Search

Abstract The growth of semiconductor (SC) nanowires (NW) by CVD using Au-catalyzed VLS process has been widely studied over the past few years. Among others SC, it is possible to grow pure Si or SiGe NW thanks to these techniques. Nevertheless, Au could deteriorate the electric properties of SC and the use of other metal catalysts will be mandatory if NW are to be designed for innovating electronic. First, this article's focus will be on SiGe NW's growth using Au catalyst. The authors managed to grow SiGe NW between 350 and 400°C. Ge concentration (x) in Si1- x Ge x NW has been successfully varied by modifying the gas flow ratio: R = GeH4/(SiH4 + GeH4). Characterization (by Raman spectroscopy and XRD) revealed concentrations varying from 0.2 to 0.46 on NW grown at 375°C, with R varying from 0.05 to 0.15. Second, the results of Si NW growths by CVD using alternatives catalysts such as platinum-, palladium- and nickel-silicides are presented. This study, carried out on a LPCVD furnace, aimed at defining Si NW growth conditions when using such catalysts. Since the growth temperatures investigated are lower than the eutectic temperatures of these Si-metal alloys, VSS growth is expected and observed. Different temperatures and HCl flow rates have been tested with the aim of minimizing 2D growth which induces an important tapering of the NW. Finally, mechanical characterization of single NW has been carried out using an AFM method developed at the LTM. It consists in measuring the deflection of an AFM tip while performing approach-retract curves at various positions along the length of a cantilevered NW. This approach allows the measurement of as-grown single NW's Young modulus and spring constant, and alleviates uncertainties inherent in single point measurement.

Abstract In a recent paper written by Hilbe et al (BMC vet res, 2009), the nature and specificity of the prion protein deposition in the kidney of feline species affected with feline spongiform encephalopathy (FSE) were clearly considered doubtful. This article was brought to our attention because we published several years ago an immunodetection of abnormal prion protein in the kidney of a cheetah affected with FSE. At this time we were convinced of its specificity but without having all the possibilities to demonstrate it. As previously published by another group, the presence of abnormal prion protein in some renal glomeruli in domestic cats affected with FSE is indeed generally considered as doubtful mainly because of low intensity detected in this organ and because control kidneys from safe animals present also a weak prion immunolabelling. Here we come back on these studies and thought it would be helpful to relay our last data to the readers of BMC Vet res for future reference on this subject. Here we come back on our material as it is possible to study and demonstrate the specificity of prion immunodetection using the PET-Blot method (Paraffin Embedded Tissue - Blot). It is admitted that this method allows detecting the Proteinase K (PK) resistant form of the abnormal prion protein (PrPres) without any confusion with unspecific immunoreaction. We re-analysed the kidney tissue versus adrenal gland and brain samples from the same cheetah affected with TSE using this PET-Blot method. The PET-Blot analysis revealed specific PrPres detection within the brain, adrenal gland and some glomeruli of the kidney, with a complete identicalness compared to our previous detection using immunohistochemistry. In conclusion, these new data enable us to confirm with assurance the presence of specific abnormal prion protein in the adrenal gland and in the kidney of the cheetah affected with FSE. It also emphasizes the usefulness for the re-examination of any available tissue blocks with the PET-Blot method as a sensitive complementary tool in case of doubtful PrP IHC results.

