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Pre-training deep learning models with large data sets of natural images, such as ImageNet, has become the standard for endoscopic image analysis. This approach is generally superior to training from scratch, due to the scarcity of high-quality medical imagery and labels. However, it is still unknown whether the learned features on natural imagery provide an optimal starting point for the downstream medical endoscopic imaging tasks. Intuitively, pre-training with imagery closer to the target domain could lead to better-suited feature representations. This study evaluates whether leveraging in-domain pre-training in gastrointestinal endoscopic image analysis has potential benefits compared to pre-training on natural images. To this end, we present a dataset comprising of 5,014,174 gastrointestinal endoscopic images from eight different medical centers (GastroNet-5M), and exploit self-supervised learning with SimCLRv2, MoCov2 and DINO to learn relevant features for in-domain downstream tasks. The learned features are compared to features learned on natural images derived with multiple methods, and variable amounts of data and/or labels (e.g. Billion-scale semi-weakly supervised learning and supervised learning on ImageNet-21k). The effects of the evaluation is performed on five downstream data sets, particularly designed for a variety of gastrointestinal tasks, for example, GIANA for angiodyplsia detection and Kvasir-SEG for polyp segmentation. The findings indicate that self-supervised domain-specific pre-training, specifically using the DINO framework, results into better performing models compared to any supervised pre-training on natural images. On the ResNet50 and Vision-Transformer-small architectures, utilizing self-supervised in-domain pre-training with DINO leads to an average performance boost of 1.63% and 4.62%, respectively, on the downstream datasets. This improvement is measured against the best performance achieved through pre-training on natural images within any of the evaluated frameworks. Moreover, the in-domain pre-trained models also exhibit increased robustness against distortion perturbations (noise, contrast, blur, etc.), where the in-domain pre-trained ResNet50 and Vision-Transformer-small with DINO achieved on average 1.28% and 3.55% higher on the performance metrics, compared to the best performance found for pre-trained models on natural images. Overall, this study highlights the importance of in-domain pre-training for improving the generic nature, scalability and performance of deep learning for medical image analysis. The GastroNet-5M pre-trained weights are made publicly available in our repository: huggingface.co/tgwboers/GastroNet-5M_Pretrained_Weights., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Jacques J. Bergman reports financial support was provided by Olympus Corporation Tokyo, Japan. Peter H.N. de With reports financial support was provided by Olympus Corporation Tokyo, Japan. Fons van der Sommen reports financial support was provided by Olympus Corporation Tokyo, Japan. Jacques J. Bergman reports financial support was provided by PENTAX Medical. Jacques J. Bergman reports financial support was provided by Medtronic. Jacques J. Bergman reports financial support was provided by Aqua medical., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Dieulafoy's lesion (DL) is an uncommon vascular malformation-an aberrant, dilated submucosal arteriole (1-3 mm thick, 10 x nv). It runs near the mucosal surface and protrudes, and may potentially induce gastrointestinal bleeding (GIB). It usually originates in the stomach (upper lesser curvature), with endoscopy being the diagnostic, therapeutic modality of choice. Jejunal DL (JDL) is a rare cause of obscure GIB (OGIB) that is challenging for endoscopists and threatens patient lives. Other diagnostic techniques such as Tc99m-labeled red blood cell scintigraphy, well established in the classic armamentarium for OGIB diagnosis, cannot overcome endoscopic procedures. We report the case of a patient with OGIB secondary to an exceptionally located Dieulafoy's lesion who underwent combined endoscopic treatment.

Background: Sedation, ranging from minimal, moderate and deep sedation to general anesthesia, improves patient comfort and procedure quality in gastrointestinal endoscopy (GIE). There are currently no comprehensive recommendations on sedation practice in diagnostic and therapeutic GIE. We aimed to investigate real-life sedation practice in elective GIE., Methods: We performed a multicentric observational study across 14 Endoscopy Units in Italy. We recorded consecutive data on all diagnostic procedures performed with Anesthesiologist-directed care (ADC) and all therapeutic procedures performed with ADC or non-Anesthesiologist sedation (NAS) over a three-month period., Results: Dedicated ADC is available five days/week in 28.6% (4/14), four days/week in 21.5% (3/14), three days/week in 35.7% (5/14), two days/week in 7.1% (1/14) and one day/week in 7.1% (1/14) of participating Centers. ADC use for elective diagnostic GIE varied from 15.4% to 75.1% of the total number of procedures performed with ADC among different Centers. ADC use for elective therapeutic GIE varied from 10.8% to 98.9% of the total number of elective therapeutic procedures performed among different Centers., Conclusions: Our study highlights the lack of standardization and consequent great variability in sedation practice for elective GIE, with ADC being potentially overused for diagnostic procedures and underused for complex therapeutic procedures. A collaborative effort involving Endoscopists, Anesthesiologist and Institutions is needed to optimize sedation practice in GIE.

Introduction: Although propofol is widely preferred as a sedative agent in gastrointestinal endoscopy, its use is commonly associated with hemodynamic adverse events. New sedatives, such as ciprofol, are emerging with promising results. Thus, we aimed to perform a systematic review and meta-analysis to compare efficacy-, safety-, and satisfaction-related outcomes between ciprofol and propofol for adult sedation in gastrointestinal endoscopy., Evidence Acquisition: We systematically searched MEDLINE, Embase, and Cochrane databases for randomized controlled trials comparing sedation with ciprofol vs. propofol in adult patients undergoing gastrointestinal endoscopy. Risk ratios (RRs) and mean differences (MDs) with their 95% confidence intervals (95% CIs) were employed for dichotomous and continuous outcomes, respectively, using a random-effects model. We conducted all statistical analyses using R software (version 4.2.1)., Evidence Synthesis: We included six trials (1225 patients). The ciprofol group had a significantly lower risk of respiratory depression (RR 0.47; 95% CI 0.31, 0.71) and injection pain (RR 0.09; 95% CI 0.04, 0.20) compared with the propofol group, while there were no significant differences in other adverse events between both drugs. There were no significant differences between both groups in time-related outcomes, as well as in the probability of procedure success (RR 1.01; 95% CI 0.99, 1.03). Additionally, ciprofol provided a significantly higher patient satisfaction compared with propofol (MD 0.19; 95% CI 0.08, 0.31)., Conclusions: This systematic review and meta-analysis demonstrated similar clinical efficacy and better safety profile of ciprofol compared with propofol for adult sedation in gastrointestinal endoscopies. Furthermore, patient satisfaction scores were higher with ciprofol.

