD group for naïve strictures (P = 0.0449). The ERI group had a lower 12‐month re‐stricture rate than the EBD group (37.9% vs 61.8%, P = 0.0309) and a more prolonged patency time (181.5 ± 263.1 vs 74.5 ± 82.0, P = 0.0233). Between the two interventions, recurrent and refractory strictures had similar RFS (P = 0.0598; P = 0.7668). Multivariate analysis revealed initial ERI treatment was an independent predictive factor for lower re‐stricture risk after ERI intervention (odds ratio = 0.047, P = 0.001). Few adverse events were observed after ERI or EBD (3.0% vs 2.1%, P = 0.6918). Conclusions: ERI is associated with lower re‐stricture rates with better patency and RFS compared with EBD for naive strictures. [ABSTRACT FROM AUTHOR]

Balloon‐assisted enteroscopy allows endoscopic treatments in the deeper segments of the small bowel. Endoscopic balloon dilation has become a popular minimally invasive alternative for the treatment of Crohn's disease‐associated small intestinal strictures. As a supplement to the Clinical Practice Guidelines for Enteroscopy, the Japan Gastroenterological Endoscopy Society's Working Committee has developed the present "Guidelines for endoscopic balloon dilation in treating Crohn's disease‐associated small intestinal strictures," based on new scientific techniques and evidence. The guidelines cover standard procedures for the insertion route of the balloon endoscope, bowel preparation, indications, procedure‐related complications, efficacy, target diameter and duration, management of multiple strictures, and the current state of combined and alternative treatments. Unresolved future research questions are also listed in this guideline. [ABSTRACT FROM AUTHOR]

This article describes a laparoscopic-assisted endoscopic procedure called a "clean sweep" for removing small bowel polyps in patients with Peutz Jeghers Syndrome (PJS). The technique combines laparoscopy and intra-operative enteroscopy to completely remove hamartomas from the entire small bowel, reducing the risk of future recurrences. The procedure is minimally invasive, safe, and has good postoperative outcomes. It is intended for patients with PJS who have extensive, symptomatic, and endoscopically-unreachable or unresectable small bowel hamartomas. The article provides detailed technical instructions and includes visual aids to illustrate the procedure. [Extracted from the article]

A 44‐year‐old man presented to our hospital with lower gastrointestinal bleeding. We performed balloon‐assisted enteroscopy, which revealed diverticulum and stricture at the ileum. The patient underwent segmental small bowel resection and diagnosed with Meckel's diverticulum. We should keep in mind the possibility of intestinal stricture due to Meckel's diverticulum. [ABSTRACT FROM AUTHOR]

Background: Persistent descending mesocolon (PDM) is a fetal abnormality in which the left‐sided colon is not fused to the retroperitoneum, and it is often accompanied by the adhesion between the mesocolon and small bowel mesentery. Due to its rarity, whether PDM exhibits anatomical characteristics of the inferior mesenteric artery (IMA) and left colic artery (LCA), and how the anomaly affects laparoscopic surgery are largely unknown. We investigated the branches of these arteries and outcomes of patients who underwent laparoscopic surgery. Methods: Based on computed tomography (CT) and three‐dimensional CT angiography, branching patterns of the IMA, LCA and branches originating from the LCA were analysed in 954 patients with left‐sided colon or rectal cancer. PDM was diagnosed by preoperative CT colonography, and confirmed at time of surgery. The anatomical features of the vessels and short‐term outcomes of laparoscopic surgery were compared between patient groups stratified by PDM. Results: Twelve patients (1.3%) were diagnosed with PDM. No branching pattern of the IMA specific to PDM was noted. On the other hand, patients with PDM had fewer branches (mean: 1.0) from the LCA than those without PDM (mean: 1.8, p = 0.009). In patients undergoing laparoscopic surgery, outcomes such as operative time, intraoperative blood loss, and number of harvested nodes were comparable between the two patient groups. Conclusion: Few branches of the LCA characterize PDM. PDM does not complicate laparoscopic surgery of the left‐sided colon and rectum. However, the above anatomical feature increases the risk of poor colonic perfusion when dividing the LCA. [ABSTRACT FROM AUTHOR]