Background and study aims Use of fluoroscopy in gastrointestinal endoscopy is an essential aid in advanced endoscopic interventions. However, it also raises concerns about radiation exposure. This study aimed to develop consensus-based statements for safe and effective use of fluoroscopy in gastrointestinal endoscopy, prioritizing the safety and well-being of healthcare workers and patients. Methods A modified Delphi approach was employed to achieve consensus over three rounds of surveys. Proposed statements were generated in Round 1. In the second round, panelists rated potential statements on a 5-point scale, with consensus defined as ≥80% agreement. Statements were subsequently prioritized in Round 3, using a 1 (lowest priority) to 10 (highest priority) scale. Results Forty-six experts participated, consisting of 34 therapeutic endoscopists and 12 endoscopy nurses from six continents, with an overall 45.6% female representation (n = 21). Forty-three item statements were generated in the first round. Of these, 31 statements achieved consensus after the second round. These statements were categorized into General Considerations (n = 6), Education (n = 10), Pregnancy (n = 4), Family Planning (n = 2), Patient Safety (n = 4), and Staff Safety (n = 5). In the third round, accepted statements received mean priority scores ranging from 7.28 to 9.36, with 87.2% of statements rated as very high priority (mean score ≥ 9). Conclusions This study presents consensus-based statements for safe and effective use of fluoroscopy in gastrointestinal endoscopy, addressing the well-being of healthcare workers and patients. These consensus-based statements aim to mitigate risks associated with radiation exposure while maintaining benefits of fluoroscopy, ultimately promoting a culture of safety in healthcare settings., Competing Interests: Conflict of Interest Tyler Berzin - Consultant for: Medtronic, Boston Scientific, Wision AI, Microtech. Alan N. Barkun - Consultant for Olympus Inc and Medtronic Inc. Cecilia Binda – Lecturer for Steris, Fujifilm, Boston Scientific, Q3 Medical. Alessandro Fugazza – Consultant for Boston Scientific. Rogier P. Voermans - Consultancy and research grant for Boston Scientific, Research grant Prion Medical; Consultancy fee form from Cook Medical. Lecturer Viatris and Zambon. Nauzer Forbes – Speaker for Boston Scientific, Pentax Medical. Consultant for Boston Scientific, Pentax Medical and AstraZeneca. Mariano Villarroel – Consultant for Boston Scientific. Yen-I Chen – Consultant for Boston Scientific. President of Chess Medical. Robert Bechara – Consultant for Olympus, Pentax, Vantage, Medtronic, Pendopharm. Payal Saxena – Consultant for Boston Scientific, Ambu, Erbe. Amrita Sethi – Consultant for Boston Scientific, Interscope, Medtronic, Olympus; Research Support for Boston Scientific, Fujifilm and ERBE. Cesare Hassan: Fujifilm Co. (consultancy); Medtronic Co. (consultancy). Alessandro Repici: Fujifilm Co. (consultancy); Olympus Corp (consultancy); Medtronic Co. (consultancy). Bret Peterson – Consultant for Olympus, Pentax. Investigator for Boston Scientific and Ambu. Silvia Carrara – Consultant for Olympus and Aboca. Jeffrey D. Mosko – Speaker for Boston Scientific, Pendopharm, SCOPE rounds, Vantage, Medtronic. Medical Advisory Board for Pendopharm, Boston Scientific, Janssen, Pentax, Fuji. Grants and Research support from CAG. Christopher W. Teshima – Speaker for Medtronic and Boston Scientific, Consultant for Boston Scientific. Gary R. May – Consultant for Olympus. Speaker for Pentax, Fuji and Medtronic. Samir C Grover –Research grants and personal fees from AbbVie and Ferring Pharmaceuticals, personal fees from Takeda, Sanofi, and BioJAMP, education grants from Janssen, and has equity in Volo Healthcare. All the authors have no relevant financial disclosures or conflicts of interest to declare., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Objectives: Bariatric surgery can greatly ameliorate obesity and its associated metabolic disorders. Alteration of foregut anatomy, as is seen after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch, renders traditional access to the biliary tree difficult, if not impossible. This may complicate management of anastomotic biliary complications after liver transplant., Materials and Methods: In this single-center study, we retrospectively reviewed all adult patients with a history of any bariatric surgery who underwent liver transplant during the period January 2017 to December 2022. We obtained demographic information of donors and recipients. Outcomes of interest included the modality in which the anastomotic biliary complications were managed., Results: Of 261 patients who underwent liver transplant at our center during the study period, 9 had a history of bariatric surgery. Anastomotic biliary complications occurred in 3 of 9 patients (33%). No significant differences were shown in donor age, ischemia time, etiology of liver disease, or Model for End-Stage Liver Disease sodium score at time of transplant between the 2 groups. All anastomotic biliary complications occurred in patients with a history of Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch. Interventions included advanced endoscopy, endoscopic ultrasonography, and lumen-apposing metal stent to access the remnant stomach and biliopancreatic limb (n = 2) and surgical revision following percutaneous transhepatic biliary drain placement (n = 1). At the end of the study, none experienced recurrent stricture., Conclusions: Anastomotic biliary complications are well-described after liver transplant. A multidisciplinary approach with interventional radiology and inter-ventional gastroenterology can be beneficial to address strictures that arise in recipients with a history of Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch.

Background and Aims: EUS-guided gastroenterostomy (EUS-GE) is effective in relieving gastric outlet obstruction. Several techniques used to create EUS-GEs have been described. However, these techniques are dependent on passing a guidewire beyond the obstruction. We describe a direct needle-puncture technique that allows for successful EUS-GE creation without a guidewire., Methods: The direct antegrade EUS-GE method often involves passing a guidewire and tube beyond the obstruction to distend the small bowel. An oblique echoendoscope is then positioned in the stomach to locate the distended small bowel. An electrocautery-enhanced lumen-apposing metal stent (LAMS) is used to create the anastomosis. However, in cases when neither endoscope nor guidewire can be passed across the obstruction, the direct needle-puncture technique can be used. With the oblique echoendoscope positioned in the stomach, a collapsed loop of small bowel is located adjacent to the gastric wall. A 19-gauge needle is used to puncture the gastric and small bowel wall. The small bowel is distended with a mixture of saline, methylene blue, and contrast via a standard water pump connected to the needle. An antispasmodic is administered, and an electrocautery-enhanced LAMS is then introduced into the working channel to create a gastroenterostomy using the freehand method., Results: The direct needle-puncture technique was performed in 4 patients for these indications: postsurgical inflammation causing gastric outlet obstruction (case 1), tumor infiltration causing gastric outlet obstruction (cases 2A and 2B), and pancreaticobiliary limb access in a duodenal switch (case 3). The video shows the technique performed in a patient with postsurgical inflammation and a patient with duodenal tumor infiltration., Conclusions: The direct needle-puncture technique is useful for performing gastroenterostomy when the guidewire cannot be passed beyond the obstruction. It can also be used to gain access to a targeted bowel limb in altered anatomy for diagnostic and therapeutic purposes., Competing Interests: Dr Baron is a consultant for Cook Endoscopy, Boston Scientific, Olympus, Medtronic, ConMed, and W.L. Gore. Dr Trieu disclosed no financial relationships relevant to this publication., (© 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Background/aims: Self-expandable metallic stents (SEMSs) are widely adopted for the palliation of dysphagia in patients with malignant esophageal strictures. An important adverse event is the development of SEMS-induced esophagorespiratory fistulas (SEMS-ERFs). This study aimed to assess the risk factors related to the development of SEMS-ERF after SEMS placement in patients with esophageal cancer., Methods: This retrospective study was performed at the Instituto do Cancer do Estado de São Paulo. All patients with malignant esophageal strictures who underwent esophageal SEMS placement between 2009 and 2019 were included in the study., Results: Of the 335 patients, 37 (11.0%) developed SEMS-ERF, with a median time of 129 days after SEMS placement. Stent flare of 28 mm (hazard ratio [HR], 2.05; 95% confidence interval [CI], 1.15-5.51; p=0.02) and post-stent chemotherapy (HR, 2.0; 95% CI, 1.01-4.00; p=0.05) were associated with an increased risk of developing SEMS-ERF, while lower-third tumors were a protective factor (HR, 0.5; 95% CI, 0.26-0.85; p=0.01). No difference was observed in overall survival., Conclusion: The incidence of SEMS-ERFs was 11%, with a median time of 129 days after SEMS placement. Post-stent chemotherapy and a 28 mm stent flare were associated with a higher risk of SEMS-ERF.