Objective: To assess whether use of glucagon-like peptide-1 (GLP-1) receptor agonists before upper gastrointestinal endoscopy is associated with increased risk of pulmonary aspiration or discontinuation of the procedure compared with sodium-glucose cotransporter-2 (SGLT-2) inhibitors., Design: Cohort study., Setting: Two deidentified US commercial healthcare databases., Participants: 43 365 adults (≥18 years) with type 2 diabetes who used a GLP-1 receptor agonist or SGLT-2 inhibitor within 30 days before upper gastrointestinal endoscopy., Main Outcome Measures: The primary outcome was pulmonary aspiration on the day of or the day after endoscopy, defined using diagnostic codes. The secondary outcome was discontinuation of endoscopy. Risk ratios and corresponding 95% confidence intervals (CIs) were estimated after fine stratification weighting based on propensity score., Results: After weighting, 24 817 adults used a GLP-1 receptor agonist (mean age 59.9 years; 63.6% female) and 18 537 used an SGLT-2 inhibitor (59.8 years; 63.7% female). Among users of GLP-1 receptor agonists and SGLT-2 inhibitors, the weighted risk per 1000 people was, respectively, 4.15 and 4.26 for pulmonary aspiration and 9.79 and 4.91 for discontinuation of endoscopy. Compared with SGLT-2 inhibitor use, GLP-1 receptor agonist use was not associated with an increased risk of pulmonary aspiration (pooled risk ratio 0.98, 95% CI 0.73 to 1.31), although it was associated with a higher risk for discontinuation of endoscopy (1.99, 1.56 to 2.53)., Conclusions: In this comparative cohort study, no increased risk of pulmonary aspiration during upper gastrointestinal endoscopy was observed among adults with type 2 diabetes using GLP-1 receptor agonists compared with SGLT-2 inhibitors within 30 days of the procedure; however, GLP-1 receptor agonists were associated with a higher risk of discontinuation of endoscopy, possibly owing to a higher risk of retained gastric content. In the absence of evidence from randomized trials, these findings could inform future practice recommendations on the preprocedural protocol for patients requiring endoscopy., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: SJC has a close family member employed by a Johnson & Johnson company and reports consultancy for Wolters-Kluwer and Alexion Pharmaceuticals. DJW reports consultancy for Novo Nordisk and serving as a data monitoring committee member for SOUL and FLOW trials. EP is principal investigator of a research grant to the Brigham and Women’s Hospital from Boehringer Ingelheim, not related to the topic of this work. CCT reports the following activities: Apollo Endosurgery – consultant/research support (consulting fees/institutional research grants); Bariendo – Founder/Board Member/Ownership Interest; BlueFlame Healthcare Venture Fund – Founder/General Partner; Boston Scientific – consultant (consulting fees)/research support (institutional research grant); Medtronic – consultant (consulting fees); ELLES – founder/board member/ownership interest; Endoquest Robotics – consultant, institutional research grant; Enterasense – founder, consultant, board member, ownership interest; EnVision Endoscopy – founder, board member, consultant, ownership interest; ERBE – institutional research grant; Fractyl – consultant/advisory board member (consulting fees)/research support; FujiFilm – consultant/institutional research grant; GI Dynamics – consultant (consulting fees)/ research support (institutional research grant); GI Windows – founder, board member, ownership interest; Lumendi – consultant/institutional research grant; Olympus/Spiration – consultant (consulting fees)/research support (Equipment Loans); Society for Metabolic and Bariatric Endoscopy (SMBE) – founder/president/ownership interest; Softac – consultant/ownership interest; USGI Medical – consultant (consulting fees)/advisory board member (consulting fees)/research support (institutional research grant); Xenter – consultant/SAB/ownership interest., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Gastrointestinal endoscopic procedures (GIEP's) are an essential part of patient care both diagnostically and therapeutically. Post-GIEP infections may be higher than previously reported and may not have been accurately captured in the past. The aim of this study was to determine the incidence and associated factors of bacteremia associated with GIEP's., Methods: This is retrospective study of GIEPs performed over a five-year period (2018-2022) at an academic medical center. Electronic health records (EHR) identified GIEPs and positive blood cultures within 30 days of procedure. Statistical analysis was performed using non-parametric testing to compare variables due to the small number of positive blood cultures., Results: EHR identified 18,986 GIEP's and 52 true and unique bacteremia out of 17,093 blood cultures during the five-year study period. The highest rate of positive blood culture of 2.84% (18/ 634) was associated with ERCP and the lowest 0.08% (7/ 9029) was associated with colonoscopy., Discussion: Our study showed a reflection of the endemic rate of bacteremia post GIEP's. Our study cannot differentiate endogenous infection versus contaminated (exogenous) endoscopes. ERCP procedures are disproportionately associated with higher incidence of bacteremia., Conclusions: Clinical surveillance in non-outbreak settings is essential for estimating GIEP related infections. It should be combined with endoscopic reprocessing audits for appropriate prevention of GIEP associated infections., (Copyright © 2024 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We designed this trial to compare the recovery time of remimazolam and propofol in elderly patients undergoing painless gastrointestinal endoscopy., Patients and Methods: In this randomized, non-Inferiority trial, 360 patients aged 65 years or older, scheduled for elective outpatient gastrointestinal endoscopy, were randomly assigned to the remimazolam combined with fentanyl (RF) group or the propofol combined with fentanyl (PF) group. The primary outcome was the post-anesthesia care unit (PACU) stay time, defined as the time from the end of the examination to scoring 9 points using the Modified Post-Anesthetic Discharge Scoring System (MPADSS) criteria. Secondary outcomes included sedation-related adverse events, recall, injection pain, as well as postoperative Quality of Recovery-15 (QoR-15) scores and Pittsburgh Sleep Quality Index (PSQI) scores at 1 day, 1 week, and 1 month postoperatively., Results: A total of 351 patients completed the study, with 174 receiving remimazolam and 177 receiving propofol. The PACU stay time in RF group was non-inferior to that in PF group [14 (11, 18) vs 13 (10, 17), mean difference 1 (95% confidence interval 0, 2), P =0.084 for noninferiority]. However, remimazolam was associated with lower rate of hypoxemia [4.7% (8/180) vs 12.4% (22/180), P =0.011], reduced use of vasoactive drugs [1 (0, 1) vs 1 (1, 2), P <0.001], less injection pain [2 (1.2%) vs 35 (21.3%), P <0.001], and lower recall [20 (11.8%) vs 36 (20.3%), P =0.034]. There were no differences in the QoR-15 scores and PSQI scores at postoperative 1 day, 1 week, and 1 month between groups., Conclusion: This non-inferiority study revealed that in elderly outpatients undergoing gastrointestinal endoscopy, remimazolam achieved recovery times comparable to propofol, with fewer associated complications., Competing Interests: The authors report no conflicts of interest in this work., (© 2024 Lu et al.)

