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Background The use of fully covered lumen-apposing metal stents (LAMS) for benign short gastrointestinal (GI) strictures has been reported. This study aimed to evaluate the safety and efficacy of LAMS for refractory GI strictures. Methods A retrospective analysis was performed of patients who underwent LAMS placement for benign GI strictures in 8 United States centers. The primary outcomes were technical success and initial clinical response. Secondary outcomes were reintervention rate and adverse events. Results A total of 51 patients underwent 61 LAMS placement procedures; 33 (64.7%) had failed previous treatments. The most common stricture location was the pylorus (n=17 patients). Various sizes of stents were used, with 15-mm LAMS placed in 45 procedures, 20-mm LAMS in 14 procedures, and 10-mm LAMS in 2 procedures. The overall technical success, short-term clinical response and reintervention rate after stent removal were 100%, 91.8% and 31.1%, respectively. Adverse events were reported in 17 (27.9%) procedures, with stent migration being the most common (13.1%). In subgroup analysis, both 15 mm and 20 mm stents had comparable short-term clinical response and adverse event rates. However, stent migration (15.6%) was the most common adverse event with 15-mm LAMS while pain (14.3%) was the most common with 20-mm LAMS. The reintervention rate was 80% at 200-day follow up after stent removal. Conclusions Using LAMS for treatment of short benign GI strictures is safe and effective. Larger LAMS, such as the new 20 mm in diameter, may have a lower stent migration rate compared to smaller diameter LAMS. [ABSTRACT FROM AUTHOR]

Background and Aims: EUS-guided biliary drainage has emerged as a technique to enable endobiliary drainage in failed ERCP. A newer model, lumen-apposing metal stents (LAMS), with a cautery-enhanced delivery system became available in the USA in late 2015. This cautery-tipped version may facilitate EUS-guided choledochoduodenostomy (EUS-CD), but data using this model are lacking.Methods: We reviewed outcomes of attempted EUS-CD using cautery-enhanced LAMS from 6, US centers. The following data were collected: patient and procedure details, technical success, adverse events, clinical success (resolution of jaundice or improvement in bilirubin > 50%), and biliary re-interventions.Results: EUS-CD was attempted in 67 patients (mean age 68.8) with malignant obstruction after failed ERCP between September 2015 and April 2018. EUS-CD was technically successful in 64 (95.5%). A plastic or metal stent was inserted through the lumen of the deployed LAMS in 50 of 64 (78.1%) patients to maintain a non-perpendicular LAMS axis into the bile duct. Adverse events occurred in 4 (6.3%) and included: abdominal pain (n = 2), peritonitis that responded to antibiotics (n = 1), and bleeding requiring transfusion (n = 1). Among 40 patients with follow-up of > 4 weeks, clinical success was achieved in 100%. Biliary re-interventions for obstruction were needed in 7(17.5%), in 3 of 6 (50.0%) that underwent EUS-CD with LAMS alone versus 4 of 34 (5%) with LAMS plus an axis-orienting stent (p = 0.02).Conclusion: EUS-CD using LAMS with cautery-enhanced delivery systems has high technical and clinical success rates, with a low rate of adverse events. Inserting an axis-orienting stent through the lumen of the LAMS may reduce the need for biliary re-interventions. [ABSTRACT FROM AUTHOR]

Background: The combination of prophylactic pancreatic stent placement (PSP) - a temporary plastic stent placed in the pancreatic duct - and rectal non-steroidal anti-inflammatory drugs (NSAIDs) is recommended for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk cases. Preliminary data, however, suggest that PSP may be unnecessary if rectal NSAIDs are administered. Given the costs and potential risks of PSP, we aim to determine whether rectal indomethacin obviates the need for pancreatic stent placement in patients undergoing high-risk ERCP.Methods/design: The SVI (Stent vs. Indomethacin) trial is a comparative effectiveness, multicenter, randomized, double-blind, non-inferiority study of rectal indomethacin alone versus the combination of rectal indomethacin and PSP for preventing PEP in high-risk cases. One thousand four hundred and thirty subjects undergoing high-risk ERCP, in whom PSP is planned solely for PEP prevention, will be randomized to indomethacin alone or combination therapy. Those who are aware of study group assignment, including the endoscopist, will not be involved in the post-procedure care of the patient for at least 48 hours. Subjects will be assessed for PEP and its severity by a panel of independent and blinded adjudicators. Indomethacin alone will be declared non-inferior to combination therapy if the two-sided 95 % upper confidence bound of the treatment difference is less than 5 % between the two groups. Biological specimens will be obtained from trial participants and centrally banked.Discussion: The SVI trial is designed to determine whether PSP remains necessary in the era of NSAIDs pharmacoprevention. The associated bio-repository will establish the groundwork for important scientific breakthrough.Trial Registration: NCT02476279, registered June 2015. [ABSTRACT FROM AUTHOR]

The article presents the guidelines on bowel preparation before colonoscopy prepared by three leading gastrointestinal societies in the U.S. Dietary regimens should include clear liquids and low-residue foods on the first four days as it has been proven to be a beneficial adjunct to other mechanical cleansing systems. Tap water or sodium phosphate enemas are given on the evening prior to the procedure in conjunction with dietary restrictions or cathartics.