Video 1A 51-year-old woman underwent orthotopic liver transplant with duct-to-duct anastomosis for primary biliary cholangitis 8 months prior to presentation. Two months postoperatively, she presented with clinical biliary pancreatitis. An MRCP performed on admission demonstrates dilated donor biliary tree and a severe stricture at the anastomosis. An index ERCP shows an indwelling surgical biliary "stent" exiting the duodenal papillae and anastomotic stricture. The surgical stent was removed, a sphincterotomy was performed, and there was an inability to traverse the anastomotic stricture. A representative cholangiogram shown here demonstrates the presence of a severe stricture completely obstructing the biliary tree. ERCP was done the next day, placing a 10-mm × 8-cm fully covered metal stent throughout the anastomosis. Three months later, the stent was removed because there was recurrent stricture at the site of anastomosis. Four months after stent removal, the patient again presented with clinical and laboratory obstructive biliary disease. A follow-up MRCP showed a severe anastomotic biliary stricture with an upstream stone. Several attempts were made to pass ERCP antegrade through the stenosis. However, they were unsuccessful. The rate-limiting step for successful recanalization was guidewire passage across the stricture. In this case, there was complete obliteration of the lumen by fibrosis. Efforts to pass 0.025-inch and 0.035-inch angled hydrophilic guidewires were unsuccessful. Recurrent stricturing was believed to be because of ischemia or inadequate recanalization. Our approach was to attempt antegrade recanalization and biliary decompression through an EUS-guided hepatogastrostomy. However, antegrade recanalization was unsuccessful and led to retrograde cholangioscopy using a single-use endoscope (SpyScope DS-2; Boston Scientific, Marlborough, Mass, USA) 4 weeks later. This video shows the cholangioscopic recanalization process. There was no passage of contrast antegrade or retrograde. During the cholangioscopy, there was no visible lumen. The area of suspected anastomosis based on the pearly white appearance of scar tissue was approached using mini-forceps (SpyBite; Boston Scientific) and a bite-on-bite approach to re-establish a lumen for stent placement. We used the pearly scar tissue as a guide to ensure the correct site for recanalization. We felt comfortable doing this because a hepatogastrostomy and sphincterotomy were thought to be protective against any bile leak if tunneling had dissected out of the duct. Moreover, contrast injection was used periodically to monitor progression into the duct. Eventually, the forceps were advanced into the proximal biliary tree under cholangioscopic direction, re-establishing a lumen. Bile is seen flowing through the identified lumen. While a rendezvous approach with antegrade transillumination and a percutaneous SpyScope DS-2 might be safer for recanalization of complete obstruction, the process would require multiple admissions and procedures for percutaneous access and fistula maturation. This might increase morbidity for this patient with no difference in outcome. We propose that cholangioscopic recanalization along with protection from bile leakage would be a reasonable approach in this case and similar cases with altered anatomy, hepatogastrostomy in place, or unavailability for follow-up or multiple procedures. This is an intraoperative radiographic representation. On the left, the cholangiogram is seen in place and the mini-forceps are passing through it into the proximal biliary tree. On the right, passage of the guidewire with balloon dilation of the stricture is shown. The stone previously seen on MRCP passed spontaneously. A follow-up cholangiogram showed luminal patency. A 10-mm × 10-cm fully covered metal stent (Viabil; W.L. Gore, Flagstaff, Ariz, USA) was placed across anastomosis., Competing Interests: Dr Baron is a consultant and speaker for Ambu, Boston Scientific, Cook Endoscopy, Medtronic, Olympus America, and W.L. Gore. The other authors did not disclose any financial relationships., (© 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Competing Interests: Conflict of Interest Dr. Todd Baron is a consultant and speaker for Boston Scientific, W.L. Gore, Cook Endoscopy, and Olympus America