Purpose: To investigate the impacts of remimazolam tosilate on gastrointestinal hormones and motility in patients undergoing gastrointestinal endoscopy with sedation., Methods: A total of 262 American Society of Anesthesiologists Physical Status I or II patients, aged 18-65 years, scheduled for gastrointestinal endoscopy with sedation, were randomly allocated into two groups (n = 131 each): the remimazolam tosilate group (Group R) and the propofol group (Group P). Patients in Group R received 0.2-0.25 mg/Kg remimazolam tosilate intravenously, while those in Group P received 1.5-2.0 mg/kg propofol intravenously. The gastrointestinal endoscopy was performed when the Modified Observer's Assessment of Alertness/Sedation scores were ≤3. The primary endpoints included the endoscopic intestinal peristalsis rating by the endoscopist; serum motilin and gastrin levels at fasting without gastrointestinal preparation (T0), before gastrointestinal endoscopy (T1), and before leaving the Post Anesthesia Care Unit (T2); and the incidences of abdominal distension during Post Anesthesia Care Unit., Results: Compared with Group P, intestinal peristalsis rating was higher in Group R (P < .001); Group R showed increased motilin and gastrin levels at T2 compared with Group P (P < .01). There was a rise in motilin and gastrin levels at T1 and T2 compared with T0 and at T2 compared with T1 in both groups (P < .01). The incidence of abdominal distension was lower in Group R (P < .05)., Conclusion: Compared with propofol used during gastrointestinal endoscopy with sedation, remimazolam tosilate mildly inhibits the serum motilin and gastrin levels, potentially facilitating the recovery of gastrointestinal motility., (© The Author(s) 2024. Published by Oxford University Press on behalf of Fellowship of Postgraduate Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Dyspepsia is a very prevalent upper gastrointestinal tract symptoms complex. Some of these symptoms might arise from serious underlying diseases, so the promotion of evidence-based guidelines could potentially better align evaluation and treatment., Aim: To determine the value of alarm features as a predictive factor for significant endoscopic findings (SEFs) among hospitalized patients presenting with dyspepsia., Methods: We conducted a retrospective case-control study including information about 6208 endoscopic procedures performed for hospitalized patients. Patients were divided into two groups, with and without SEFs, and compared to elucidate the ability of the different alarm features to predict SEFs., Results: During the study, 605 patients fulfilled the inclusion criteria. When the demographics and clinical characteristics of the two groups were compared, tachycardia ( P < 0.05), normocytic anemia, ( P < 0.05), leukocytosis ( P < 0.05), and hypoalbuminemia ( P < 0.05) documented on admission prior to endoscopy were strong predictors of SEFs. Among the alarm features, upper gastrointestinal bleeding, persistent vomiting, odynophagia [odds ratio (OR) = 3.81, P < 0.05; OR = 1.75, P = 0.03; and OR = 7.81, P = 0.07, respectively] were associated with SEFs. Unexplained weight loss was strongly associated with malignancy as an endoscopic finding (OR = 2.05; P < 0.05). In addition, long-term use of anti-aggregate medications other than aspirin ( P < 0.05) was correlated to SEFs., Conclusion: Novel predictors of SEFs were elucidated in this study. These parameters could be used as an adjunctive in decision making regarding performing upper endoscopy in hospitalized patients with dyspepsia., Competing Interests: Conflict-of-interest statement: The authors have no conflicts of interest to declare., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

Purpose: Remimazolam is a novel short-acting benzodiazepine used for sedation and general anesthesia. This study aimed to evaluate the efficacy and safety of remimazolam besylate in elderly patients who underwent diagnostic gastrointestinal endoscopy., Patients and Methods: A total of 120 patients aged 60-75 years were randomly allocated to one of two groups. Remifentanil 0.3μg/kg was used for analgesia. Patients were administered remimazolam besylate 7 mg (R group) or etomidate 0.1 mg/kg combined with 1% propofol 0.5 mg/kg (EP group) for induction, supplemental repeated doses were given as needed. Some time metrics, vital signs, adverse events were evaluated. Patients' Mini-cog score and recovery questionnaires were compared., Results: Compared to the EP group, the induction time was slightly longer in the R group (1.50 VS 1.15 minutes) (P<0.05), the time spent in the post-anesthesia care unit (PACU) was shorter (15.17 VS 17.40 minutes) (P<0.05). Compare with EP group, SBP was lower in R group at T15 and T25 time point, but heart rate was higher in T2, T3, T5 (P< 0.05). The Mini-Cog score was higher after the procedure (2.83 VS 2.58) (P<0.05). The incidence of respiratory adverse events was higher in the EP group than R group (18.3% VS 5.0%, P < 0.05). The most common adverse event in R group was hiccups. The sedation satisfaction rate and degree of amnesia were higher in the R group (66.7% VS 11.7%) (P < 0.05), and the effect on patient's life within 24 hours was lower (12.0% VS 30.5%) (P < 0.05)., Conclusion: The safety and efficacy of remimazolam besylate are not inferior to those of etomidate combined with propofol, rendering it a safe option for sedation during gastrointestinal endoscopy in ASA I-II elderly patients, but care should be taken to monitor the occurrence of hiccups., Competing Interests: The authors report no conflicts of interest in this work., (© 2024 Zhang et al.)

Early detection of esophageal and gastric cancers offers the possibility of curative treatments with less-invasive interventions than traditional surgical approaches. This review highlights the main endoscopic therapeutic modalities used for early esophageal and gastric malignancies. Endoscopic resection techniques include endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). EMR is beneficial for smaller, well-defined lesions and involves resecting the superficial layer of the mucosa. In contrast, ESD permits en bloc resection of larger lesions, including those involving the superficial submucosa, offering precise histopathological assessments and reduced recurrence rates. As such, multidisciplinary collaboration is essential to achieve optimal outcomes., Competing Interests: Disclosure The authors have no conflicts of interest to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

In this retrospective study spanning 2016 to 2022, we aimed to evaluate the diagnostic utility of upper gastrointestinal endoscopy (UGE) in children under 18 years presenting with severe unexplained iron deficiency anemia (IDA), defined as microcytic anemia of hemoglobin ≤7 g/dL with low ferritin levels. Of 106 children hospitalized for severe anemia, 29 had unexplained IDA (mean hemoglobin level of 6.2 [3.2 to 6.9] gr/dL), and 25 of them underwent UGE. The mean age was 10.7 ± 3.9 years, with 76% being female. Ten children (40%) had gastrointestinal (GI) symptoms at presentation. The cause of IDA was found in 18 (72%) of 25 children who underwent UGE, of whom 12 were without GI symptoms. Gastric nodularity, erosions, or polyps were observed in 68%, and gastritis was evident in 72% based on histopathology. Helicobacter pylori was found in 50% of those with gastritis. Follow-up showed normalized hemoglobin levels in 92% of cases, with only 2 children requiring repeat iron therapy. Our findings underscore the importance of incorporating UGE into the diagnostic investigation of severe unexplained IDA in children, irrespective of the presence of GI symptoms., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Antithrombotic agents, including antiplatelet agent and anticoagulants are widely used in Korea due to increasing incidence of cardio-cerebrovascular disease and aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. Clinical practice guideline regarding this issue which was developed by the Korean Society of Gastrointestinal Endoscopy was published in 2020. However, since then, new evidence has emerged for the use of dual antiplatelet therapy and direct anticoagulant management, and revised guidelines were issued in the US and Europe. Accordingly, the previous guidelines were revised, cardiologists also participated in the development group, and the recommendations went through a consensus process among international experts. This guideline presents 14 recommendations made according to the Grading of Recommendations, Assessment, Development, and Evaluation methodology, and was reviewed by multidisciplinary experts. This guideline provides useful information that can assist endoscopists in the management of patients on antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.