Background. The diagnosis of isolated small bowel Crohn's disease (ISBCD) has always been challenging. Aims. This study is aimed at comparing the clinical features and double-balloon enteroscopy (DBE) characteristics of ISBCD with those of other small bowel ulcerative diseases (OSBUD). Methods. Patients with coexisting colonic and/or ileal valve lesions (n = 45) or whose final diagnosis was not determined (n = 29) were excluded. One hundred thirty-nine patients with ISBCD and 62 patients with OSBUD found by DBE were retrospectively analyzed. Results. The age of ISBCD onset was lower than that of OSBUD (OR 0.957, 95% CI 0.938-0.977, p < 0.001). Abdominal pain was more common in ISBCD (OR 4.986, 95% CI 2.539-9.792, p < 0.001). Elevated fibrinogen levels (OR 1.431, 95% CI 1.022-2.003, p = 0.037) and lower levels of D-dimer (OR 0.999, 95% CI 0.999-1.000, p = 0.017) were also more supportive of the diagnosis of ISBCD. Nonsteroidal anti-inflammatory drugs (NSAIDs) used for more than two weeks decreased the probability of a diagnosis of ISBCD (OR 0.173, 95% CI 0.043-0.695, p = 0.013). Abdominal computed tomography revealed a higher proportion of skip lesions in ISBCD than in OSBUD (OR 9.728, 95% CI 3.676-25.742, p < 0.001). The ulcers of ISBCD were more distributed in the ileum (111 (79.9%) vs. 29 (46.8%), p < 0.001), and their main morphology differed in different intestinal segments. Longitudinal ulcers (OR 14.293, 95% CI 4.920-41.518, p < 0.001) and large ulcer (OR 0.128, 95% CI 0.044-0.374, p < 0.001) contributed to the differentiation of ISBCD from OSBUD. We constructed a diagnostic model, ISBCD index (AUROC = 0.877 , 95% CI: 0.830-0.925), using multifactorial binary logistic regression to help distinguish between these two groups of diseases. Conclusion. Clinical features, laboratory tests, abdominal computed tomography, DBE characteristics, and pathology help to distinguish ISBCD from OSBUD. [ABSTRACT FROM AUTHOR]

Background: Studies have suggested that physicians are steadily being paid less per Medicare service over time based on inflation‐adjusted dollars. The objective of this study was to determine whether this phenomenon was true for rhinologic procedures. Methods: This study was a retrospective analysis of the 2000‐2021 Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule investigating fees for in‐office endoscopies (Current Procedural Terminology [CPT] codes 31231‐31238), in‐office balloon ostial dilation (CPTs 31295‐31298), in‐facility low‐relative value unit (RVU) surgeries (<10 work RVUs [wRVUs]; CPTs 31239‐31288 and 61782), and in‐facility high‐RVU surgeries (>10 wRVUs; CPTs 31290‐31294). Total number of and reimbursements for these services was obtained from yearly National Part B Summary Datafiles. Results: Between 2000 and 2021, adjusted reimbursements for low‐ and high‐wRVU rhinologic surgeries decreased by 50.0% and 36.1%, respectively. The average compound annual growth rate (CAGR) decrease was 3.3% and 2.1%, respectively. Excluding a 48.3% unadjusted reimbursement increase between 2000 and 2004, endoscopies saw an adjusted reimbursement decrease of 29.4% from 2004 onward, an average CAGR of −2.1%. From 2011 onward, balloon ostial dilations saw a decrease in adjusted reimbursement of 43.8%, an average CAGR of −6.0%. Nevertheless, after inflation adjustment, National Part B data reveal that Medicare paid more, in total, for these procedures in 2019 than in 2000 due to increasing utilization. Conclusion: Medicare reimbursements are complex, adjusted yearly, and undergo constant federal scrutiny due to the increasing costs of health care. These results suggest that, in terms of real dollars, rhinologic procedures have seen a large gradual decrease in Medicare reimbursement, which is important information for policymakers and surgeons alike. [ABSTRACT FROM AUTHOR]