The transcendence of endoscopic ultrasound (EUS) from diagnostic to therapeutic tool has revolutionized management options in the field of gastroenterology. Through EUS-guided methods, pancreaticobiliary obstruction can now be utilized as an alternative to surgical and percutaneous approaches. This modality also allows for gallbladder drainage in patients who are not ideal operative candidates. By utilizing its unique imaging capabilities, EUS also allows for drainage access points in cases of gastric outlet obstruction as well as windows to ablate pancreatic cystic lesions. As technical progress continues to evolve, interventional gastroenterology continues to push the envelope of minimally invasive therapeutic procedures in a multidisciplinary setting. In this comprehensive review, we set out to describe current indications and innovations through EUS., Competing Interests: Dr. Todd H. Baron is a consultant and speaker for Boston Scientific, W.L. Gore, Cook Endoscopy, and Olympus America. Dr. Andrew Canakis declares no relevant funding for this work. All authors disclosed no financial relationships., (Copyright © 2023 by The Author(s). Published by S. Karger AG, Basel.)

Background and Objectives: Percutaneous transhepatic biliary drainage (PTBD) and EUS-guided choledochoduodenostomy (EUS-CD) are alternate therapies to endoscopic retrograde cholangiopancreatography with stent placement for biliary decompression. The primary outcome of this study is to compare the technical and clinical success of PTBD to EUS-CD in patients with distal biliary obstruction. Secondary outcomes were adverse events (AEs), need for reintervention, and survival., Methods: A multicenter retrospective cohort study from three different centers was performed. Cox regression was used to compare time to reintervention and survival and logistic regression to compare technical and clinical success and AE rates. Subgroup analysis was performed in patients with malignant biliary obstruction (MBO)., Results: A total of 86 patients (58 PTBD and 28 EUS-CD) were included. The two groups were similar with respect to age, gender, and cause of biliary obstruction, with malignancy being the most common etiology (80.2%). EUS-CD utilized lumen-apposing metal stents in 15 patients and self-expandable metal biliary stents in 13 patients. Technical success was similar been EUS-CD (100%) and PTBD (96.6%; P = 0.3). EUS-CD was associated with higher clinical success compared to PTBD (84.6% vs. 62.1%; P = 0.04). There was a trend toward lower rates of AEs with EUS-CD 14.3% versus PTBD 29.3%, odds ratio: 0.40 (95% confidence interval [CI]: 0.12-1.33, P = 0.14). The need for reintervention was significantly lower among patients who underwent EUS-CD (10.7%) compared to PTBD (77.6%) (hazard ratio: 0.07, 95% CI: 0.02-0.24; P < 0.001). A sensitivity analysis of only patients with MBO demonstrated similar rate of reintervention between the groups in individuals who survived 50 days or less after the biliary decompression. However, reintervention rates were lower for EUS-CD in those with longer survival., Conclusion: EUS-CD is a technically and clinically highly successful procedure with a trend toward lower AEs compared to PTBD. EUS-CD minimizes the need for reintervention, which may enhance end-of-life quality in patients with MBO and expected survival longer than 50 days., Competing Interests: None

The benefit of endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of primary sclerosing cholangitis (PSC) remains controversial. To identify predictors of jaundice resolution after ERCP and whether resolution is associated with improved patient outcomes, we conducted a retrospective cohort study of 124 patients with jaundice and PSC. These patients underwent endoscopic biliary balloon dilation and/or stent placement at an American tertiary center, with validation in a separate cohort of 102 patients from European centers. Jaundice resolved after ERCP in 52% of patients. Median follow-up was 4.8 years. Independent predictors of jaundice resolution included older age (P = 0.048; odds ratio [OR], 1.03 for every 1-year increase), shorter duration of jaundice (P = 0.059; OR, 0.59 for every 1-year increase), lower Mayo Risk Score (MRS) (P = 0.025; OR, 0.58 for every 1-point increase), and extrahepatic location of the most advanced biliary stricture (P = 0.011; OR, 3.13). A logistic regression model predicted jaundice resolution with area under the receiver operator characteristic curve of 0.67 (95% confidence interval, 0.5-0.79) in the validation set. Independent predictors of death or transplant during follow-up included higher MRS at the time of ERCP (P < 0.0001; hazard ratio [HR], 2.33 for every 1-point increase), lower total serum bilirubin before ERCP (P = 0.031; HR, 0.91 for every 1 mg/dL increase), and persistence of jaundice after endoscopic therapy (P = 0.003; HR, 2.30). Conclusion: Resolution of jaundice after endoscopic treatment of biliary strictures is associated with longer transplant-free survival of patients with PSC. The likelihood of resolution is affected by demographic, hepatic, and biliary variables and can be predicted using noninvasive data. These findings may refine the use of ERCP in patients with jaundice with PSC., (© 2021 The Authors. Hepatology Communications published by Wiley Periodicals LLC on behalf of American Association for the Study of Liver Diseases.)

