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Background and study aims Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) for pancreatic neuroendocrine tumors (NETs) and intraductal pancreatic mucinous neoplasia (IPMN) with worrisome features or high-risk stigmata (WF/HRS) has been evaluated in few series with short-term outcomes. This studyʼs primary endpoint was to assess the long-term efficacy of EUS-RFA in patients with NETs or pancreatic cystic neoplasms (PCNs) over at least 3 years. Patients and methods Twelve patients had 14 NETs with a mean 13.4-mm size (10–20) and 17 patients had a cystic tumor (16 IPMN, 1 MCA) with a 29.1-mm mean size (9–60 were included. They were treated with EUS-guided RFA, evaluated prospectively at 1 year, and followed annually for at least 3 years. Results The mean duration of follow-up was 42.9 months (36–53). Four patients died during follow-up (17–42 months) from unrelated diseases.At 1-year follow-up, and 85.7 % complete disappearance was seen in 12 patients with 14 NETs. At the end of follow-up (45.6 months), complete disappearance of tumors was seen in 85.7 % of cases. One case of late liver metastasis occurred in a patient with initial failure of EUS-RFA. At 1-year follow-up, a significant response was seen in 70.5 % of 15 patients with PCNs. At the end of the follow-up, there was a significant response in 66.6 % with no mural nodules. Two cases of distant pancreatic adenocarcinoma unrelated to IPMN occurred. Conclusions EUS-RFA results for pancreatic NETs or PCNs appear to be stable during 42 months of follow-up.

Background During endoscopic retrograde cholangiopancreatography (ERCP), access to the common bile duct (CBD) can be problematic after unintentional insertion of the guidewire into the pancreatic duct. We conducted a prospective, randomized study in order to compare biliary cannulation success rates of early double-guidewire (EDG) and repeated single-guidewire (RSG) techniques in patients with inadvertent passage of the guidewire into the pancreatic duct. Methods Patients with a native papilla were randomly assigned to either the EDG or RSG groups after unintentional insertion of the guidewire into the pancreatic duct. The primary outcome was successful selective CBD cannulation within 10 minutes. The secondary outcomes were successful final selective bile duct cannulation, time to bile duct cannulation, and frequency of post-ERCP pancreatitis (PEP). Results 142 patients were randomized and selective bile duct cannulation was achieved in 57/68 patients (84 %) in the EDG group and in 37/74 patients (50 %) in the RSG group within 10 minutes (relative risk 1.34; 95 % confidence interval 1.08–6.18; P Conclusion The EDG technique significantly increased the success rate of biliary duct cannulation within 10 minutes compared with an RSG approach.

ObjectiveDue to an annual progression rate of Barrett’s oesophagus (BO) with low-grade dysplasia (LGD) between 9% and 13% per year endoscopic ablation therapy is preferred to surveillance. Since this recommendation is based on only one randomised trial, we aimed at checking these results by another multicentre randomised trial with a similar design.DesignA prospective randomised study was performed in 14 centres comparing radiofrequency ablation (RFA) (maximum of 4 sessions) to annual endoscopic surveillance, including patients with a confirmed diagnosis of BO with LGD. Primary outcome was the prevalence of LGD at 3 years. Secondary outcomes were the prevalence of LGD at 1 year, the complete eradication of intestinal metaplasia (CE-IM) at 3 years, the rate of neoplastic progression at 3 years and the treatment-related morbidity.Results125 patients were initially included, of whom 82 with confirmed LGD (76 men, mean age 62.3 years) were finally randomised, 40 patients in the RFA and 42 in the surveillance group. At 3 years, CE-IM rates were 35% vs 0% in the RFA and surveillance groups, respectively (pConclusionRFA modestly reduced the prevalence of LGD as well as progression risk at 3 years. The risk-benefit balance of endoscopic ablation therapy should therefore be carefully weighted against surveillance in patients with BO with confirmed LGD.Trial registration numberNCT01360541.

Peroralcholangio-pancreatoscopy (POCP) is used for diagnosis and treatment of biliopancreatic disease when standard endoscopy (ERCP) or pre-operative imaging workup failed. We aimed to evaluate the diagnostic and therapeutic performance of POCP in complex biliary and pancreatic diseases.Patients with indeterminate biliary or pancreatic duct (PD) strictures, and patients with failure of complex biliary or pancreatic stones removal, were enrolled (six centers). The primary endpoint evaluated malignancy diagnostic performances (accuracy, sensitivity, specificity) and therapeutic performances (biliary or pancreatic stones extraction). Secondary endpoints evaluated: technical success in lesion visualization, ease of maneuvering, image quality and 30-days complications.From November 2016 to March 2018, 66 patients were included: 29/37 women/men, median age (IQR): 73 (64-82). Fifty-three patients had diagnostic POCP and 13 patients therapeutic POCP. One endoscopist with one or two endoscopy nurses performed 94% of the POCP. The 'POCP visual impression' of malignancy showed 92.0% sensitivity, 92.9 % specificity and 92.5 % overall accuracy compared with the final diagnosis. 'POCP-guided samples histological analysis' showed 75.0 % sensitivity and 91.6% specificity. The technical success for lesion visualization was 98.5%. The median VAS scores for insertions in bile and PD were respectively 9.0 (8.1-9.6) and 9.0 (8.8-10.0). Median VAS score for access to the lesion and image quality were respectively 9.0 (7.7-9.6) and 9.0 (7.9-9.7). Only three 30-day minor complications occurred without any major complications.POCP was an effective, safe and easy-to-use tool in routine clinical practice for the management of complex diagnostic and therapeutic biliary and pancreatic diseases (NCT03190343).