Purpose: To compare the influences of propofol, ciprofol and remimazolam on dreaming during painless gastrointestinal endoscopy., Methods: This study was a single-center, prospective, parallel-design, double-blind, randomized clinical trial. Between May 2023 and October 2023, patients undergoing elective painless gastrointestinal endoscopy were recruited and randomly allocated into one of the three groups. Demographic data, intraoperative information, incidence of dreaming, insufficient anesthesia and intraoperative awareness, type of dream, patient satisfaction score, adverse events, and improvement of sleep quality were collected., Results: The difference in incidence of dreaming among the three groups was not significant (33.33% vs 48.33% vs 41.67%, p =0.061). The number of patients with intraoperative hypotension in the propofol group was larger than that of the remimazolam group (32 vs 12, p =0.001). However, the cases of intraoperative hypotension between propofol group and ciprofol group or ciprofol group and remimazolam group were comparable (32 vs 22, p =0.122; 22 vs 12, p =0.064). The percentage of insufficient anesthesia between propofol group and remimazolam group was significant (13.33% vs 1.67%, p =0.001), while no statistical difference was detected between propofol group and remimazolam group or ciprofol group and remimazolam group (13.33% vs 5.00%, p =0.025; 5.00% vs 1.67%, p =0.150). The ability of propofol to improve sleep quality at 1st post-examination day was significantly better than that of remimazolam (86.21% vs 72.88%, p =0.015), while it was not significant between propofol group and ciprofol group or ciprofol group and remimazolam group (86.21% vs 80.36%, p =0.236; 72.88% vs. 72.88%, p =0.181). Incidence of intraoperative awareness, intraoperative hypoxia, type of dream, satisfaction score, adverse events during recovery, and sleep improvement on the 7th post-examination day was not significant among the groups., Conclusion: Anesthesia with propofol, ciprofol and remimazolam, respectively, for gastrointestinal endoscopy did not induce statistical difference in the incidence of dreaming, despite that all of them are more likely to induce pleasant dreams., Competing Interests: The authors declare that there are no existing or potential conflicts of interest in this work., (© 2024 Zhou et al.)

Background: Gastrointestinal (GI) endoscopy is one of healthcare's main contributors to climate change. We aimed to assess healthcare professionals' attitudes and the perceived barriers to implementation of sustainable GI endoscopy., Methods: The LEAFGREEN web-based survey was a cross-sectional study conducted by the European Society of Gastrointestinal Endoscopy (ESGE) Green Endoscopy Working Group. The questionnaire comprised 39 questions divided into five sections (respondent demographics; climate change and sustainability beliefs; waste and resource management; single-use endoscopes and accessories; education and research). The survey was available via email to all active members of the ESGE and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) in March 2023., Results: 407 respondents participated in the survey (11% response rate). Most participants (86%) agreed climate change is real and anthropogenic, but one-third did not consider GI endoscopy to be a significant contributor to climate change. Improvement in the appropriateness of endoscopic procedures (41%) and reduction in single-use accessories (34%) were considered the most important strategies to reduce the environmental impact of GI endoscopy. Respondents deemed lack of institutional support and knowledge from staff to be the main barriers to sustainable endoscopy. Strategies to reduce unnecessary GI endoscopic procedures and comparative studies of single-use versus reusable accessories were identified as research priorities., Conclusions: In this survey, ESGE and ESGENA members acknowledge climate change as a major threat to humanity. Further improvement in sustainability beliefs and professional attitudes, reduction in inappropriate GI endoscopy, and rational use of single-use accessories and endoscopes are critically required., Competing Interests: E. Rodríguez de Santiago has received fees from Olympus (educational and advisory roles), Apollo Endosurgery (educational activities), Norgine (congress fee) and Casen Recordati (congress fee). I.M. Gralnek has received fees from Motus GI, Medtronic, Boston Scientific, CheckCap, Clexio Biosciences, Astra-Zeneca, and Vifor Pharma. M. Dinis-Ribeiro has received fees for consultancy (Roche and Medtronic). J.A. Cunha Neves, H. Pohl, V. Lorenzo-Zuñiga, M.F. Cunha, A.M. Voiosu, C. Römmele, D. Penman, E. Albeniz Arbizu, K. Siau, L. Donnelly, L. Elli, M. Pioche, U. Beilenhoff, M. Arvanitakis, B.L.A.M. Weusten, R. Bisschops, C. Hassan, and H. Messmann declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: Although endoscopic ultrasound (EUS) plays a critical role in the management of subepithelial lesions (SEL) of upper gastrointestinal tract many can be classified solely by a thorough upper gastrointestinal endoscopy (UGE) which can reduce the burden of additional studies., Aims: Analyze the impact of a stepwise approach starting with a second-look UGE before the decision of EUS in patients referred to our center with suspected SEL., Methods: Retrospective cohort study which included all adult patients referred to our center between 2015 and 2020 with suspected SEL.Second-look UGE evaluated the location, size, color, surface characteristics, movability and consistency of the SEL and bite-on-bite biopsies were performed. Decisions on SEL management and follow-up were collected., Results: A total of 193 SEL (190 patients) were included. At the index-UGE, stomach was the most frequent location (n = 115;59.6%). Most patients performed a second-look UGE (n = 180; 94.7%). A minority was oriented directly to EUS (n = 8;4.2%) or endoscopic resection (n = 2; 1.1%). In patients who underwent a second-look UGE, SEL were excluded in 25 (13.9%) and 21 (11.7%) did not need further work-up. The remaining patients were submitted to EUS (n = 88;48.9%), surveillance by UGE (n = 44; 24.4%) or endoscopic resection (n = 2; 1.1%)., Conclusion: Systematically performing a second-look UGE, in patients referred with suspected SEL, safely preclude the need for subsequent investigation in approximately one-fourth of the patients. As UGE is less invasive and more readily available, we suggest that a second-look UGE should be the initial approach in SEL management., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