Background & Aims: Gastrointestinal diseases account for considerable health care use and expenditures. We estimated the annual burden, costs, and research funding associated with gastrointestinal, liver, and pancreatic diseases in the United States., Methods: We generated estimates using data from the National Ambulatory Medical Care Survey; National Hospital Ambulatory Medical Care Survey; Nationwide Emergency Department Sample; National Inpatient Sample; Kids' Inpatient Database; Nationwide Readmissions Database; Surveillance, Epidemiology, and End Results program; National Vital Statistics System; Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research; MarketScan Commercial Claims and Encounters data; MarketScan Medicare Supplemental data; United Network for Organ Sharing registry; Medical Expenditure Panel Survey; and National Institutes of Health (NIH)., Results: Gastrointestinal health care expenditures totaled $119.6 billion in 2018. Annually, there were more than 36.8 million ambulatory visits for gastrointestinal symptoms and 43.4 million ambulatory visits with a primary gastrointestinal diagnosis. Hospitalizations for a principal gastrointestinal diagnosis accounted for more than 3.8 million admissions, with 403,699 readmissions. A total of 22.2 million gastrointestinal endoscopies were performed, and 284,844 new gastrointestinal cancers were diagnosed. Gastrointestinal diseases and cancers caused 255,407 deaths. The NIH supported $3.1 billion (7.5% of the NIH budget) for gastrointestinal research in 2020., Conclusions: Gastrointestinal diseases are responsible for millions of health care encounters and hundreds of thousands of deaths that annually costs billions of dollars in the United States. To reduce the high burden of gastrointestinal diseases, focused clinical and public health efforts, supported by additional research funding, are warranted., (Copyright © 2022 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Video 1Palliation of malignant distal colonic obstruction via a percutaneous endoscopic colostomy using a lumen-apposing metal stent., (© 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Background: The use of fully covered lumen-apposing metal stents (LAMS) for benign short gastrointestinal (GI) strictures has been reported. This study aimed to evaluate the safety and efficacy of LAMS for refractory GI strictures., Methods: A retrospective analysis was performed of patients who underwent LAMS placement for benign GI strictures in 8 United States centers. The primary outcomes were technical success and initial clinical response. Secondary outcomes were reintervention rate and adverse events., Results: A total of 51 patients underwent 61 LAMS placement procedures; 33 (64.7%) had failed previous treatments. The most common stricture location was the pylorus (n=17 patients). Various sizes of stents were used, with 15-mm LAMS placed in 45 procedures, 20-mm LAMS in 14 procedures, and 10-mm LAMS in 2 procedures. The overall technical success, short-term clinical response and reintervention rate after stent removal were 100%, 91.8% and 31.1%, respectively. Adverse events were reported in 17 (27.9%) procedures, with stent migration being the most common (13.1%). In subgroup analysis, both 15 mm and 20 mm stents had comparable short-term clinical response and adverse event rates. However, stent migration (15.6%) was the most common adverse event with 15-mm LAMS while pain (14.3%) was the most common with 20-mm LAMS. The reintervention rate was 80% at 200-day follow up after stent removal., Conclusions: Using LAMS for treatment of short benign GI strictures is safe and effective. Larger LAMS, such as the new 20 mm in diameter, may have a lower stent migration rate compared to smaller diameter LAMS., Competing Interests: Conflict of Interest: Meir Mizrahi: Boston Scientific – Consultant. Yazan Fahmawi indicated no relevant financial relationships. Manoj Kumar indicated no relevant financial relationships. Benjamin Tharian: Boston Scientific – Consultant. Salman Ali Khan indicated no relevant financial relationships. Sumant Inamdar indicated no relevant financial relationships. Neil Sharma: Boston Scientific – Consultant. Dushant Uppal indicated no relevant financial relationships. Vanessa Shami indicated no relevant financial relationships. Mahmood Syed Kashif indicated no relevant financial relationships. Moamen Gabr indicated no relevant financial relationships. Douglas Pleskow: Boston scientific – Consultant. Tyler Berzin: Boston Scientific – Consultant. Douglas Adler: Boston Scientific – Consultant, (Copyright: © 2021 Hellenic Society of Gastroenterology.)

Background and Aims: Serial stent placement may be necessary during endoscopic interventions, but the passage of a guidewire alongside an initial stent can be challenging, time-consuming, and sometimes unsuccessful. We describe a modification of a cytology brush catheter to allow simultaneous placement of 2 guidewires to facilitate serial stent placement and demonstrate its application in different scenarios., Methods: This is a retrospective series of 3 patients with different conditions (acute cholecystitis, pancreas pseudocyst, and severe biliary stricture) in whom placement of a second guidewire facilitated serial stent placement. A step-by-step demonstration of the technique is provided., Results: Serial stent placement was successful in all patients without adverse events., Conclusions: A modified cytology brush catheter can be used to deliver 2 guidewires simultaneously during ERCP and EUS procedures. This technique may improve procedural efficiency, maintain a safety track, and augment therapy in certain situations., (© 2020 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Background and Objectives: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and fine needle biopsy (FNB) are effective techniques that are widely used for tissue acquisition. However, it remains unclear how to obtain high-quality specimens. Therefore, we conducted a survey of EUS-FNA and FNB techniques to determine practice patterns worldwide and to develop strong recommendations based on the experience of experts in the field., Methods: This was a worldwide multi-institutional survey among members of the International Society of EUS Task Force (ISEUS-TF). The survey was administered by E-mail through the SurveyMonkey website. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized. Another questionnaire about the level of recommendation was designed to assess the respondents' answers., Results: ISEUS-TF members developed a questionnaire containing 17 questions that was sent to 53 experts. Thirty-five experts completed the survey within the specified period. Among them, 40% and 54.3% performed 50-200 and more than 200 EUS sampling procedures annually, respectively. Some practice patterns regarding FNA/FNB were recommended., Conclusion: This is the first worldwide survey of EUS-FNA and FNB practice patterns. The results showed wide variations in practice patterns. Randomized studies are urgently needed to establish the best approach for optimizing the FNA/FNB procedures., Competing Interests: None