Objectives A single-use duodenoscope (SUD) has been recently developed to overcome issues with endoscopic retrograde cholangiopancreatography (ERCP)-related cross-infections. The aim was to evaluate SUD safety and performance in a prospective multi-centre study. Methods All consecutive patients undergoing ERCP in six French centers were prospectively enrolled. All procedures were performed with the SUD; in case of ERCP failure, operators switched to a reusable duodenoscope. Study outcomes were the successful completion of the procedure with SUD, safety and operators' satisfaction based on a VAS 0-10 and on 22 qualitative items. The study protocol was approved by French authorities and registered (ID-RCB: 2020-A00346-33). External companies collected the database and performed statistical analysis. Results Sixty patients (34 females, median age 65.5 years old) were enrolled. Main indications were bile duct stones (41.7%) and malignant biliary obstruction (26.7%). Most ERCP were considered ASGE grade 2 (58.3%) or 3 (35.0%). Fifty-seven (95.0%) procedures were completed using the SUD. Failures were unrelated to SUD (one duodenal stricture, one ampullary infiltration, and one tight biliary stricture) and could not be completed with reusable duodenoscopes. Median operators' satisfaction was 9 (7-9). Qualitative assessments were considered clinically satisfactory in a median of 100% of items and comparable to a reusable duodenoscope in 97.9% of items. Three patients (5%) reported an adverse event. None was SUD-related. Conclusions The use of a SUD allows ERCP to be performed with an optimal successful rate. Our data show that SUD could be used for several ERCP indications and levels of complexity.

Background and study aims Large scale data on esophagogastroduodenoscopy (EGD) in Western countries are scarce. We conducted a prospective study on the diagnostic yield of upper gastrointestinal endoscopy in France. Patients and methods An online questionnaire was sent to all French gastroenterologists practicing endoscopy. Data from EGDs performed during one week were collected. A statistical extrapolation of the results to a whole year was performed. Results 342 gastrointestinal endoscopists, representative of the population of French gastroenterologists, provided data on 2735 EGDs, corresponding to 1 006 316 (95%CI = 937 080−1 075 552) procedures for the entire year. 1770 (64.7%) EGDs were performed under sedation or general anesthesia, and 930 (34%) were associated with a colonoscopy. 896 (32.8%) EGDs were normal. Hiatal hernia and esophagitis were the most frequent esophageal diagnoses, in 496 (18.1%) and 374 (13.7%) cases, respectively. Barrett’s esophagus was diagnosed in 109 (4%) patients. Among gastric lesions, endoscopic gastritis was reported in 572 (20.9%) patients; ulcer, polyps, and suspected malignancy in 78 (2.9%), 62 (2.3%), and 19 (0.7%), respectively. 1597 (58.4%) EGDs included mucosal biopsies, and 141 (5.1%) were associated with a therapeutic procedure. Conclusions We report nationwide prospective data on upper gastrointestinal endoscopy practice in France. Our data suggest that about 300 000 normal EGDs each year in France could potentially be avoided by a diagnostic strategy relying on upper GI capsule endoscopy, providing significant relief on healthcare practitioners.

Background Pancreatic neuroendocrine tumors (NETs) and intraductal pancreatic mucinous neoplasia (IPMN) with worrisome features are surgically managed. Endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA) has recently been developed. The safety of EUS-RFA was the primary end point of this study, its efficacy the secondary end point. Methods This was a prospective multicenter study that was planned to include 30 patients with a 1-year follow-up with either a NET Results 12 patients had 14 NETs (mean size 13.1 mm, range 10 – 20 mm); 17 patients had cystic tumors (16 IPMNs, 1 MCA; mean size 28 mm, range 9 – 60 mm). Overall three adverse events occurred (10 %), two of these in the first two patients (one pancreatitis, one small-bowel perforation). After these initial patients, modifications in the protocol resulted in a decrease in complications (3.5 %), with one patient having a pancreatic ductal stenosis. Among the 14 NETs, at 1-year follow-up 12 had completely disappeared (86 % tumor resolution), with three patients having a delayed response. Among the 17 PCNs, at 12 months, there were 11 complete disappearances and one diameter that decreased by > 50 % (significant response rate 71 %). All 12 mural nodules showed complete resolution. Conclusions EUS-RFA of pancreatic NETs or PCNs is safe with a 10 % complication rate, which can be decreased by improved prophylaxis for the procedure.