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

Objectives: The health-care sector contributes 4.6% of global greenhouse gas emissions, with gastroenterology playing a significant role due to the widespread use of gastrointestinal (GI) endoscopy. In this review, we aim to understand the carbon footprint in gastroenterology practice associated with GI endoscopy, conferences and recruitment, identify barriers to change, and recommend mitigating strategies., Methods: A comprehensive search of PubMed, Embase, and the Cochrane Library was conducted to explore the carbon footprint in gastroenterology practice, focusing on endoscopy, inpatient and outpatient settings, and recruitment practices. Recommendations for mitigating the carbon footprint were derived., Results: This narrative review analyzed 34 articles on the carbon footprint in gastroenterology practice. Carbon footprint of endoscopy in the United States is approximately 85,768 metric tons of CO 2 emission annually, equivalent to 9 million gallons of gasoline consumed, or 94 million pounds of coal burned. Each endoscopy generates 2.1 kg of disposable waste (46 L volume), of which 64% of waste goes to the landfill, 28% represents biohazard waste, and 9% is recycled. The per-case manufacturing carbon footprint for single-use devices and reusable devices is 1.37 kg CO 2 and 0.0017 kg CO 2 , respectively. Inpatient and outpatient services contributed through unnecessary procedures, prolonged hospital stays, and excessive use of single-use items. Fellowship recruitment and gastrointestinal conferences added to the footprint, mainly due to air travel and hotel stays., Conclusion: Gastrointestinal endoscopy and practice contribute to the carbon footprint through the use of disposables such as single-use endoscopes and waste generation. To achieve environmental sustainability, measures such as promoting reusable endoscopy equipment over single-use endoscopes, calculating institutional carbon footprints, establishing benchmarking standards, and embracing virtual platforms such as telemedicine and research meetings should be implemented., (© 2023 Japan Gastroenterological Endoscopy Society.)

Background: Mobile C-arms may be used in fixed locations, and it is recommended that qualified experts evaluate structural shielding., Purpose: To assess clinical workload distributions for mobile C-arms used in gastrointestinal endoscopy and determine the Archer equation parameters for the C-arm beam spectra., Methods: Consecutive (30 months) gastrointestinal endoscopic procedures on two Cios Alpha systems (Siemens) were retrospectively analyzed. X-ray tube voltage, tube current-time product, reference point air kerma (K a,r ), air kerma-area product (P KA ), and fluoroscopic time were examined. The primary beam half-value layer (HVL) was measured with an ionization chamber and aluminum 1100 plates. Stray radiation fraction at 1 m from a scattering source (ACR R/F phantom) was directly measured. Monte Carlo (Geant4) simulation was performed to calculate the transmission of broad X-ray beams through lead, concrete, gypsum, and steel, with X-ray HVLs matching those of the C-arm X-ray beam. The transmission data were fitted to the Archer equation., Results: The number of procedures (3509) was equivalent to 13.48 procedures per room per week. Dose quantities were 54.8 mGy (K a,r ), 18.3 Gy∙cm 2 (P KA ), and 7.8 min (fluoroscopic time) per procedure. X-ray beam irradiation events were recorded for 2906 (82.8%) procedures with 160,009 events, whose mA-minute weighted tube voltage was 91.0 kV and the workload was 0.68 mA-minute per procedure. The two rooms had a significant difference in the number of procedures per week, 17.3 (29) [mean (maximum)] and 9.6 (16), respectively. The stray radiation fraction was 9.7×10 -4 (80 kV) and 1.25×10 -3 (120 kV). Transmission fitting parameters were provided for the tube voltage (on average, 90 kV; high end, 120 kV) of the C-arm., Conclusions: This work provides workload and transmission data for mobile C-arm fluoroscopy in gastrointestinal endoscopy, which indicates a need for structural shielding evaluation of the procedure rooms., (© 2024 American Association of Physicists in Medicine.)

Background: Patient late cancelation and nonattendance for endoscopy appointments is an ongoing problem affecting the productivity and wait times of endoscopy units. Previous research evaluated a model for predictive overbooking and had promising results., Study: All endoscopy visits at an outpatient endoscopy unit during 4 nonconsecutive months were included in the data analysis. Patients who did not attend their appointment, or canceled with 48 hours of their appointment were considered nonattendees. Demographic, health, and prior visit behavior data was collected and the groups compared., Results: 1780 patients attended 2331 visits in the study period. Comparing the attendee versus non-attendees, there were significant differences in mean age, prior absenteeism, prior cancelations, and total number of hospital visits. No significant differences were seen between groups in winter versus non-winter months, the day of the week, sex distribution, type of procedure booked, or whether the referral was from specialist clinic or direct to procedure. The visit cancelation proportion (calculated excluding current visit) was substantially higher in the absentee group ( P <0.0001). A predictive model was developed and compared to current booking as well as a straight overbooking of 7%. Both overbooking models performed better than the current practice, but the predictive overbooking model did not outperform straight overbooking., Conclusions: Developing an endoscopy unit specific predictive model may not be more beneficial than straight overbooking as calculated by missed appointment percentage., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background/aims: While current guidelines recommend performing endoscopy within 24 h in case of acute upper gastrointestinal bleeding (AUGIB), the precise timing remains an issue of debate. Lactate is an established parameter for risk stratification in a variety of medical emergencies. This study evaluated the predictive ability of elevated lactate levels in identifying patients with UGIB, who may benefit from emergent endoscopy., Methods: We retrospectively analyzed all patients with elevated lactate levels, who presented to our emergency department between 01 January 2015 and 31 December 2019 due to suspected AUGIB., Results: Of 134 included cases, 81.3% had an Charlson comorbidity index of ≥3 and 50.4% presented with shock. Fifteen (11.2%) patients died and mortality rates rose with increasing lactate levels. Emergent endoscopy within 6 h (EE) and non-EE were performed in 64 (47.8%) and 70 (52.2%) patients, respectively. Patients who underwent EE had lower systolic blood pressure (107.6 mmHg vs. 123.2 mmHg; p  = 0.001) and received blood transfusions more frequently (79.7% vs 64.3%; p  = 0.048), but interestingly need for endoscopic intervention (26.6% vs 20.0%; p  = 0.37), rebleeding (17.2% vs. 15.7%; p  = 0.82) and mortality (9.4% vs. 11.4%; p  = 0.7) did not differ significantly., Conclusion: In conclusion, our findings support the recommendations of current guidelines to perform non-EE after sufficient resuscitation and management of comorbid illnesses.