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Presently, following endoscopic ultrasound (EUS)‐guided biopsy, an endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stenting is performed for palliation of malignant distal biliary obstruction (MDBO). However, technical failure and postprocedure pancreatitis are limitations to ERCP. Endoscopic ultrasonography‐guided biliary drainage (EUS‐BD) after a failed ERCP has a 90% technical success rate and has been shown to be superior when compared to percutaneous methods, making EUS an increasingly recognized option for biliary drainage. Supporting this approach, findings from recently concluded randomized trials suggest that the safety profile and technical outcomes for EUS‐BD are comparable or even superior to that of ERCP for primary biliary decompression in patients with MDBO. Also, EUS‐BD is increasingly being utilized in patients with altered surgical anatomy in lieu of percutaneous techniques and balloon‐assisted enteroscopy. A growing body of evidence supports the notion that, in the future, EUS may become the primary modality by which biliary decompression is undertaken in the majority of patients with MDBO. The roadmap to this eventuality may require further optimization of procedural techniques, technological innovations, and cost reduction. [ABSTRACT FROM AUTHOR]

Background and Aim: Meckel's diverticulum (MD) is a common congenital abnormality of the gastrointestinal (GI) tract. Although a few patients with MD present symptoms, preoperative diagnosis of MD is a clinical challenge because of its endoscopic inaccessibility. The aim of the present study was to investigate patients with MD diagnosed by double‐balloon enteroscopy (DBE) in Taiwan. Methods: We conducted a retrospective study in a tertiary referral center in middle Taiwan. The clinical characteristics, endoscopic features, histopathological findings, treatment methods, and outcomes of patients with MD diagnosed by DBE were analyzed. Results: A total of 14 male patients with MD diagnosed by DBE were enrolled. The mean age of all patients was 32.3 years. GI bleeding (78.6%) accounted for the major indication of DBE, followed by abdominal pain and Crohn's disease follow‐up. The mean distance between the ileocecal valve and MD was 68.9 cm. The average length of 12 patients with surgically resected MD was 5.2 cm. The diagnostic yields of the other modalities excepting DBE are as follows: capsule endoscopy, 50%; Meckel's scan, 11.1%; computed tomography, 16.7%; small bowel series, 0%; and angiography, 33.3%. MD presented as a large ostium in 13 patients (92.9%), a small ostium in 1 patient (7.1%), and bleeding signs in 10 patients (71.4%). Twelve patients (85.7%) underwent surgical treatment and 2 patients (14.3%) received conservative treatment. Heterotopic gastric tissue was identified in 4 patients (28.6%). Conclusion: The present study showed that DBE is a more powerful modality in detecting MD than the other conventional modalities in Taiwan. [ABSTRACT FROM AUTHOR]

With the increasing use of capsule endoscopy (CE), screening tests for the small bowel can be performed with minimal invasiveness. However, occasionally, the entire small bowel cannot be observed because of decreased peristalsis of the stomach. For such cases, we perform delivery of CE by an endoscope. We retrospectively examined the usefulness of the endoscopic delivery method using a retrieval net for patients with CE stagnation in the stomach. From 2,270 patients who underwent small-bowel CE at Hiroshima University Hospital from January 2013 to January 2020, 29 consecutive patients (1.3% of the total number) in whom the small bowel could not be observed due to CE stagnation in the stomach at the time of the initial CE underwent the endoscopic delivery method using a retrieval net for secondary small-bowel CE. This study included 16 male (55%) and 13 female (45%) patients with a mean age of 69.2 ± 13.2 years. 11 patients (38%) had a history of gastrointestinal surgical resection. The entire small bowel could be observed in 19 patients (66%), and CE reached the terminal ileum in the remaining patients. A history of gastrointestinal surgical resection was significantly more frequent in the group where the entire small bowel could not be observed. The rate of small-bowel lesion detection was 55% (16/29). There were no adverse events associated with our endoscopic delivery method. Thus, the endoscopic delivery method using a retrieval net for patients with initial CE stagnation in the stomach may be safe and useful for the detection of small-bowel lesions. [ABSTRACT FROM AUTHOR]