Background Endoscopic access to common bile duct (CBD) remains difficult in 10% of cases, requiring alternative techniques. This retrospective study with historical controls aimed to evaluate the benefit of the double guidewire (DGW) technique as part of a standardized protocol in CBD access, after failure of standard cannulation and to compare successful CBD access rates, complication rates and length of hospital stay (LOS) in two groups. Method From January 2012 to December 2014, all consecutive patients requiring therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with “difficult” access to CBD were included in a “studied group”. CBD access was “difficult” after either: 5 unsuccessful attempts, 5 unintentional insertions in the pancreatic duct or more than 10-minute-long unsuccessful attempts. This group was compared to a historical control group undergoing ERCP from January 2009 to December 2011. In the studied group, a sequential strategy including DGW technique was performed when the guidewire was unintentional passed into the pancreatic duct. In the control group, only precut technique was used. Results Among the 538 patients with naive papilla eligible for ERCP, 73 had difficult CBD access. Successful CBD access rate was higher in the studied group: 91%(50/55) vs 67%(12/18) p=0.0215. Complication rates were similar in both groups: 28% vs 20%, p=0.5207. LOS was shorter in the studied group (9.2±8.5 days vs. 14.4±7.4 days, p=0.0028). Post-ERCP cholangitis were lower in the study group: 2%(1/55) vs 22%(4/18), p = 0.0118. Conclusion After standard cannulation failure, DGW technique increased successful CBD access rate and decreased LOS without increasing complications. This article is protected by copyright. All rights reserved.

Introduction: Self-expanding metal stents (SEMS) are commonly used in the palliation of dysphagia in patients with inoperable esophageal carcinoma. However, they predispose to gastroesophageal reflux when deployed across the gastroesophageal junction. The aims of this study were to: 1) assess the influence of the antireflux valve on trans-prosthetic reflux (primary outcome); and 2) compare the results of SEMS with and without antireflux valve in terms of reflux symptoms, quality of life (QOL), improvement of dysphagia and adverse events (secondary outcomes). Patients and methods: Thirty-eight patients were enrolled in nine centers. Carcinomas were locally advanced (47 %) or metastatic. After randomization, patients received either a covered SEMS with antireflux valve (n = 20) or a similar type of SEMS with no antireflux device but assigned to standard proton pump inhibitor therapy and postural advice (n = 18). Trans-prosthetic reflux was assessed at day 2 using a radiological score based on barium esophagography performed after Trendelenburg maneuver and graded from 0 (no reflux) to 12 (maximum). Monthly telephone interviews were conducted for Organisation Mondiale de la Santé (OMS) scoring from 0 (excellent) to 5 (poor), QOL assessment (based on the Reflux-Qual Simplifié scoring system) from 0 (poor) to 100 (excellent), dysphagia scoring from 0 (no dysphagia) to 5 (complete dysphagia) and regurgitation scoring from 0 (no regurgitation) to 16 (maximum). Results: No difference was noted in terms of age, sex, size of lesion, prosthesis length or need for dilation prior to SEMS placement. No difficulty in placing SEMS nor complications were noted. Radiological scores of reflux were found to be significantly lower in patients with an antireflux stent compared to the conventional stent and associated measures. The regurgitation scores were significantly decreased in patients with antireflux stents during the first 2 months after stent placement and thereafter, they were similar in the two groups. QOL and dysphagia were improved in both groups. Survival rates were comparable in the two groups. Conclusions: No difference was observed between the two types of SEMS regarding the palliation of dysphagia and improvement of QOL. However, SEMS with an antireflux valve were more effective in preventing trans-prosthetic gastroesophageal reflux but at the cost of an increased likehood of minor adverse events (migrations and/or obstruction of the SEMS).

Le catheterisme standard permet l’acces a la voie biliaire principale (VBP) dans 80–95 % des cas. Quelle que soit l’expertise de l’endoscopiste, dans 20 % des cas, l’acces a la VBP est juge difficile. Le but de cette revue de la litterature est de definir les causes d’un catheterisme difficile de la VBP et de donner les differentes techniques permettant d’acceder a la VBP apres echec d’un catheterisme standard. Une revue systematique de la litterature a ete realisee en excluant les techniques de drainage biliaire par echoendoscopie.

La radiofrequence (RF) est un traitement valide de l’endobrachyoesophage dysplasique. Cette revue de la litterature a pour objectif d’evaluer les techniques, l’efficacite et les effets indesirables de la RF endoscopique dans d’autres indications, emergentes. Quatre etudes prospectives (total 69 patients) ont montre que la RF permettait d’obtenir une remission complete de neoplasies intraepitheliales oesophagiennes malpighiennes en dysplasie de haut grade ou avec carcinome epidermoide in situ dans 80 % des cas, avec cependant un risque substantiel de stenoses oesophagiennes proximales. Dans l’indication des ectasies vasculaires antrales de l’estomac, une etude pilote prospective (six patients), une etude prospective monocentrique ouverte (21 patients) et une etude retrospective multicentrique (24 patients) montrent que la RF semble un traitement efficace en termes de diminution du recours aux transfusions. Une etude prospective ouverte monocentrique (39 patients) et une etude retrospective multicentrique (17 patients) suggerent que la RF est un traitement efficace de la rectopathie radique hemorragique chronique. Une etude retrospective comparative (64 patients) montre que la radiofrequence ameliore la duree de permeabilite des protheses dans les situations de stenoses biliaires malignes. Une etude pilote suggere que la RF endobiliaire peut egalement etre une option interessante dans les stenoses biliaires benignes refractaires. Les donnees sont encore limitees concernant la radiofrequence lors de ponction sous echoendoscopie pour des cancers du pancreas localement avances non resequables et pour les traitements des adenopathies mediastinales. La radiofrequence endoscopique est une modalite therapeutique qui ouvre de nouvelles perspectives dans la destruction des neoplasies intraepitheliales oesophagiennes malpighiennes a un stade precoce, dans le traitement hemostatique de lesions vasculaires digestives (ectasies vasculaires antrales de l’estomac et rectopathie radique hemorragique) et dans les maladies biliaires.