Introduction: Health-related quality of life (HRQoL) examines the impact of the symptoms of dyspepsia on the daily life of sufferers. There are a few published studies related to HRQoL of persons with dyspepsia in Africa., Methods: this was a hospital-based cross-sectional study involving 324 dyspeptic patients referred for upper gastrointestinal endoscopy to the University of Benin Teaching Hospitals (UBTH) The ROME IV criteria were used to recruit patients with dyspepsia. The short form Nepean Dyspepsia Index (SF NDI) was used to assess HRQoL in all participants. Upper gastrointestinal endoscopy was performed on all 324 dyspeptic patients., Results: the mean age of patients was 47.6 ± 15.6 years. Three hundred (92.6%) patients had significantly impaired HRQoL with an SF NDI mean score of 31.3 ± 9.1. Interference with daily activities and eating and drinking subdomains were more impaired than other subdomains of HRQoL (p < 0.001). There was no statistical difference between the impaired HRQoL in patients with functional dyspepsia and organic dyspepsia (p = 0.694). Among patients with organic dyspepsia, those with upper gastrointestinal cancers had significantly worse HRQoL SF NDI mean (sd) scores (39.7 ± 5.9) compared with patients with gastritis, peptic ulcer disease and GERD with (30.3 ± 9.2, 31.5 ± 9.7 and 32.9 ± 7.1 respectively) (p = 0.01)., Conclusion: health-related quality of life is significantly impaired in patients with dyspepsia and those with upper gastrointestinal cancers having overall worse scores. The physical, social and psychological well-being of a majority of patients with dyspepsia in South-South Nigeria is negatively affected by dyspepsia., Competing Interests: The authors declare no competing interests., (Copyright: Oziegbe Egbo et al.)

Objectives: Endoscopy teaching practice is variable, which inevitably affects the training provided. There is only one Train the Paediatric Colonoscopy Trainer (TPCT) course in the UK. Informal feedback has been positive, but its practical value has never been formally assessed. We aim to assess the practical value of the TPCT course and how attendees perceive their teaching practice compared to nonattendees., Methods: A questionnaire based on the TPCT course learning aims and objectives was distributed to two groups of consultant paediatric gastroenterologists who teach colonoscopy in the UK; those who had attended the course (participants) and those who had not (controls)., Results: The 41 completed responses were received. Overall, responses indicated participants of the TPCT course rated their confidence and knowledge in teaching practices as higher than controls (4.27 vs. 3.56 p = < 0.001). There was a statistically significant difference in all areas: set (4.21 vs. 3.71 p = 0.011), dialogue (4.29 vs. 3.55 p = < 0.001) and closure (4.37 vs. 3.6 p = < 0.001) with those who attended the TPCT course giving higher ratings. There was evidence of increased understanding of key concepts such as using standardised language, conscious competence, dual task interference and performance enhancing feedback., Conclusion: Attending a TPCT course results in a higher perceived level of knowledge in fundamental teaching principles and confidence in colonoscopy teaching skills., (© 2024 European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Competing Interests: There are no financial disclosures or conflicts of interest.

Competing Interests: E. Rondonotti has received speaker's honoraria from Fujifilm Co. and has a consultancy agreement with Medtronic Co.

Competing Interests: The authors declare that they have no conflict of interest.

Background/aim: Esophagogastroduodenoscopy (EGD) is an effective screening method for early detection of gastric cancer. The GAGLESS mouthpiece has a structure that widens the pharyngeal cavity and suppresses the pharyngeal reflex. This study aimed to investigate the acceptability, safety, and feasibility of transnasal and peroral ultrathin endoscopy using GAGLESS mouthpieces (Clinical Trial Number: UMIN000036922)., Patients and Methods: This study was a multicenter, prospective, randomized, open-label trial performed using a questionnaire. The study included 101 consecutive patients who visited the participating medical institutions between June 2019 and March 2022 (median age=47 years, range=24-87 years; all male). Patients aged ≥20 years at the time of consent acquisition who were the first to undergo EGD were included in the study. The primary endpoint was the degree of distress during EGD, as determined using a visual analog scale (VAS)., Results: The VAS score during endoscopic passage through the pharynx was significantly better in the transnasal endoscopy group than in the oral endoscopy group (2.420 vs. 4.092, p=0.001). There was no significant difference in the VAS scores between the two groups during anesthesia or throughout the examination. Compared with nasal endoscopy, oral endoscopy with a GAGLESS mouthpiece did not reduce the VAS score but did significantly improve gastric visibility., Conclusion: For patients in whom there was difficulty in inserting a nasal endoscope, using a GAGLESS mouthpiece rather than a conventional mouthpiece may be more useful in reducing pain., (Copyright © 2024, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Significance: Color differences between healthy and diseased tissue in the gastrointestinal (GI) tract are detected visually by clinicians during white light endoscopy; however, the earliest signs of cancer are often just a slightly different shade of pink compared to healthy tissue making it hard to detect. Improving contrast in endoscopy is important for early detection of disease in the GI tract during routine screening and surveillance., Aim: We aim to target alternative colors for imaging to improve contrast using custom multispectral filter arrays (MSFAs) that could be deployed in an endoscopic "chip-on-tip" configuration., Approach: Using an open-source toolbox, Opti-MSFA, we examined the optimal design of MSFAs for early cancer detection in the GI tract. The toolbox was first extended to use additional classification models ( k -nearest neighbor, support vector machine, and spectral angle mapper). Using input spectral data from published clinical trials examining the esophagus and colon, we optimized the design of MSFAs with three to nine different bands., Results: We examined the variation of the spectral and spatial classification accuracies as a function of the number of bands. The MSFA configurations tested showed good classification accuracies when compared to the full hyperspectral data available from the clinical spectra used in these studies., Conclusion: The ability to retain good classification accuracies with a reduced number of spectral bands could enable the future deployment of multispectral imaging in an endoscopic chip-on-tip configuration using simplified MSFA hardware. Further studies using an expanded clinical dataset are needed to confirm these findings., (© 2024 The Authors.)

Background: Lower gastrointestinal bleeding (LGIB) is an urgent presentation with increasing prevalence and remains a common cause of hospitalization. The clinical outcome can vary based on several factors, including the cause of bleeding, its severity, and the effectiveness of management strategies. The aim of this study is to provide a comprehensive report on the clinical outcomes observed in patients with LGIB who underwent lower endoscopy., Methods: All patients who underwent emergency lower endoscopy for fresh bleeding per rectum, from May 2015 to December 2021, were included. The primary outcome was to identify the rate of rebleeding after initial control of bleeding. The second was to measure the clinical outcomes and the potential predictors leading to intervention and readmission., Results: A total of 84 patients were included. Active bleeding was found in 20% at the time of endoscopy. Rebleeding within 90 days occurred in 6% of the total patients; two of which (2.38%) were within the same admission. Ninety-day readmission was reported in 19% of the cases. Upper endoscopy was performed in 32.5% of the total cases and was found to be a significant predictor for intervention (OR 4.1, P = 0.013). Personal history of inflammatory bowel disease (IBD) and initial use of sigmoidoscopy were found to be significant predictors of readmission [(OR 5.09, P = 0.008) and (OR 5.08, P = 0.019)]., Conclusions: LGIB is an emergency that must be identified and managed using an agreed protocol between all associated services to determine who needs upper GI endoscopy, ICU admission, or emergency endoscopy within 12 hours., (Copyright © 2023 Copyright: © 2023 Saudi Journal of Gastroenterology.)