Presents an abstract of the presentation `Leaking Gallbladder Remnant With Cholelithiasis Complicating Laparoscopic Cholecystectomy,' by William G. Blackard and Todd H. Baron which appeared at the 88th Annual Scientific Assembly of the Southern Medical Association from November 2-6, 1994.

Background and Aims: EUS-guided hepaticogastrostomy has been performed for many years with most published experience from outside the United States. The luminal access point can be from the esophagus, stomach, duodenum, or jejunum; biliary access can be either into the right or left intrahepatic system. Thus, we prefer the term EUS-guided transhepatic biliary drainage (ETBD). We describe what is believed to be the largest single-center U.S. experience of ETBD for management of benign and malignant biliary disease., Methods: This was a retrospective study of all ETBD conducted by 1 endoscopist between September 2014 and May 2021., Results: Two hundred fifteen patients underwent attempted ETBD: 85 for benign disease and 130 for malignant disease. Ninety-two patients (43%) had surgically altered anatomy (SAA). In 94 patients previously endoscopic attempts failed. The approach was transesophageal in 9, transgastric in 188, transduodenal in 5, and transjejunal in 5 patients. In 1 patient a bilateral approach was used. Standard fully covered self-expandable stents of 4- to 10-cm lengths and 8- or 10-mm diameters were used. Technical success was 95.3% and clinical success was 87.25%. Forty patients (18.6%) experienced adverse events (13 mild, 21 moderate, and 6 severe according to the modified American Society for Gastrointestinal Endoscopy lexicon). Mean follow-up was 257.31 ± 308.11 days for all patients (124.53 ± 229.86 days for benign disease and 457.27 ± 466.31 days for malignant disease). Seventy-four patients (34.4%) had died at the time of data collection (66 in the malignant cohort, 8 in the benign cohort). Of those with malignancy surviving >6 months, 17.4% required reintervention., Conclusions: ETBD is effective in the management of benign and malignant biliary obstruction for patients with SAA as well as native anatomy, with a modest adverse event rate., (Copyright © 2022 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

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

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

Background: Roux-en-Y gastric bypass (RYGB) surgery is the second most common weight loss surgery in the United States. Treatment of pancreaticobiliary disease in this patient population is challenging due to the altered anatomy, which limits the use of standard instruments and techniques. Both nonoperative and operative modalities are available to overcome these limitations, including device-assisted (DAE) endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic-assisted (LA) ERCP, and endoscopic ultrasound-directed transgastric ERCP (EDGE). The aim of this study was to compare the cost-effectiveness of ERCP-based modalities for treatment of pancreaticobiliary diseases in post-RYGB patients., Methods: A decision tree model with a 1-year time horizon was used to analyze the cost-effectiveness of EDGE, DAE-ERCP, and LA-ERCP in post-RYGB patients. Monte Carlo simulation was used to assess a plausible range of incremental cost-effectiveness ratios, net monetary benefit calculations, and a cost-effectiveness acceptability curve. One-way sensitivity analyses and probabilistic sensitivity analyses were also performed to assess how changes in key parameters affected model conclusions., Results: EDGE resulted in the lowest total costs and highest total quality-adjusted life-years (QALY) for a total of $5188/QALY, making it the dominant alternative compared with DAE-ERCP and LA-ERCP. In probabilistic analyses, EDGE was the most cost-effective modality compared with LA-ERCP and DAE-ERCP in 94.4 % and 97.1 % of simulations, respectively., Conclusion: EDGE was the most cost-effective modality in post-RYGB anatomy for treatment of pancreaticobiliary diseases compared with DAE-ERCP and LA-ERCP. Sensitivity analysis demonstrated that this conclusion was robust to changes in important model parameters., Competing Interests: Dr. Baron is a consultant and speaker for Boston Scientific, W.L. Gore, Cook Endoscopy, and Olympus America. Dr. Wheeler receives unrelated grant funding from Pfizer to her institution., (© Georg Thieme Verlag KG Stuttgart · New York.)