International audience; The use of direct oral anticoagulants (DOACs) was an important step forward in the management of atrial fibrillation and venous thromboembolism (VTE). The DOACs, anti-IIa for dabigatran and anti-Xa for rivaroxaban, apixaban and edoxaban, all have a rapid onset of action and a short half life. There is no need for routine hemostasis testing for treatment monitoring of a DOAC. Compared with vitamin K antagonists (VKAs), DOACs may increase the risk of gastrointestinal bleeding (relative risk 1.25). Withholding the DOAC treatment, evaluating the time of the last intake and estimating the patient’s renal function are the first steps in the management of gastrointestinal bleeding. For patients without impaired renal function, achieving low coagulation takes around 24 h after the last intake of a DOAC. The use of DOAC antagonists will be helpful in controlling bleeding in the most severe and urgent situations. Idarucizumab is available for clinical use for dabigatran and andexanet is currently being reviewed by drug agencies for rivaroxaban, apixaban and edoxaban. It is important to assess the bleeding risk associated with the planned procedure, and the patient’s renal function before withholding DOAC therapy for a scheduled intervention. It is mandatory to strengthen the local hemostasis strategies in DOAC-treated patients undergoing a therapeutic endoscopic procedure. Resuming or not resuming anticoagulation with a DOAC after bleeding or a risky procedure depends on the thrombotic and bleeding risk as well as the procedure involved. This discussion should always involve the cardiologist and decisions should be taken by a pluridisciplinary team.

Background and study aims: Endoscopic submucosal dissection (ESD) provides a high en bloc resection rate for superficial colorectal tumors. The aims of this study were to assess the feasibility of ESD in France and to evaluate the complete resection rate at 1 year. Patients and methods: Patients with superficial rectal tumors ≥ 10 mm in size were prospectively included in the study at nine French expert centers between February 2010 and June 2012. The study was stopped temporarily because of a high complication rate. Study recruitment resumed following remedial action. Results: A total of 45 patients were included (mean age 67 years; 24 males). The immediate perforation rate was 18 % (n = 8), and salvage surgery was not required. Six patients (13 %) had late bleeding, which was treated endoscopically in five patients and surgically in one patient who had required blood transfusion. The mortality rate was zero. The en bloc resection rate was 64 % (29/45), and the curative R0 resection rate was 53 % (24/45). Three patients (7 %) had an invasive tumor (two sm1, one T2). At 1-year follow-up, endoscopic examinations showed complete resection in 38 /43 patients (88 %). At the end of the study, after the remedial action, the en bloc resection rate had increased from 52 % to 82 %, and the perforation rate had decreased significantly from 34 % to 0 %. Conclusions: The study reflects the initial prospective experience of ESD in France, and suggests that curative R0 resection rates should increase and complication rates should decrease with experience and corrective actions.

Environ 10 % de la population de plus de 70 ans est atteinte d’une lesion kystique du pancreas. Les tumeurs intracanalaires papillaires et mucineuses du pancreas (TIPMP) et les cystadenomes mucineux font partie des tumeurs kystiques pancreatiques qui ont un risque de degenerescence. l’echoendoscopie (EE) est au moins aussi sensible que l’IRM pour diagnostiquer une communication entre un kyste et un canal pancreatique. En cas de doute diagnostique, le dosage de l’ACE dans le liquide de ponction du kyste permet d’orienter vers une origine mucineuse. l’analyse cytologique est utile pour rechercher des cellules en dysplasie dans les TIPMP des canaux secondaires avec un kyste de 20–30 mm. Il est recommande de realiser une ponction apres une antibioprophylaxie et arret des antiagregants plaquettaires et anticoagulants. Grâce a sa haute resolution, l’EE est l’examen le plus performant pour rechercher des criteres morphologiques de mauvais pronostic (taille des kystes, nodules muraux, epaississement parietal). l’utilisation du contraste en EE permettrait de mieux differencier le mucus d’un nodule mural. La microscopie confocale et l’EE endocanalaire sont en cours d’evaluation. Des protocoles de surveillance des TIPMP ont ete etablis, mais leur rationnel scientifique est encore faible, c’est pourquoi une etude nationale est en cours.

Background: The aim of the study was to describe the clinical and endoscopic characteristics and management of severe acute gastrointestinal (GI) bleeding in patients treated with direct oral anticoagulants (DOACs). Methods: Patients hospitalized for severe GI bleeding under DOAC therapy were identified in 36 centres between June 2013 and March 2016. Clinical outcomes including re-bleeding, major cerebral and cardiovascular events or all-cause mortality were assessed initially and 30 days after admission. Results: A total of 59 patients with anonymized detailed endoscopy reports for severe GI bleeding were considered. Mean age was 79.3 ± 10.0 years and 61.3% of patients were men. Patients had histories of hypertension (65.6%), heart failure (29.5%), coronary artery disease (27.9%), stroke (19.7%) and peripheral vascular disease (36.1%). Life-threatening bleeding was observed in 42.6%. Mean number of packed red blood cells transfused was 3.4 (range 1–31). Aetiology of bleeding (identified in 66.2% of cases) was peptic gastroduodenal ulcers (22%), diverticula (11.9%), angiodysplasia (8.5%), colorectal neoplasia (5.1%) and anorectal causes (5.1%). Endoscopic haemostasis was performed in 37.7% of patients. A low haemoglobin level was predictive of life-threatening bleeding and death in multivariate analysis. All-cause mortality rate at day 30 was 11.8%. Conclusions: In this cohort of elderly patients with multiple comorbidities treated with DOACs, the main cause of severe acute GI bleeding was peptic gastroduodenal ulcer and mortality was high.

