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In recent years, intragastric balloons (IGBs) have emerged as an efficacious, nonsurgical modality to treat obesity. We present a case in which an IGB caused a gastric ulcer, only unearthed after the novel technique of deflation and early retrieval.

GOALS/BACKGROUND Hemospray is a new hemostatic powder recently approved for endoscopic hemostasis in gastrointestinal (GI) bleeding. Data are limited in terms of its clinical outcomes, and its role in the treatment algorithm of GI bleeds. We conducted a systematic review and meta-analysis to study the clinical performance of Hemospray in the management of GI bleeding. STUDY We searched multiple databases from inception through March 2019 to identify studies that reported on the clinical outcomes of Hemospray in GI bleeding. The primary outcome was pooled rates of clinical success after the application of Hemospray in GI bleeding. The secondary outcomes were pooled rebleeding rates and adverse events after use of Hemospray. RESULTS A total of 19 studies, 814 patients, of which 212 patients were treated with Hemospray as monotherapy, and 602 patients were treated with Hemospray with conventional hemostatic techniques. Overall pooled clinical success after the application of Hemospray was 92% [95% confidence interval (95% CI), 87%-96%; I2=70.4%]. Overall pooled early rebleeding rates after application of Hemospray was 20% (95% CI, 16%-26%; I2=54%). Overall pooled delayed rebleeding rates after the application of Hemospray was 23% (95% CI, 16%-31%; I2=34.9%). There was no statistical difference in clinical success (RR, 1.02; 95% CI, 0.96-1.08; P=0.34) and early rebleeding (RR, 0.89; 95% CI, 0.75-1.07; P=0.214) in studies that compared the use of Hemospray as monotherapy versus combination therapy with conventional therapy. CONCLUSIONS Hemospray is highly effective in achieving immediate hemostasis in gastrointestinal bleeding. However, due to significantly high rebleeding rates, Hemospray is not suited for definitive long-term therapy.

Ileocecal valve (ICV) lesions are difficult to resect endoscopically and patients are often referred for laparoscopic colectomy. ICV involvement has been shown to be related to technical failure and tumor recurrence after endoscopic mucosal resection (EMR) and represents a challenge for endoscopic submucosal dissection (ESD). Few publications have focused specifically on endoscopic management of ICV lesions. We developed a novel ESD technique, the “doughnut resection,” for circumferential ICV adenomas with terminal ileum involvement. Two circumferential mucosal incisions are performed, one in the ileum and the other in the cecum, followed by submucosal dissection of the disk of tissue between the two incisions around a guiding stent placed across the valve that helps guide the dissection as it crosses the valve orifice. The lesion is removed en bloc in the shape of a “doughnut” with two concentric assessable lateral margins. The underwater ESD technique and a gastroscope were used to facilitate the resection. Seven patients received the doughnut resection. The median patient age was 67 years. All patients had prior biopsy and three had prior endoscopic resection (1–6 times). The median specimen diameter was 4.5 cm (range 3–8). All resections were en bloc and R0. There was no perforation, delayed bleeding, or other clinically significant adverse events. After a median follow-up of 21 months (range 12–32), there was no tumor recurrence. The “doughnut resection” is a feasible, safe, and effective method to remove circumferential ICV lesions endoscopically even for patients with multiple prior tumor manipulations.

Endoscopic submucosal dissection (ESD) is challenging in the right colon. Traction devices can make it technically easier. In this study, we evaluated a flexible grasper with articulating tip and elbow-like bending (IgE) through a double-balloon surgical platform (DESP), compared with an earlier generation grasper without elbow-like bending (Ig). The reach of Ig/IgE was investigated at eight locations using a synthetic colon within a 3D model. Using a fresh porcine colorectum, 4 cm pseudo-polyps were created at the posterior wall of the ascending colon. Fifty-four ESD procedures were performed using three techniques: standard ESD (STD), ESD using Ig (DESP+Ig), and ESD using IgE (DESP+IgE). IgE was able to reach the full circumference at all the locations, whereas the medial walls proximal to the descending colon were out of Ig’s reach. Compared with the STD, both DESP+Ig and DESP+IgE showed significantly shorter procedure time (STD vs. DESP+Ig vs. DESP+IgE = median 48.9 min vs. 38.6 vs. 29.9) and fewer injuries (1.5 vs. 0 vs. 0). Moreover, the DESP+IgE had a shorter procedure time than the DESP+Ig (p=0.0025). The IgE with DESP increased instrument reach compared to Ig, and likely represented a traction tool for excision of large pseudo-polyps in the right colon.