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

Background & Aims: Distinction of immunoglobulin G4-associated cholangitis (IAC) from primary sclerosing cholangitis (PSC) or cholangiocarcinoma is challenging. We aimed to assess the performance characteristics of endoscopic retrograde cholangiography (ERC) for the diagnosis of IAC., Methods: Seventeen physicians from centers in the United States, Japan, and the United Kingdom, unaware of clinical data, reviewed 40 preselected ERCs of patients with IAC (n = 20), PSC (n = 10), and cholangiocarcinoma (n = 10). The performance characteristics of ERC for IAC diagnosis as well as the κ statistic for intraobserver and interobserver agreement were calculated., Results: The overall specificity, sensitivity, and interobserver agreement for the diagnosis of IAC were 88%, 45%, and 0.18, respectively. Reviewer origin, specialty, or years of experience had no statistically significant effect on reporting success. The overall intraobserver agreement was fair (0.74). The operating characteristics of different ERC features for the diagnosis of IAC were poor., Conclusions: Despite high specificity of ERC for diagnosing IAC, sensitivity is poor, suggesting that many patients with IAC may be misdiagnosed with PSC or cholangiocarcinoma. Additional diagnostic strategies are likely to be vital in distinguishing these diseases., (Copyright © 2011 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Direct endoscopic necrosectomy (DEN) for treatment of walled-off pancreatic necrosis (WOPN) has been performed as an alternative to operative or percutaneous therapy., Objective: To report the largest combined experience of DEN performed for WOPN., Design: Retrospective chart review., Setting: Six U.S. tertiary medical centers., Patients: A total of 104 patients with a history of acute pancreatitis and symptomatic WOPN since 2003., Interventions: DEN for WOPN., Main Outcome Measurements: Resolution or near-resolution of WOPN without the need for surgical or percutaneous intervention and procedural complications., Results: Successful resolution was achieved in 95 of 104 patients (91%). Of the patients in whom it failed, 5 died during follow-up before resolution, 2 underwent operative drainage for persistent WOPN, 1 required surgery for massive bleeding on fistula tract dilation, and 1 died periprocedurally. The mean time to resolution from the initial DEN was 4.1 months. The first débridement was performed a mean of 63 days after the initial onset of acute pancreatitis. In 73%, the entry was transgastric with median tract dilation diameter of 18 mm. The median number of procedures was 3 with 2 débridements. Complications occurred in approximately 14% and included 5 retrogastric perforations/pneumoperitoneum, which were managed nonoperatively. Univariate analysis identified a body mass index >32 as a risk factor for failed DEN., Limitations: Retrospective, highly specialized centers., Conclusions: This large, multicenter series demonstrates that transmural, minimally invasive endoscopic débridement of WOPN performed in the United States is an efficacious and reproducible technique with an acceptable safety profile., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Pancreatic pseudocysts can be drained endoscopically via the transpapillary or the transmural routes. We sought to assess endoscopic methods of pseudocyst drainage., Methods: A web-based survey was sent to American Society for Gastrointestinal Endoscopy (ASGE) members in the United States (U.S.) and internationally., Results: Of the 3054 endoscopists to whom the survey was sent, 266 (8.7%) replied; 198 performed pseudocyst drainage (103 [52%] ASGE members from the United States and 95 [48%] international members). The median of the total number of drainages per physician was 15 (range 1-364). The transgastric route was the most commonly used drainage route (65%). Transmural entry was performed by using a needle-knife in 53% of transmural drainages that were not EUS-guided. The number of stents placed ranged from 1 to 5 and these remained in place for 2 to 30 weeks. CT scan was used before drainage by 95% of all respondents. EUS imaging was used before drainage by 72 of 103 (70%) US endoscopists compared with 56 of 95 (59%) international endoscopists (p = 0.1). EUS-guided drainage was used by 56% of US endoscopists compared with 43% international endoscopists (p = 0.06)., Conclusions: The most common site of transmural entry for drainage of pancreatic pseudocysts appears to be the transgastric route. Although CT is the most commonly used predrainage imaging modality, EUS is used before and during transmural drainage of pseudocysts in both the U.S. and abroad, particularly in academic medical centers. Use of EUS before or during drainage does not appear to be significantly different among endoscopists in the United States and internationally.

Aims: There is little published literature evaluating the accuracy of patients' perceptions of the quality of their own bowel preparation for colonoscopy. The aim of this article was to compare patients' perceptions of the adequacy of their bowel preparation with the endoscopists' rating at colonoscopy., Methods: Outpatients undergoing elective colonoscopy completed surveys assessing bowel preparation. Patient responses regarding quality of bowel preparation were compared with endoscopists' assessment of colonic preparation. A residual stool score was also calculated for each subject based on the amount of stool, consistency of residual stool, and percentage of bowel visualized., Results: A total of 474 patients were enrolled. Patients' perceptions of the quality of their bowel preparation were inaccurate when compared to the endoscopists' rating (sensitivity, 75%; specificity, 34%; accuracy, 50%). Overall correlation with endoscopists' rating was low, r = 0.08. Young patient age (<61 yr) was an independent predictor of both adequate bowel preparation ( p= 0.009) and agreement of patient/endoscopist ratings ( p= 0.003)., Conclusions: Patients are unreliable judges of the quality of their own bowel preparation, tending to overestimate the cleanliness of their colon. Conversely, a patient's fear that their preparation is suboptimal is also inaccurate. A colonoscopy should not be canceled on the basis of a patient's perception that the quality of their preparation is poor.