Patient acceptability of the preparation is a key factor in the success of colonoscopy, yet standard polyethylene glycol solutions are poorly tolerated owing to their high volume (4L) and low palatability. This study compared the efficacy, safety and acceptability of a 2L polyethylene glycol+ascorbate solution with a standard 4-L polyethylene glycol solution.Adults referred for colonoscopy were randomised to 2-L polyethylene glycol+ascorbate (n=202) or 4-L polyethylene glycol solution (n=198). Colon cleansing success was assessed using the Harefield Cleansing Scale(©) and the Aronchick scale. Safety and acceptability were also assessed.Successful cleansing was achieved in 94.1% and 90.9% of subjects with the 2-L and 4-L solutions respectively using the Harefield Cleansing Scale(©) and 94.6% and 90.0% using the Aronchick scale (non significant). Despite better acceptability and tolerability, no superiority over the standard 4-L preparation was demonstrated. Fewer treatment-related adverse events were reported with the 2-L solution (80.2% versus 89.9%, p=0.011). More subjects were willing to take the 2L PEG+ascorbate solution again (87% versus 51%, p0.001), found it easier to drink (80% versus 70%, p=0.025), with a better taste (p=0.01).Two-litre polyethylene glycol+ascorbate solution, with a similar high degree of cleansing and superior acceptability and tolerability, presents an alternative to 4-L polyethylene glycol when compliance is an issue.

Summary Endoscopic evaluation after chemoradiotherapy (CR) is impossible with an esophageal stent in place. The main study objective was to evaluate self-expanding plastic stent (SEPS) removal post-CR. Secondary end-points were the improvement of dysphagia and patients' quality of life. From October 2008 to March 2011, 20 dysphagic patients who suffered from advanced esophageal cancer were enrolled in a multicenter, prospective study. SEPS was inserted prior to CR and then removed endoscopically. SEPS efficiency (dysphagia score) and tolerance, as well as the patients' quality of life (European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire validated for the esophagus), were monitored. Continuous variables were compared using a paired t-test analysis for matched data. A P-value of less than 0.05 was considered statistically significant. Twenty patients (15 men and 5 women), aged 61.5 years (±9.88) (range 43–82 years), with adenocarcinoma (n = 12) and squamous cell carcinoma (n = 8), were enrolled. SEPS were successfully inserted in all patients (100%). There was one perforation and three episodes of migration. All of these complications were medically treated. The mean dysphagia score at the time of stent placement was 2.79 (0.6). Mean dysphagia scores obtained on day 1 and day 30 post-SEPS placement were 0.7 (0.9) (P < 0.0001) and 0.45 (0.8) (P < 0.0001), respectively. Quality of Life Questionnaire validated for the esophagus score showed an improvement in dysphagia (P = 0.01) and quality of oral feeding (P = 0.003). All SEPS were removed endoscopically without complications. In two patients, the stent was left in place due to metastatic disease. SEPS are extractable after CR of esophageal cancer. Early stenting by SEPS prior to and during CR may reduce dysphagia and improve quality of oral alimentation.

Background and study aims: Previous reports of simultaneous presence of esophageal varices (EV) and achalasia suggest placement of a transjugular intrahepatic portosystemic shunt (TIPS) and surgical myotomy or endoscopic therapy. We report the case of a 64-year-old man who received anticoagulant therapy for a myeloproliferative disorder with extensive portal thrombosis which was a contraindication to placement of a TIPS.

The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. P2Y12 receptor antagonists (clopidogrel, prasugrel, ticagrelor) For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation). Warfarin The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance. Direct Oral Anticoagulants (DOAC) For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30–50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).

Contexte Peu de donnees sont disponibles sur la pratique de la coloscopie et son rendement diagnostique en Europe. Nous avons mene une etude prospective nationale d’evaluation de la pratique de la coloscopie et des performances diagnostiques de cet examen.