Background and Aim: With the advent of video capsule endoscopy (VCE) and device‐assisted enteroscopy (DAE), the indication of intraoperative enteroscopy (IOE) has become limited due to reported high morbidity/mortality. Most of the earlier studies on IOE were small/from pre‐VCE/DAE era. We aimed to evaluate the impact of IOE in management of small bowel disorders (SBD) in post‐VCE/DAE era. Methods: Patients with SBD undergoing IOE over last 15 years were evaluated retrospectively. Overall diagnostic/therapeutic yield, incremental diagnostic yield over preoperative investigations, and adverse events were noted. We also evaluated the number of cases in which IOE changed the management or guided surgical or endoscopic therapy. Rebleeding and recurrence were evaluated in patients with available follow‐up data. Results: A total of 89 patients (59 male, 9–82 years) were included in the study. Overall diagnostic and therapeutic yield were 92.1% and 85.4%, respectively. Common findings of IOE were benign ulcers/strictures (30.1%), vascular lesions (26%), diverticula (15.1%), and tumors (13.7%). A total of 49.4% (44/89), 36% (32/89), and 20.2% (18/89) underwent VCE, DAE, or both, respectively, before IOE. Incremental diagnostic yield over preoperative work‐up was 31.5% (28/89), and IOE changed the management in 37.1% (33/89) patients. IOE was used to guide surgery/endotherapy in 39.3% (35/89) patients. Recurrent gastrointestinal bleed occurred in 21.2% (14/66) patients. Morbidity and mortality rates were 20.2% (18/89) and 3.4% (3/89), respectively. Conclusions: Intraoperative enteroscopy remains an essential technique to evaluate SBD and can detect new and additional lesions even after extensive preoperative evaluation. IOE is useful in guiding therapy in preoperatively identified lesions and can change management in a substantial proportion of patients. Hence, IOE has a definitive role in post‐VCE/DAE era in carefully selected patients with SBD. [ABSTRACT FROM AUTHOR]

Background: Critically ill patients frequently develop feeding intolerance, which is difficult to predict. In healthy subjects, gastric motility, assessed by nasogastric balloon tube, correlated with gastric emptying. We now investigated this correlation in critically ill patients, as well as the feasibility and safety of such application in a pilot study.Methods: Endotracheally intubated adults scheduled to receive enteral nutrition (EN) were included. After insertion of a double-lumen nasogastric balloon tube and radiographic confirmation of position, balloon pressure was recorded for 10 hours after inflation (4 hours fasted, 2 hours during administration of 13 C-labeled EN, and 4 hours postprandially). Gastric motility was expressed as Gastric Balloon Motility Index (GBMI), reflecting the fraction of time in which phasic gastric contractions occurred. Gastric emptying was assessed by 13 C-octanoate breath test and expressed as gastric half-emptying time (GET½). Correlation between GBMI (assessed in different time intervals) and GET½ was investigated by Pearson/Spearman correlation. Feasibility was defined as the success of tube placement and pressure recording. Safety was assessed based on adverse device effects.Results: Thirty patients were enrolled, of whom 19 had paired GBMI and GET½ data. There was no correlation between GBMI and GET½. The tube was successfully placed in 28/30 (93.3%) patients. In 3/28 (10.7%) patients, balloon leakage precluded analysis. Two safety events were directly linked to the device.Conclusion: This pilot study showed no significant correlation between balloon-assessed gastric motility and emptying in critically ill patients. The feasibility/safety profile of the balloon tube appears similar to that of standard nasogastric tubes. [ABSTRACT FROM AUTHOR]

Despite improvements in imaging modalities, causative lead points in adult intussusception may be difficult to diagnose. Such lead points can be malignant, causing recurrence or metastases if left unresected. We describe a case of transient adult jejunojejunal intussusception, in which intraoperative endoscopy was used to confirm the absence of a lead point. A 39-year-old woman with a history of laparoscopic oophorectomy presented with epigastric pain, nausea, and vomiting. Contrast computed tomography revealed jejunojejunal intussusception, with no visible lead point. Spontaneous reduction was confirmed during exploratory laparoscopy. After lysis of adhesions, intraoperative peroral jejunoscopy was performed with the surgeons' assistance. Endoscopy confirmed the absence of tumor, and bowel resection was avoided. No recurrence has been observed during 24 months of follow-up. Intraoperative endoscopy may provide additional reassurance for the absence of a lead point in cases where preoperative enteroscopy cannot be performed and no lead points can be identified on imaging. [ABSTRACT FROM AUTHOR]