Endoscopic ultrasound (EUS) was originally devised as a novel diagnostic technique to enable endoscopists to stage malignancies and acquire tissue. However, it rapidly advanced toward therapeutic applications and has provided gastroenterologists with the ability to effectively treat and manage advanced diseases in a minimally invasive manner. EUS-guided biliary drainage (EUS-BD) has gained considerable attention as an approach to provide relief in malignant and benign biliary obstruction for patients when endoscopic retrograde cholangiopancreatography (ERCP) fails or is not feasible. Such instances occur in those with surgically altered anatomy, gastroduodenal obstruction, periampullary diverticulum or prior transampullary duodenal stenting. While ERCP remains the gold standard, a multitude of studies are showing that EUS-BD can be used as an alternative modality even in patients who could successfully undergo ERCP. This review will shed light on recent EUS-guided advancements and techniques in malignant and benign biliary obstruction., Competing Interests: Competing interests: THB: consultant and speaker for Boston Scientific, WLG, Cook Endoscopy, Medtronic and Olympus America., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

An amendment to this paper has been published and can be accessed via the original article.

Description: The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition., Methods: This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 15 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors, who are advanced endoscopists or hepatopancreatobiliary surgeons with extensive experience in managing and teaching others to care for patients with pancreatic necrosis. BEST PRACTICE ADVICE 1: Pancreatic necrosis is associated with substantial morbidity and mortality and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition. In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center. BEST PRACTICE ADVICE 2: Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (ie, gas in the collection, bacteremia, sepsis, or clinical deterioration). Routine use of prophylactic antibiotics to prevent infection of sterile necrosis is not recommended. BEST PRACTICE ADVICE 3: When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored (eg, carbapenems, quinolones, and metronidazole). Routine use of antifungal agents is not recommended. Computed tomography-guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases. BEST PRACTICE ADVICE 4: In patients with pancreatic necrosis, enteral feeding should be initiated early to decrease the risk of infected necrosis. A trial of oral nutrition is recommended immediately in patients in whom there is absence of nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction. When oral nutrition is not feasible, enteral nutrition by either nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible. Total parenteral nutrition should be considered only in cases where oral or enteral feeds are not feasible or tolerated. BEST PRACTICE ADVICE 5: Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure or with associated complications, including gastrointestinal luminal obstruction; biliary obstruction; recurrent acute pancreatitis; fistulas; or persistent systemic inflammatory response syndrome. BEST PRACTICE ADVICE 6: Pancreatic debridement should be avoided in the early, acute period (first 2 weeks), as it has been associated with increased morbidity and mortality. Debridement should be optimally delayed for 4 weeks and performed earlier only when there is an organized collection and a strong indication. BEST PRACTICE ADVICE 7: Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line, nonsurgical approaches in managing patients with walled-off pancreatic necrosis (WON). Endoscopic therapy through transmural drainage of WON may be preferred, as it avoids the risk of forming a pancreatocutaneous fistula. BEST PRACTICE ADVICE 8: Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks), and in those with WON who are too ill to undergo endoscopic or surgical intervention. Percutaneous drainage should be strongly considered as an adjunct to endoscopic drainage for WON with deep extension into the paracolic gutters and pelvis or for salvage therapy after endoscopic or surgical debridement with residual necrosis burden. BEST PRACTICE ADVICE 9: Self-expanding metal stents in the form of lumen-apposing metal stents appear to be superior to plastic stents for endoscopic transmural drainage of necrosis. BEST PRACTICE ADVICE 10: The use of direct endoscopic necrosectomy should be reserved for those patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore, self-expanding metal stents/lumen-apposing metal stents alone or plastic stents combined with irrigation. Direct endoscopic necrosectomy is a therapeutic option in patients with large amounts of infected necrosis, but should be performed at referral centers with the necessary endoscopic expertise and interventional radiology and surgical backup. BEST PRACTICE ADVICE 11: Minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity. BEST PRACTICE ADVICE 12: Multiple minimally invasive surgical techniques are feasible and effective, including videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement. Selection of approach is best determined by pattern of disease, physiology of the patient, experience and expertise of the multidisciplinary team, and available resources. BEST PRACTICE ADVICE 13: Open operative debridement maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures. BEST PRACTICE ADVICE 14: For patients with disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in patients with reasonable operative candidacy. Insufficient evidence exists to support the management of the disconnected left pancreatic remnant with long-term transenteric endoscopic stenting. BEST PRACTICE ADVICE 15: A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage using either plastic stents and irrigation or self-expanding metal stents/lumen-apposing metal stents alone, followed by direct endoscopic necrosectomy, and then surgical debridement is reasonable, although approaches may vary based on the available clinical expertise., (Copyright © 2020. Published by Elsevier Inc.)