Le Dual-Knife® (Olympus) est un nouveau couteau frequemment utilise pour la dissection sous-muqueuse du fait de sa surete et de sa precision. L’objet de cette etude etait d’evaluer l’efficacite et la tolerance du traitement endoscopique du diverticule de Zenker avec le Dual-Knife® assiste d’un diverticuloscope (Cook®). De fevrier 2009 a octobre 2011, 21 patients (14 hommes et sept femmes) dont l’âge moyen etait de 70,7 ± 10,2 ans, presentant un diverticule de Zenker symptomatique, ont ete inclus dans une etude prospective multicentrique non randomisee. La myotomie du muscle cricopharyngien etait realisee avec le Dual-Knife® apres exposition du septum diverticulaire grâce au diverticuloscope. En fin de procedure, un ou deux clips etaient positionnes a l’extremite distale de la dissection. Tous les patients decrivaient des symptomes incluant une dysphagie (n = 15; 71,4 %), des regurgitations et/ou troubles de la deglutition (n = 19; 90 %). Seize patients (75 %) avaient un diverticule dont la profondeur etait superieure ou egale a 30 mm. Toutes les complications etaient notees. Les symptomes des patients (dysphagie, regurgitation, troubles de la deglutition et inhalations) etaient evalues lors de consultations de surveillance regulieres ou par telephone. Le test utilise determine la probabilite que les deux parametres soient fortement lies au seuil p = 0,05 (test CMH). Une p-value inferieure a 0,05 indique une forte liaison entre les deux parametres, donc on accepte l’hypothese qu’il n’y a pas d’effet traitement. Les donnees ont ete analysees a l’aide du logiciel SAS (version 9.2; SAS Institute Inc, Cary, NC). Tous les patients ont ete traites avec succes lors de la premiere session. Nous n’avons eu aucune complication grave. Une hemorragie immediate a ete traitee endoscopiquement avec succes a l’aide d’une pince d’hemostase. Tous les patients sont sortis dans les 48 heures suivant l’intervention. A un mois et au moment de l’evaluation de suivi (7,85 mois [3–12]), la dysphagie et les regurgitations etaient significativement ameliorees (p = 0,48/0,18 et 0,68/,041 respectivement). Dix-huit patients (85,7 %) n’avaient plus aucun symptome. Pour trois patients, la dysphagie et/ou les regurgitations persistaient de manieres plus moderees. La dysphagie et/ou les regurgitations ont recidive pour deux patients (9,5 %). Un deuxieme traitement endoscopique a ete necessaire et un patient a ete opere. Au final, le traitement endoscopique etait efficace dans 90,4 % des cas. La diverticulotomie endoscopique au Dual-Knife® aide du diverticuloscope est une alternative therapeutique sure et efficace pour des patients atteints d’un diverticule de Zenker symptomatique.

Le traitement des calculs de la voie biliaire principale (VBP) est endoscopique dans un grand nombre de cas. La sphincterotomie suivie d’une extraction du ou des calculs est en regle generale suffisante. Il existe cependant des situations d’echecs, qui vont necessiter d’utiliser d’autres techniques pour eviter la chirurgie. Il importe de connaitre les criteres predictifs d’echec. Ceux-ci sont principalement la taille du calcul, leur nombre, l’impaction dans le sphincter, et le diametre de la VBP inferieur a celui du calcul. Dans de telles situations, la premiere technique consiste a realiser une lithotritie mecanique (LM) qui permet l’extraction des calculs difficiles dans plus de 90 % des cas. En cas d’echec, d’autres alternatives sont possibles. La plus simple consiste a mettre une ou plusieurs protheses plastiques, qui, lorsqu’elles sont laissees en place, entrainent souvent une fragmentation des calculs, voire leur elimination. La deuxieme technique, plus recente, est la macrodilatation du sphincter d’Oddi. Celle-ci est effectuee avec un ballon dont le diametre est adapte a celui du calcul (12 a 20 mm). Enfin, une lithotritie intracorporelle (electrohydraulique ou laser) peut etre realisee, en centre expert le plus souvent.

With the increasing use of antiplatelet agents (APA), their management during the periendoscopic period has become a more common and more difficult problem. The increase in use is due to the availability of new drugs and the widespread use of drug-eluting coronary stents. Acute coronary syndromes can occur when APA therapy is withheld for noncardiovascular interventions. Guidelines about APA management during the periendoscopic period are traditionally based on assessments of the procedure-related risk of bleeding and the risk of thrombosis if APA are stopped. New data allow better assessment of these risks, of the necessary duration of APA discontinuation before endoscopy, of the use of alternative procedures (mostly for endoscopic retrograde cholangiopancreatography [ERCP]), and of endoscopic methods that can be used to prevent bleeding (following colonic polypectomy). This guideline makes graded, evidence-based, recommendations for the management of APA for all currently performed endoscopic procedures. A short summary and two tables are included for quick reference.

Background & Aims Little is known about the magnitude of the risk of anal and rectal cancer in patients with anal and/or perineal Crohn's disease. We aimed to assess the risk of anal and rectal cancer in patients with Crohn's perianal disease followed up in the Cancers Et Surrisque Associe aux Maladies Inflammatoires Intestinales En France (CESAME) cohort. Methods We collected data from 19,486 patients with inflammatory bowel disease (IBD) enrolled in the observational CESAME study in France, from May 2004 through June 2005; 14.9% of participants had past or current anal and/or perianal Crohn's disease. Subjects were followed up for a median time of 35 months (interquartile range, 29–40 mo). To identify risk factors for anal cancer in the total CESAME population, we performed a case-control study in which participants were matched for age and sex. Results Among the total IBD population, 8 patients developed anal cancer and 14 patients developed rectal cancer. In the subgroup of 2911 patients with past or current anal and/or perianal Crohn's lesions at cohort entry, 2 developed anal squamous-cell carcinoma, 3 developed perianal fistula–related adenocarcinoma, and 6 developed rectal cancer. The corresponding incidence rates were 0.26 per 1000 patient-years for anal squamous-cell carcinoma, 0.38 per 1000 patient-years for perianal fistula–related adenocarcinoma, and 0.77 per 1000 patient-years for rectal cancer. Among the 16,575 patients with ulcerative colitis or Crohn's disease without anal or perianal lesions, the incidence rate of anal cancer was 0.08 per 1000 patient-years and of rectal cancer was 0.21 per 1000 patient-years. Among factors tested by univariate conditional regression (IBD subtype, disease duration, exposure to immune-suppressive therapy, presence of past or current anal and/or perianal lesions), the presence of past or current anal and/or perianal lesions at cohort entry was the only factor significantly associated with development of anal cancer (odds ratio, 11.2; 95% CI, 1.18-551.51; P = .03). Conclusions In an analysis of data from the CESAME cohort in France, patients with anal and/or perianal Crohn's disease have a high risk of anal cancer, including perianal fistula–related cancer, and a high risk of rectal cancer.