Majority of jejunal diverticulum is asymptomatic, but 10-30% presented with intestinal haemorrhage, small bowel perforation, diverticulitis, abscess, intestinal obstruction and malabsorption.4 Jejunal diverticulum only contributes approximately 3% of all gastrointestinal bleeding. The most common cause in elderly is angiodysplasia.1 However, the current case with small bowel bleeding arising from jejunal diverticulum presented with a massive gastrointestinal bleeding resulting in an urgent laparotomy with jejunum resection. [Extracted from the article]

A 74-year-old male with a history of metastatic melanoma presents with persistently abnormal small bowel findings on PET-CT scan. The patient had persistent FDG uptake near the ileocolic junction on imaging, concerning for metastatic melanoma. Capsule endoscopy demonstrated ulcerated mucosa in the distal ileum. This area was biopsied and tattooed via retrograde double-balloon enteroscopy to confirm the diagnosis of metastatic melanoma and facilitate subsequent small bowel resection. The case illustrates a unique case of metastatic melanoma to the small bowel and the utility of capsule endoscopy and balloon-assisted enteroscopy to assist in diagnosis and management of metastatic disease. [ABSTRACT FROM AUTHOR]

Background and Aim: The implementation rates of pediatric gastrointestinal endoscopy are increasing with advancements in the devices used and pediatricians' skills. As part of the Japan Pediatric Endoscopy Study Group, we aimed to investigate the rates of pediatric gastrointestinal endoscopy use and the associated adverse events through a nationwide survey. Methods: A questionnaire was sent to 630 institutions in Japan. The numbers of pediatric gastrointestinal endoscopy cases and adverse events occurring during endoscopy, from April 2011 to March 2016, were investigated. Results: Responses were obtained from 445 facilities. The total number of pediatric gastrointestinal endoscopies was 37 447 and that of endoscopic examinations was 32 219 (86.0%), with esophagogastroduodenoscopy accounting for 18 484 cases; ileal colonoscopy, 11 936; endoscopic retrograde cholangiopancreatography, 389; wireless capsule endoscopy, 897; and balloon‐assisted enteroscopy, 513. The number of endoscopic treatments was 5228, followed by balloon dilatation (1703), foreign body removal (989), and polypectomy (822); 201 adverse events (0.54%) occurred, 79 of which presented during endoscopic examination (0.25%). Eight serious perforations were noted in 0.0054% and 0.025% of those undergoing esophagogastroduodenoscopy and colonoscopy, respectively. Overall, 122 adverse events (2.33%) occurred in association with endoscopic treatment. One case of cardiopulmonary arrest occurred because of accidental extubation. However, no deaths occurred. Conclusion: Endoscopic examinations had a slightly higher adverse event rate, because of an increase in endoscopic retrograde cholangiopancreatography and small intestine enteroscopy, than that reported in previous studies, but the adverse event rate of endoscopic treatment did not increase. [ABSTRACT FROM AUTHOR]