EUS-guided gallbladder drainage (EUS-GBD) is utilized for the treatment of acute cholecystitis and symptomatic cholelithiasis in patients who are poor operative candidates. Over the last several years, improved techniques and accessories have facilitated GBD. Recent literature demonstrated effectiveness and safety of EUS-guided GBD. Available data suggest at least similar results when compared to percutaneous cholecystostomy. EUS-guided GBD can be performed as a primary intervention in patients with cholecystitis who are unfit for urgent surgical intervention and as a secondary intervention to internalize biliary drainage in patients with indwelling percutaneous cholecystostomy catheters. Various stents can be used for -EUS-guided GBD. The optimal device and technique have yet to be determined, although at the present time, the use of luminal apposing stents is preferred. The purpose of this review is to provide the highlights of the most recent literature on EUS-guided GBD., Competing Interests: Dr. Baron is a consultant and speaker for Medtronic, Boston Scientific, W.L. Gore, Cook Endoscopy and Olympus America., (Copyright: © 2019 Spring Media Publishing Co. Ltd.)

Background and study aims  Indications for accessing the duodenum, and/or excluded stomach in Roux-en-Y gastric bypass (RYGB) patients extend beyond diagnosis and treatment of pancreaticobiliary maladies. Given the high technical and clinical success of EUS-directed transgastric ERCP (EDGE) in RYGB anatomy, we adopted this transgastric (anterograde) approach to evaluate and treat luminal and extraluminal pathology in and around the excluded gut in RYGB patients. EUS-directed transgastric intervention ("EDGI"), other than ERCP, is the terminology we have chosen to describe this heterogenous group of transgastric diagnostic and/or interventional endoscopic procedures (transgastric interventions) performed via a lumen-apposing mental stent (LAMS) in select patients with RYGB. Patients and methods  A multicenter (n = 4), retrospective study of RYGB patients with suspected luminal or extraluminal pathology, in or around the duodenum and/or excluded stomach, underwent EDGI using LAMS between December 2015 and January 2019. Results  A total of 14 patients (78.6 % women; mean age, 55.7 + 12.4 years) underwent EDGI via LAMS. Technical and clinical success rates of EDGI were 100 %. The most common transgastric interventions were diagnostic EUS of extraluminal pathology (n = 6, 42.7 %) and endoscopic biopsy of gastroduodenal luminal abnormalities (n = 5, 35.7 %). Two moderate-severity adverse events due to LAMS maldeployment occurred during EUS-JG creation (14.3 %), and each instance was successfully rescued with a bridging stent. Conclusions  A variety of gastroduodenal luminal and extraluminal disorders in RYGB patients can be effectively diagnosed and managed using EDGI via LAMS.

Background and study aims  The aim of the current study was to review the outcomes of a large-scale international registry on endoscopic ultrasound-guided gallbladder drainage (EGBD) that encompasses different stent systems in patients who are at high-risk for cholecystectomy. Patients and methods  This was a retrospective international multicenter registry on EGBD created by 13 institutions around the world. Consecutive patients who received EGBD for several indications were included. Outcomes include technical and clinical success, unplanned procedural events (UPE), adverse events (AEs), mortality, recurrent cholecystitis and learning curve of the procedure. Results  Between June 2011 and November 2017, 379 patients were recruited to the study. Technical and clinical success were achieved in 95.3 % and 90.8 % of the patients, respectively. The 30-day AE rate was 15.3 % and 30-day mortality was 9.2 %. UPEs were significantly more common in patients with EGBD performed for conversion of cholecystostomy and symptomatic gallstones ( P  < 0.001); and by endoscopists with experience of fewer than 25 procedures ( P  = 0.033). Both presence of clinical failure ( P  = 0.014; RR 8.69 95 %CI [1.56 - 48.47]) and endoscopist experience with fewer than 25 procedures ( P  = 0.002; RR 4.68 95 %CI [1.79 - 12.26]) were significant predictors of 30-day AEs. Presence of 30-day AEs was a significant predictor of mortality ( P  < 0.001; RR 103 95 %CI [11.24 - 944.04]). Conclusion  EGBD was associated with high success rates in this large-scale study. EGBD performed for indications other than acute cholecystitis was associated with higher UPEs. The number of cases required to gain competency with the technique by experienced interventional endosonographers was 25 procedures.

Background and study aims  Endoscopic ultrasound-guided hepaticoenterostomy (EUS-HE) is an effective method of endoscopic biliary drainage in cases where endoscopic retrograde cholangiopancreatography has failed or is deemed impossible. Indications for EUS-HE have expanded, resulting in increased interest by endoscopists to learn the procedure; however, few data exist on breadth of application or experience needed to develop proficiency. We describe utilization of EUS-HE for biliary decompression at a large tertiary referral center along with procedural learning curve. Patients and methods  Retrospective evaluation of 60 consecutive patients who underwent attempted EUS-HE by one endoscopist from February 2016 through June 2018. Procedures were divided into chronological and summative experience quartiles. We compared procedural success rate, procedural utilization, and procedure duration over time. Results  Sixty patients underwent attempted EUS-HE during the study period: 35 with surgically altered anatomy, 23 with malignant biliary obstruction, 35 outpatients, 35 females; median age, 66 years. The procedure was technically successful in 53 patients. Success rates by summative experience quartile were 80 %, 80 %, 93.3 % and 100 % respectively. Beginning at patient number 40, the remaining cases had a success rate of 100 %. Utilization increased from eight cases in the first chronological quartile to 28 in the fourth. There was no significant reduction in procedure duration over time. Conclusion  For an experienced endoscopist, EUS-HE could be performed effectively and safely after the experience of 40 cases. Limitations of this study include a single endoscopist and heterogeneous patient population with variable anatomy that may affect procedural success. Future studies should include data from multiple centers and endoscopists.