Background: Gastrointestinal angiodysplasias (GIADs) could be responsible for recurrent bleeding and severe anemia. Somatostatin analogs could reduce transfusion requirements in these patients but no randomized controlled study is available. The main objective of the ANGIOPAS phase II double-blinded randomized, noncomparative study was to assess the effectiveness of pasireotide-LAR in reducing transfusion requirements in patients with refractory GIADs bleeding. Methods: A total of 22 patients with transfusion requirements ⩾6 units of packed red blood cells (pRBCs) during the 6 months prior to inclusion were randomized to receive pasireotide-LAR 60 mg ( n = 10) or placebo ( n = 12) every 28 days for 6 months. Patients were then followed for an additional 6 months after stopping treatment. Results: The pasireotide-LAR and placebo groups were equivalent for age, sex, comorbidities and transfusion requirement during the reference period (median 13 and 9.5 pRBCs). A 50 and 83% success rate (success defined as a decrease of at least 30% of transfused pRBCs) was observed in the pasireotide-LAR arm in the Intent to Treat (ITT) and per protocol (PP) analysis respectively. The need for transfusion during the intervention period was 3 pRBC units in the pasireotide-LAR group (range 0–26) and 11.5 pRBC units in the placebo group (range 0–23). Overall, three cases with glycemic control impairment were observed in the pasireotide-LAR group including one de novo diabetes. Conclusion: This double-blinded noncomparative randomized phase II study suggests, for the first time, the effectiveness of pasireotide-LAR 60 mg every 28 days to decrease the transfusion requirement in patients with recurrent bleeding due to GIADs.

BACKGROUND AND STUDY AIM: Polyp miss rates during colonoscopy have been calculated in a few tandem or back-to-back colonoscopy studies. Our objective was to assess the adenoma miss rate while limiting technique or operator expertise biases, i. e. by performing a large multicenter study, with same-day back-to-back video colonoscopy, done by two different operators in randomized order and blinded to the other examination. PATIENTS AND METHODS: 294 patients at 11 centers were included. Among the 286 analyzable tandem colonoscopies, miss rates were calculated in both a lesion- and patient-based analysis. Each of these rates was determined for polyps overall, for adenomas, and then for lesions larger than 5 mm, and for advanced adenomas. Univariate and logistic regression analysis were performed to define independent variables associated with missed polyps or adenomas. RESULTS: The miss rates for polyps, adenomas, polyps ≥ 5 mm, adenomas ≥ 5 mm, and advanced adenomas were, respectively, 28, 20, 1, 9 and 11 %. None of the masses with a carcinomatous (n = 3) or carcinoid component (n = 1) was missed. The specific lesion miss rates for patients with polyps and adenomas were respectively 36 and 26 % but the corresponding rates were 23 and 9.4 % when calculated for all 286 patients. The diameter (1-mm increments) and number of polyps (≥ 3) were independently associated with a lower polyp miss rate, whereas sessile or flat shape and left location were significantly associated with a higher miss rate. Adequacy of cleansing, presence of diverticula, and duration of withdrawal for the first procedure were not associated with adenoma miss rate. CONCLUSIONS: We confirm a significant miss rate for polyps or adenoma during colonoscopy. Detection of flat polyps is an issue that must be focused on to improve the quality of colonoscopy.

BACKGROUND AND STUDY AIM: The learning curve for endoscopic ultrasonography (EUS) is known to be difficult, especially in the field of pancreatic and biliary diseases. The aim of this study was to assess the impact of a live pig model developed for EUS credentialing in France. METHODS: A total of 17 trainees obtained hands-on EUS experience using a live pig model. Trainees were asked to visualize anatomical structures, to carry out fine-needle aspiration (FNA) on lymph nodes in the liver hilum, and to perform celiac neurolysis. Assessment of the FNA procedure or celiac neurolysis included measurement of time (seconds), evaluation of the precision of the puncture (mm), and existence of technical errors. RESULTS: A significant improvement between a pre-test and post-test was observed for diagnostic procedures in the following anatomical areas: splenic mesenteric vein, vena cava, splenic mesenteric artery, celiac tree, pancreatic gland, and bile duct. For lymph node FNA, a significant improvement was observed in the duration of the procedure (84 seconds vs. 60 seconds; P = 0.01), and precision (4.2 mm vs. 1.8 mm; P = 0.009), but not for the rate of technical error (29 % vs. 6 %; not significant [n. s.]). For celiac neurolysis, a significant improvement was observed in procedure time (150 seconds vs. 84 seconds; P = 0.003), but not in the rate of technical error (6 % vs. 6 %; n. s.) or precision (4.2 mm vs. 2.8 mm; n. s.). CONCLUSION: Teaching EUS with a live pig model significantly increased competence in diagnostic procedures with regard to visualizing anatomical structures, performance of FNA and, to a lesser extent, EUS-guided celiac neurolysis.