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

Background and Aims: Digestive endoscopy is a resource-intensive activity with a conspicuous carbon footprint and an estimated rate of inappropriateness. However, the carbon costs of inappropriate endoscopic procedures still remain obscure. Here we evaluated the environmental impact of inappropriate endoscopic examinations., Methods: We calculated the carbon cost of a standard endoscopic procedure (EGD and colonoscopy [CLS]), taking into account the items (eg, disposable materials, personal protective equipment) and energy required for the endoscopy procedure itself and the cleaning process. The rates of inappropriateness and the mortality cost of carbon (MCC) of endoscopic examinations in different scenarios were calculated., Results: EGD and CLS presented a carbon cost of 5.43 kg and 6.71 kg of CO 2 , respectively. Different scenarios were evaluated, according to the number of endoscopic procedures performed in Italy per 1000 inhabitants and the reported data on their inappropriateness. The carbon cost of inappropriate EGD and CLS in Italy was 4133 CO 2 metric tons per year (MCC, .93), ranging from 3527 to 4749, and equivalent to 1,760,446 L of gasoline consumed. Applying the same data to the European population, the estimated carbon footprint of inappropriate digestive endoscopy in Europe was 30,804 metric tons., Conclusions: The environmental impact of inappropriate endoscopic procedures in Europe is remarkable. These results highlight the need to adopt novel strategies aimed at reducing both the carbon footprint of digestive endoscopy and the rate of inappropriate procedures., Competing Interests: Disclosure All authors disclosed no financial relationships. Research support for this study was provided in part by the Italian Ministry of Health–Current Research IRCCS for authors from the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico-Milano., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Purpose: White light imaging (WLI) is a commonly seen examination mode in endoscopy. The particular light in compound band imaging (CBI) can highlight delicate structures, such as capillaries and tiny structures on the mucosal surface. These two modes complement each other, and doctors switch between them manually to complete the examination. This paper proposes an endoscopy image fusion system to combine WLI and CBI., Methods: We add a real-time rotatable color wheel in the light source device of the AQ-200 endoscopy system to achieve rapid imaging of two modes at the same position of living tissue. The two images corresponding to the pixel level can avoid registration and lay the foundation for image fusion. We propose a multi-scale image fusion framework, which involves Laplacian pyramid (LP) and convolutional sparse representation (CSR) and strengthens the details in the fusion rule., Results: Volunteer experiments and ex vivo pig stomach trials are conducted to verify the feasibility of our proposed system. We also conduct comparative experiments with other image fusion methods, evaluate the quality of the fused images, and verify the effectiveness of our fusion framework. The results show that our fused image has rich details, high color contrast, apparent structures, and clear lesion boundaries., Conclusion: An endoscopy image fusion system is proposed, which does not change the doctor's operation and makes the fusion of WLI and CBI optical staining technology a reality. We change the light source device of the endoscope, propose an image fusion framework, and verify the feasibility and effectiveness of our scheme. Our method fully integrates the advantages of WLI and CBI, which can help doctors make more accurate judgments than before. The endoscopy image fusion system is of great significance for improving the detection rate of early lesions and has broad application prospects., (© 2023. CARS.)

Background: A considerable number of patients with nonvariceal upper gastrointestinal bleeding (UGIB) need endoscopic intervention., Objective: The aim of this study was to determine factors that predict the need for endoscopic intervention at the time of admission to the emergency department., Methods: Consecutive patients with International Classification of Diseases, Tenth Revision diagnosis code K92.2 (gastrointestinal hemorrhage) who underwent upper endoscopy between February 2019 and February 2022, including patients diagnosed with nonvariceal UGIB in the emergency department in the study were reviewed retrospectively. The patients were divided into two groups: those treated endoscopically and those not treated endoscopically. These two groups were compared according to clinical and laboratory findings at admission and independent predictors for endoscopic intervention were determined using multivariate regression analysis., Results: Although 123 patients (30.3%) were treated endoscopically, endoscopic treatment was not required in 283 (69.7%) patients. Syncope, mean arterial pressure (MAP), and blood urea nitrogen (BUN) at admission were independent predictors for endoscopic intervention in the multivariate analysis, after adjusting for endoscopy time. The area under the curve of the syncope+MAP+BUN combination for endoscopic intervention was 0.648 (95% CI 0.588-0.708). Although the syncope+MAP+BUN combination predicted the need for intervention significantly better than pre-endoscopy Rockall and AIMS65 scores (p = 0.010 and p < 0.001, respectively), there was no significant difference in its comparison with the Glasgow-Blatchford score (p = 0.103)., Conclusions: Syncope, MAP, and BUN at admission were independent predictors for endoscopic therapy in patients with nonvariceal UGIB. Rather than using complicated scores, it would be more practical and easier to predict the need for endoscopic intervention with these three simple parameters, which are included in the Glasgow-Blatchford score., Competing Interests: Declaration of competing interest Authors have no conflicts of interest to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Monocular depth estimation plays a fundamental role in clinical endoscopy surgery. However, the coherent illumination, smooth surfaces, and texture-less nature of endoscopy images present significant challenges to traditional depth estimation methods. Existing approaches struggle to accurately perceive depth in such settings., Method: To overcome these challenges, this paper proposes a novel multi-scale residual fusion method for estimating the depth of monocular endoscopy images. Specifically, we address the issue of coherent illumination by leveraging image frequency domain component space transformation, thereby enhancing the stability of the scene's light source. Moreover, we employ an image radiation intensity attenuation model to estimate the initial depth map. Finally, to refine the accuracy of depth estimation, we utilize a multi-scale residual fusion optimization technique., Results: To evaluate the performance of our proposed method, extensive experiments were conducted on public datasets. The structural similarity measures for continuous frames in three distinct clinical data scenes reached impressive values of 0.94, 0.82, and 0.84, respectively. These results demonstrate the effectiveness of our approach in capturing the intricate details of endoscopy images. Furthermore, the depth estimation accuracy achieved remarkable levels of 89.3 % and 91.2 % for the two models' data, respectively, underscoring the robustness of our method., Conclusions: Overall, the promising results obtained on public datasets highlight the significant potential of our method for clinical applications, facilitating reliable depth estimation and enhancing the quality of endoscopy surgical procedures., Competing Interests: Declaration of competing interest The authors declare that there are no conflicts of interest related to this article., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