Objective: To report our experience with ureterolysis for the management of retroperitoneal fibrosis. Methods: The data of 25 patients who underwent ureterolysis due to primary retroperitoneal fibrosis between 2002 and 2017 were reviewed retrospectively. Initial symptoms, laterality, renal function status (initial/final), operation complications and serum creatinine levels (diagnosis/preoperative/6 months, 12 months postoperatively) were recorded. After surgery, patients were followed up by ultrasonography and serum creatinine levels. Patients with impaired results underwent furosemide renogram and/or late phase of computed tomography. Factors affecting final serum creatinine levels were evaluated. The χ2‐test was used for nominal data among groups. The level of statistical significance was set as P < 0.05. Results: A total of 19 patients (76%) were operated bilaterally. The mean follow‐up period was 46.2 ± 9.2 months. Among 44 operated renal units, non‐functioning kidney developed in seven (15.9%). A total of 34 renal units (77.3%) did not require any additional surgical intervention, and two underwent balloon dilatation (4.5%), one (2.25%) followed with double J stent changes. Two patients developed end‐stage renal disease secondary to bilateral unresolved obstruction. High final serum creatinine levels developed in eight (32%) patients without dialysis. Eight patients (32%) were treated with immunosuppressive therapy for systemic recurrence. There was a significant relationship between preoperative serum creatinine levels with final serum creatinine levels (P = 0.005). There was no statistically significant relationship between diagnosis serum creatinine levels with final serum creatinine levels and postoperative dialysis requirement (P = 0.79 and P = 0.817, respectively). Conclusions: Ureterolysis provides acceptable success with low complication rates in patients with retroperitoneal fibrosis. Preoperative high‐serum creatinine levels can be considered as a risk factor for long‐term renal impairment and these patients should be followed closely. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to define and compare the clinical course of granulomatous (GCD) vs non‐granulomatous Crohn's disease (NGCD). Methodology: All consecutive patients who had undergone small or large bowel resection for Crohn's disease from 2000 to 2008 in a District General Hospital were collated retrospectively for histological evidence of GCD vs NGCD. Patients were assessed using the Montreal classification and data were collected for the number of recurrences requiring hospital admissions, re‐operations and septic complications over a follow‐up period of 10 or more years. Results: Fifty‐four patients were included in the study, 28 had GCD and 26 NGCD. The mean follow up for both groups was 13.5 years. No patients were excluded. Patients with GCD were younger but there were no other differences in age, sex, family history and smoking status. In patients with confirmed granulomata on resectional histology, there was an increased incidence of subsequent intra‐abdominal abscess formation after surgery (P <.05), an increased number of subsequent operations (P <.05) and shorter time to recurrences requiring hospital admissions (P <.05). The granulomatous cohort of patients had an apparent but not significant increased incidence of fistulating disease and stoma formation. Conclusions: This study showed an increased risk of postoperative complications in patients with granulomatous Crohn's disease. Further studies are required to confirm that presence of granulomas in Crohn's disease is predictive of a poor prognosis and the need for more aggressive medical management. [ABSTRACT FROM AUTHOR]

We herein report the first case of rectal stenosis that developed after internal hemorrhoid treatment with aluminum potassium sulfate and tannic acid (ALTA) therapy that was successfully treated by laparoscopic surgery. A 72‐year‐old man suffered from a fever and rectal stenosis after undergoing internal hemorrhoid treatment with a submucosal injection of ALTA at a previous clinic. Three months after ALTA therapy, he developed frequent mucous and bloody stools. Lower intestinal tract endoscopy revealed circumferential severe rectal stenosis. He was therefore referred to our hospital. The patient suffered from frequent stool build‐up and difficulty defecating. We performed balloon‐dilatation intervention. The stenosis was not improved at all. Five months after ALTA therapy, we performed laparoscopic low anterior resection with diverting ileostomy. Three months after the operation, ileostomy takedown was performed. The patient has experienced no rectal stenosis in the 2 years since his radical operation. [ABSTRACT FROM AUTHOR]

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While the history of colonoscopy is lengthy, with such procedures said to have been performed before Christ walked the earth, very few advancements were made for quite some time. Development of Colonoscopy in Japan The development of colonoscopes in Japan has progressed with associated advances in gastroscopes. We herein discuss the history of the development and advancement of colonoscopy in Japan, with a focus on white-light colonoscopy, including chromoendoscopy. [Extracted from the article]