Biliary bipolar radiofrequency ablation (RFA) is a new treatment for extrahepatic cholangiocarcinoma (CCA) currently under evaluation. The purpose of this study was to evaluate the safety, particularly biliary fistula occurrence, and the feasibility of biliary RFA in a homogeneous group of patients treated using the same RFA protocol. Twelve patients with inoperable or unresectable CCA were included in a bicentric case series study. After removal of biliary plastic stents, a radiofrequency treatment with a new bipolar probe (Habib™ EndoHBP®) was applied. The energy was delivered by a RFA generator (VIO® 200 D), supplying electrical energy at 350 kHz and 10 W for 90 s. At the end of the procedure, one or more biliary stents were left in place. Adverse events were assessed per-procedure and during follow-up visits. CCA was confirmed in all patients by histology (66 %), locoregional evolution or metastatic evolution. The types of CCA were Bismuth I stage (N = 4), Bismuth II stage (N = 3), Bismuth III stage (N = 2) and Bismuth IV stage (N = 3). No serious adverse events occurred within 30 days following endoscopic treatment: One patient had a sepsis due to bacterial translocation on day 1 and another had an acute cholangitis on day 12 due to early stent migration. No immediate or delayed biliary fistula was reported. The ergonomics of the probe made treatment easy in 100 % of cases. Mean survival was 12.3 months. Endoscopic radiofrequency treatment of inoperable CCA appears without major risks and is feasible. No major adverse events or biliary fistula were identified.

L’exploration de l’intestin grele par videocapsule (VCE) se generalise et son rendement diagnostique est bien etabli. Son impact dans le traitement ou la prise en charge des patients suspects d’etre atteints d’une pathologie intestinale est peu connu et doit etre precise pour determiner sa cotation et prise en charge dans la nouvelle CCAM. Notre objectif a ete de definir l’impact diagnostique et therapeutique immediat et a long terme de la VCE.

One side effect of the immunomodulatory effect of interferon is the possible triggering or exacerbation of systemic or cutaneous sarcoidosis. We report two new cases and offer an exhaustive review of the literature. A 39-year-old man with type C chronic active hepatitis developed new respiratory symptoms and pulmonary infiltrates with hilar and mediastinal adenopathy after 7 months of treatment with pegylated interferon. The evolution was favourable after stopping treatment. The second patient developed cutaneous lesions after 6 months of treatment. Resolution occurred after the discontinuation of the treatment. In these two cases ribavirin was stopped before the first signs of sarcoidosis.

Dual-Knife(®) (Olympus) and Hydride-Knife(®) are new needle knives frequently used for submucosal dissection because of their safety and precision. In this study we aimed to evaluate the efficacy and safety of such devices in the diverticulopexy by flexible endoscopy.From February 2009 to March 2013, 42 patients (25 men), mean age 74.5, with symptomatic Zenker's diverticulum, were included in a non-randomized prospective multicenter study. The symptoms described by all patients include dysphagia, regurgitation and/or swallowing disorders. The diverticulopexy was performed with the Dual-Knife(®) or Hydrid-Knife(®), after septum exposure with the diverticuloscope, and terminated with distal tip clips positioning. All complications were noted. Patients' symptoms were regularly assessed during follow-up visits or telephone interviews.The first endoscopy treatment was successful for all patients. Thirty-seven patients (88%) had symptoms improvement after the first treatment. The recurrence rate was 14% (6 patients); a second endoscopic treatment was required 12 months on average after the first treatment, with 100% efficiency. Mid-term (16 months) efficiency was 91.67% after 1 to 3 endoscopic treatments. A total of 55 procedures were performed without perforation or significant bleeding and 3 patients underwent surgery. In multivariate analysis, the diverticulum size and the type of dissection knife were not risks factors for recurrence.Endoscopic diverticuloscope-assisted diverticulotomy with submucosal dissection knives is a safe and effective alternative treatment for patients with a symptomatic Zenker's diverticulum measuring between 2 and 10 cm.

Si la ponction-aspiration sous echoendoscopie de la surrenale gauche est une methode sure et rentable, seulement deux etudes ont ete publiees sur la faisabilite de la ponction-aspiration sous echoendoscopie de la surrenale droite. Un patient de 45 ans a subi une ponction- aspiration sous controle echoendoscopique, par voie transduodenale, d’une volumineuse lesion de la surrenale droite. Il presentait un cancer endocrine peu differencie du poumon; lors de la surveillance, le TDM a trouve une lesion de 40 mm de la surrenale droite. La ponction sous echoendoscopie a montre qu’il s’agissait d’une metastase de son cancer pulmonaire, ce diagnostic a ete confirme par une resection chirurgicale. La ponction-aspiration sous echoendoscopie par voie transduodenale de la surrenale droite semble possible et sure.