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

Background/objective: Increasing infectious rate estimates and low microbiological surveillance affect safety of gastrointestinal endoscopy globally. Single use endoscopes and accessories have been claimed to improve safety, but there is lack of data on their indication and sustainability. We aimed to identify a series of best practice recommendations for the use of single use endoscopes and accessories using a modified Delphi., Methods/design: Consensus statements for the use of single use endoscopy and accessories were developed using a modified Delphi process, utilizing an international endoscopist expert panel of 62 experts from 33 nations. The main steps in the process were selecting the consensus group, conducting systematic literature reviews, developing statements, and anonymous voting on the statements until consensus was reached. High-risk patients were defined as those with multi-drug-resistant infections, immunosuppressive medication or chemotherapy, post-transplantation, or with severe neutropenia., Results: Of the 26 statements that were voted upon through two rounds, 17 statements reached consensus. Category 1: single use accessories (8 statements), related to defining recommendations for the use of single use accessories in all patient populations or high-risk patients. Category 2: clinical indication for single use endoscopes (9 statements), including indications to high-risk patients, protecting the endoscope apparatus and contamination measures in endoscopy units. Category 3: technical factors (4 statements), related to superior performance and technical specifications with the new innovation. Category 4: environmental issues (2 statements), concerning mechanisms that reduce the detrimental burden to the environment. Category 5: financial implications (3 statements), related to healthcare policies, cost neutrality and other financial associations of single use endoscopy., Conclusions: This is the first international initiative in determining clinical indications for single use endoscopy and accessories. The study's findings should serve as a framework for future physicians to guide future research and aid the proper evidence-based indications for the implementation of single use endoscopes in clinical practice., Competing Interests: Conflict of interest Cesare Hassan: Consulting fees for Fuji, and Medtronic. Alessandro Repici: Consulting fees for Fuji, Olympus, and Medtronic and receiving research grant and speaker fees from Boston Scientific, ERBE, Alfasigma, Norgine. Pradeep Bhandari: Research support from Fujifilm Europe, Boston Scientific, Pentax and Olympus Medical. Other authors declare no competing interests., (Copyright © 2023 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Objective: This article aimed to analyze upper endoscopic findings in the HIV patient population to elucidate the upper-gastrointestinal complications related to HIV infection. Gastrointestinal (GI) disorders in individuals living with HIV/AIDS exhibit diverse and often nonspecific manifestations, imposing substantial morbidity and mortality burdens. Endoscopic evaluation with biopsies is essential in the diagnosis and management of these conditions. Delayed treatment due to undetected GI abnormalities during endoscopic examinations can lead to poorer health outcomes., Methods: This systematic review has determined the findings of upper-GI endoscopy of HIV-infected patients. Online databases of PubMed, Web of Science, Jisc Library Hub Discover, and Library of Congress have been searched using relevant keyword combinations. We have retrieved all the pertinent papers and reports published in English and screened them against inclusion/exclusion criteria for data extraction in two steps. First, titles/abstracts have been evaluated and then full-text screening has been performed by independent researchers. This study has adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist., Results: In this review, 24 articles have been included in the final analysis. The study has focused on the characteristics of participants and the findings of endoscopic evaluations. The participants of the study have been HIV-positive patients, and the majority of them have undergone endoscopy due to gastrointestinal symptoms. The biopsy regions primarily targeted have been observed to be the esophagus, stomach, and duodenum. The most common result of the biopsy specimens has been chronic active gastritis., Conclusion: To improve clinical practice, this systematic review sought to provide an up-to-date reference for upper gastrointestinal endoscopic findings of HIV-infected persons. Our results are in line with earlier research showing how effective endoscopy is for determining a precise diagnosis and directing care. The majority of HIV patients with gastrointestinal symptoms have been found to have opportunistic infections and persistent active gastritis as well as mucosal abnormalities of the upper gastrointestinal tract. Studies have shown that endoscopic and histological assessment can aid in the early detection and management of issues involving the upper gastrointestinal tract., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background and Aim: Greenhouse gas emissions are the fundamental cause of global warming, with CO 2 being the most contributive. Carbon reduction has been widely advocated to mitigate the climate crisis. The endoscopy unit is the third highest waste-generating department in a hospital. The awareness and acceptance of the practice of green endoscopy among healthcare workers is unclear., Method: An online survey was conducted over a 5-week period from July to August 2023 in the Asia-Pacific region, which targeted endoscopists, nurses, and other healthcare professionals of the endoscopy unit. The primary outcome was the agreement to adopt green endoscopy. The secondary outcomes included views on sustainable practices, factors associated with increased acceptance of green endoscopy, the acceptance of different carbon reduction measures, and the perceived barriers to implementation., Results: A total of 259 valid responses were received. Overall, 79.5% of participants agreed to incorporate green endoscopy into their practice. Nevertheless, existing green policies were only reported by 12.7% of respondents. The level of understanding of green endoscopy is the only significant factor associated with its acceptance (odds ratio 3.10, P < 0.007). Potential barriers to implementation include healthcare cost increment, infection risk, inadequate awareness, and lack of policy and industrial support., Conclusion: Green endoscopy is well accepted among healthcare workers but not widely implemented. The level of understanding is highly associated with its acceptance, highlighting the importance of education. A reliable assessment tool is needed to quantify the environmental impact of endoscopy. Further studies are needed to ascertain its benefit and cost effectiveness., (© 2023 The Authors. Journal of Gastroenterology and Hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

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

Objectives: This study aimed to confirm whether premedication with pronase before endoscopy improves mucosal visualization and increases precancerous lesion and cancer lesion detection rates., Materials and Methods: From June 2018 to April 2019, out-patients scheduled for endoscopy from 13 hospitals were screened to be randomly allocated in a 2:1 ratio to premedication with pronase (group A) and water (group B). The primary endpoint was mucosal visibility scores, and the secondary endpoint was precancerous and cancer lesion detection rates. This trial was registered at Chinese Clinical Trial Registry, and the registration number was ChiCTR1800016853., Results: Group A showed significantly lower mucosal visibility scores (better mucosal visibility) of esophagus, stomach, and duodenum than group B, with all P -values <0.001. The overall cancer detection rates between group A and group B were 0.83 and 1.08%, and overall detection rates of precancerous and cancer lesion were 4.4 and 4.9%, both without significant difference ( P =1.000 and 0.824). In addition, the flushing volume (milliliter) of group A (10.52±23.41) was less than group B (36.30±52.11) ( P <0.001), and the flushing frequency of group A (0.46±1.01) was fewer than group B (1.62±2.12) ( P <0.001)., Conclusions: Premedication with pronase could achieve better mucosal visibility and decrease flushing frequency and volume, but may not increase lesion detection rates., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)