Background and study aims  The use of lumen apposing metal stents (LAMS) during EUS-guided transmural drainage (EUS-TD) of pancreatic walled-off necrosis (WON) has gained popularity. Data supporting their use in WON over plastic stents (PS), however, remain scarce. The aim of this study was to compare the clinical efficacy of LAMS (Axios, Boston Scientific) with PS in WON. Patients and methods  This was a multicenter, retrospective study involving 14 centers. Consecutive patients who underwent EUS-TD of WON (2012 - 2016) were included. The primary end point was clinical success defined as WON size ≤ 3 cm within a 6-month period without need for percutaneous drainage (PCD) or surgery. Results  A total of 189 patients (mean age 55.2 ± 15.6 years, 34.9 % female) were included (102 LAMS and 87 PS). Technical success rates were similar: 100 % in LAMS and 98.9 % in PS ( P  = 0.28). Clinical success was attained in 80.4 % of LAMS and 57.5 % of PS ( P  = 0.001). Rate of PCD was similar (13.7 % LAMS vs. 16.3 % PS, P  = 0.62), while PS was associated with a greater need for surgery (16.1 % PS vs. 5.6 % LAMS, P  = 0.02). Adverse events (AEs) were observed in 9.8 % of LAMS and 10.3 % of PS ( P  = 0.90) and were rated as severe in 2.0 % and 6.9 %, respectively ( P  = 0.93). After excluding patients with < 6 months follow-up, the rate of WON recurrence following initial clinical success was greater with PS (22.9 % PS vs. 5.6 % LAMS, P  = 0.04). Conclusions  When compared to PS, LAMS in WON is associated with higher clinical success, shorter procedure time, lower need for surgery, and lower rate of recurrence.

Background & Aims: Estimates of disease burden can inform national health priorities for research, clinical care, and policy. We aimed to estimate health care use and spending among gastrointestinal (GI) (including luminal, liver, and pancreatic) diseases in the United States., Methods: We estimated health care use and spending based on the most currently available administrative claims from commercial and Medicare Supplemental plans, data from the GI Quality Improvement Consortium Registry, and national databases., Results: In 2015, annual health care expenditures for gastrointestinal diseases totaled $135.9 billion. Hepatitis ($23.3 billion), esophageal disorders ($18.1 billion), biliary tract disease ($10.3 billion), abdominal pain ($10.2 billion), and inflammatory bowel disease ($7.2 billion) were the most expensive. Yearly, there were more than 54.4 million ambulatory visits with a primary diagnosis for a GI disease, 3.0 million hospital admissions, and 540,500 all-cause 30-day readmissions. There were 266,600 new cases of GI cancers diagnosed and 144,300 cancer deaths. Each year, there were 97,700 deaths from non-malignant GI diseases. An estimated 11.0 million colonoscopies, 6.1 million upper endoscopies, 313,000 flexible sigmoidoscopies, 178,400 upper endoscopic ultrasound examinations, and 169,500 endoscopic retrograde cholangiopancreatography procedures were performed annually. Among average-risk persons aged 50-75 years who underwent colonoscopy, 34.6% had 1 or more adenomatous polyps, 4.7% had 1 or more advanced adenomatous polyps, and 5.7% had 1 or more serrated polyps removed., Conclusions: GI diseases contribute substantially to health care use in the United States. Total expenditures for GI diseases are $135.9 billion annually-greater than for other common diseases. Expenditures are likely to continue increasing., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: EUS-guided biliary drainage (EUS-BD) was shown to be useful for malignant biliary obstruction (MBO). However, there is lack of consensus on how EUS-BD should be performed., Methods: This was a worldwide multi-institutional survey among members of the International Society of EUS conducted in February 2018. The survey consisted of 10 questions related to the practice of EUS-BD., Results: Forty-six endoscopists of them completed the survey. The majority of endoscopists felt that EUS-BD could replace percutaneous transhepatic biliary drainage after failure of ERCP. Among all EUS-BD methods, the rendezvous stenting technique should be the first choice. Self-expandable metal stents (SEMSs) were recommended by most endoscopists. For EUS-guided hepaticogastrostomy (HGS), superiority of partially-covered SEMS over fully-covered SEMS was not in agreement. 6-Fr cystotomes were recommended for fistula creation. During the HGS approach, longer SEMS (8 or 10 cm) was recommended. During the choledochoduodenostomy approach, 6-cm SEMS was recommended. During the intrahepatic (IH) approach, the IH segment 3 was recommended., Conclusion: This is the first worldwide survey on the practice of EUS-BD for MBO. There were wide variations in practice, and randomized studies are urgently needed to establish the best approach for the management of this condition., Competing Interests: There are no conflicts of interest