Background: The management of patients presenting with malignant small bowel obstruction is a challenging paradigm. The aim of this systematic review was to examine different management strategies in these complex patients. The primary outcomes evaluated were the type of intervention, 30‐day morbidity and mortality and overall survival rates. Methods: A systematic literature review of EMBase, Medline, PubMed and the Cochrane Library was performed using Preferred Reporting Items for Systematic reviews and Meta‐Analyses for studies reporting on conservative and operative management of malignant small bowel obstruction. Results: Fifteen studies (n = 882 patients) reporting on outcomes for malignant small bowel obstruction were analysed. Outcomes measured were primarily survival and relief of obstructive symptoms. The median age ranged from 52 to 66 years. The most common cause of malignant small bowel obstruction was gynaecological in nature (56%), followed by colorectal (19%). Four hundred and eighty‐six patients underwent primary surgical management and the remaining 396 patients were assigned to non‐surgical intervention. Median overall survival in the operative studies ranged from 2.5 to 7.4 months compared with 0.9 to 1.9 months (P < 0.05). The 30‐day mortality ranged from 13% to 28% in those who underwent surgical interventions versus 2% to 61% in the non‐surgical group (P = 0.09). No significant difference in median survival in gastrointestinal (GI) and gynaecological malignancies was observed (4.3 versus 5.0 months, P = 0.12). Morbidity ranged from 21% to 85% in the surgical group and 12% to 29% in the percutaneous groups (P < 0.05). Conclusion: Surgical intervention in malignant small bowel obstruction is associated with significant morbidity, although it may improve survival in selected patients with gynaecological and colorectal malignancy. It is imperative that realistic goals and expectations are discussed with patients preoperatively. [ABSTRACT FROM AUTHOR]

Aim: Intra‐operative enteroscopy (IE) is a valid diagnostic tool which can be adopted in order to identify the precise location of bleeding gastrointestinal angiodysplasias (GIADs) of the small bowel. We describe a novel IE technique that may increase the diagnostic yield by maintaining a steady distension of the bowel and that prevents microtrauma to the intestinal mucosa and spillage of enteric content into the operative field. Methods: After laparotomy, a centimetric transverse enterotomy is performed approximately at the middle of the small bowel. A 12‐mm trocar with balloon is then introduced and insufflated. The small bowel is gently distended by carbon dioxide insufflation. Through the trocar, a paediatric colonscope is then inserted and the enteroscopy is performed either retrogradely to the duodenum or anterogradely to the caecum. Once located, surgery is tailored to the precise site of bleeding, with a consequent sparing of intestinal resection. Results: IE with 12‐mm trocar with balloon was adopted in four elderly patients undergoing surgery for bleeding GIADs. The length of small bowel resection ranged from 10 to 200 cm, depending on the number of GIADs. Operating time ranged from 210 to 275 min. Intra‐operative blood loss was nil. No patient developed organ‐space or wound infections. There was no recurrence of bleeding from the midgut. Conclusion: Performing IE through a balloon trocar may increase the diagnostic accuracy of the procedure with the benefit of reducing the risk of traumatic injury to the bowel and the risk of surgical site infection. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a technique used to access the biliary tree in patients with surgically altered anatomy. Additionally, development of EUS-HG fistula permits intraductal therapy, thereby preventing patients from requiring surgery or percutaneous transhepatic biliary drainage (PTBD), thus decreasing morbidity. This clinical vignette describes an 83-year-old man with a history of gangrenous cholecystitis requiring cholecystectomy, partial gastrectomy, and Roux-en-Y gastrojejunostomy who presented to an outside hospital with abdominal pain and fever and found to have cholangitis and choledocholithiasis. He underwent two endoscopic retrograde cholangiopancreatography (ERCP) procedures at an outside hospital which were unsuccessful due to an inaccessible major papilla in the setting of the patient's surgically altered anatomy. On arrival to Wake Forest, the patient underwent EUS-HG with successful biliary drainage and resolution of cholangitis. He returned for ERCP three months later with balloon sphincteroplasty, cholangioscopy, and electrohydraulic lithotripsy (EHL) performed through the existing metal stent (hepaticogastrostomy), resulting in stone fragmentation and antegrade removal with balloon sweeps. Repeat cholangioscopy post-EHL and balloon sweeps showed complete duct clearance with no residual stones. The hepaticogastrostomy stent was subsequently removed, and the patient recovered without any complications. [ABSTRACT FROM AUTHOR]

Background. Gallstone ileus is an infrequent cause of small bowel obstructions (SBO), accounting for only 0.1-5% of SBOs and 25% of nonstrangulating causes of SBO in the elderly population. There is scant literature available regarding the use of laparoscopy to treat gallstone ileus. Currently, much of the literature available is limited to case reports only. Methods. A complete laparoscopic approach was utilized to manage a 65-year-old woman with morbid obesity who presented with gallstone ileus. With regard to our technical approach, we describe the technical approach that facilitates safe laparoscopic examination of the entire small bowel and can be applied to other acute care surgery cases involving small bowel pathology. Results. The patient's postoperative course was complicated by new-onset atrial fibrillation which was treated medically with good response. She was safely discharged on postoperative day 2. Conclusion. Laparoscopy is a feasible option for the management of gallstone ileus and can lead to decreased morbidity compared to laparotomy. The technique described allows for laparoscopic examination of the entire small bowel. [ABSTRACT FROM AUTHOR]

Summary: Background: Evidence for endoscopic balloon dilation of small intestinal strictures in Crohn's disease (CD) using balloon‐assisted enteroscopy is scarce. Aim: To evaluate endoscopic balloon dilation for the treatment of small intestinal CD strictures using balloon‐assisted enteroscopy. Methods: Citations in Embase, MEDLINE, and Cochrane were systematically reviewed. In a meta‐analysis of 18 studies with 463 patients and 1189 endoscopic balloon dilations, technical success was defined as the ability to dilate a stricture. Individual data were also obtained on 218 patients to identify outcome‐relevant risk factors. Results: In the pooled per‐study analysis, technical success rate of endoscopic balloon dilation was 94.9%, resulting in short‐term clinical efficacy in 82.3% of patients. Major complications occurred in 5.3% of patients. During follow‐up, 48.3% of patients reported symptom recurrence, 38.8% were re‐dilated and 27.4% proceeded to surgery. On the per‐patient‐based multivariable analysis, that patients with disease activity in the small intestine had lower short‐term clinical efficacy (odds ratio 0.32; 95% confidence interval 0.14‐0.73, P = 0.007). Patients with concomitant active disease in the small and/or large intestine had an increased risk to proceed toward surgery (hazard ratio 1.85; 95% confidence interval 1.09‐3.13, P = 0.02 and hazard ratio 1.77; 95% confidence interval 1.34‐2.34, P < 0.001). Conclusions: Balloon‐assisted enteroscopy for dilatation of CD‐associated small intestinal strictures has high short‐term technical and clinical efficacy and low complication rates. However, up to two‐thirds of patients need re‐dilation or surgery. [ABSTRACT FROM AUTHOR]

Background and aims: Endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) has been established as a safe and accurate method for diagnosing a pancreatic mass; however, EUS‐FNA for patients with surgically altered upper gastrointestinal (UGI) anatomy has not yet been investigated sufficiently. Therefore, the feasibility and safety of EUS‐FNA in these patients were retrospectively investigated. Methods: Patients in whom EUS‐FNA was performed between March 2008 and April 2017 were retrospectively investigated in terms of EUS‐FNA technical success, procedure time, diagnostic accuracies of cytology and histology, and procedure‐related adverse events. Results: Twenty‐five EUS‐FNAs were performed for 15 pancreatic body‐to‐tail and 10 head lesions. All patients underwent EUS‐FNA successfully; however, changing of the echoendoscope to a forward‐viewing echoendoscope and preplacement of a nasobiliary catheter by balloon‐assisted enteroscopy for guidance were needed in one and two cases, respectively. The median procedure time was 26 min (range, 16–70). The diagnostic accuracies were 76%, 84%, and 88% for cytology, histology, and combined use, respectively. Adverse events were not observed. Conclusions: Endoscopic ultrasound‐guided FNA is a safe and efficient method for diagnosing a pancreatic mass even in patients with surgically altered UGI anatomy. Nevertheless, some sophisticated techniques are required for pancreatic head lesions if reaching the duodenum after passing through the jejunal limb is required for visualization of the pancreatic mass. [ABSTRACT FROM AUTHOR]