Endoscopic submucosal dissection (ESD) is challenging in the right colon. Traction devices can make it technically easier. In this study, we evaluated a flexible grasper with articulating tip and elbow-like bending (IgE) through a double-balloon surgical platform (DESP), compared with an earlier generation grasper without elbow-like bending (Ig). The reach of Ig/IgE was investigated at eight locations using a synthetic colon within a 3D model. Using a fresh porcine colorectum, 4 cm pseudo-polyps were created at the posterior wall of the ascending colon. Fifty-four ESD procedures were performed using three techniques: standard ESD (STD), ESD using Ig (DESP + Ig), and ESD using IgE (DESP + IgE). IgE was able to reach the full circumference at all the locations, whereas the medial walls proximal to the descending colon were out of Ig’s reach. Compared with the STD, both DESP + Ig and DESP + IgE showed significantly shorter procedure time (STD vs. DESP + Ig vs. DESP + IgE = median 48.9 min vs. 38.6 vs. 29.9) and fewer injuries (1.5 vs. 0 vs. 0). Moreover, the DESP + IgE had a shorter procedure time than the DESP + Ig (p = 0.0025). The IgE with DESP increased instrument reach compared to Ig, and likely represented a traction tool for excision of large pseudo-polyps in the right colon.

Background Deep enteroscopy-assisted ERCP (DEA-ERCP) in post-bariatric Roux-en-Y (RY) anatomy is challenging. Laparoscopy-assisted ERCP (LA-ERCP) and EUS-directed transgastric ERCP (EDGE) are technically easier and faster but are more invasive and morbid procedures. Therefore, we have used DEA-ERCP as our first-line approach, reserving EDGE and LA-ERCP for cases in which adjunctive techniques that cannot be performed through an enteroscope are required (eg, EUS-FNA, sleeve sphincter of Oddi manometry), or DEA-ERCP failures. The 2 main methods for DEA-ERCP are balloon- and spirus-assisted. Current literature on spiral enteroscopy ERCP (SE-ERCP) in bariatric RY anatomy is scant with low success rates reported. Our center has nearly exclusively used SE-ERCP for bariatric patients. Here, we report one of the largest such series to date. Methods This is a retrospective cohort study of consecutive patients with bariatric-length RY anatomy who had SE-ERCP from December 2009 to October 2016 at a tertiary care center, by one operator (S.N.S.). Primary outcomes included success at reaching the papilla, cannulation success, success of desired therapeutic intervention, and overall SE-ERCP success. Results Thirty-five SE-ERCPs were performed (28 in bariatric RY gastric bypass and 7 other long-limb RY surgical reconstructions). The papilla was reached in 86% (30/35) of cases. Cannulation success in patients in whom deep cannulation was indicated (28/30) was 100% (28/28 cases, including the 24 cases with native papilla). Therapeutic ERCP success was 100% (28/28). Overall SE-ERCP success was 86% (30/35). Median length of stay was 3 days. Median procedure time was 189 minutes. Reasons for SE-ERCP failures included RY anastomosis stricture, adhesions (2), long Roux limb, and redundant small bowel. Two of these patients underwent interventional radiology-guided percutaneous biliary drainage, 2 patients had laparoscopy-assisted ERCP, and 1 patient had EUS-guided antegrade cholangioscopy with sphincteroplasty and stone clearance. There were no adverse events. Conclusion With sufficient allotted time (median procedure time ∼3 hours) and high operator experience (a single-operator volume that exceeds that of other published series), SE-ERCP is safe and effective in bariatric, long-limb RY patients with an overall success rate of 86%, which is higher than previously reported.

Achalasia is a debilitating condition resulting from the failure of appropriate lower esophageal sphincter relaxation. Traditionally, the treatment of choice for achalasia has been a Heller myotomy, performed either via laparotomy or laparoscopically. The latter method has gained wide popularity in its documented lower postoperative morbidity. Recently, however, a new technique has been developed that can be performed by both thoracic surgeons and endoscopists-Per-Oral Endoscopic Myotomy. This procedure offers an alternative to invasive surgery and provides excellent outcomes with minimal recovery time.1 This article would help familiarize radiologists with this new technique, as well as both normal and abnormal postoperative appearances.

INTRODUCTION: COVID-19 pandemic has ravaged the world with more than 1 million cases, and 110,000 deaths as of June 2020 This pandemic impacted our healthcare system by all angles including outpatient care Telehealth was extensively utilized We conducted a study to assess the impact of Telehealth during the COVID-19 Pandemic on patient care METHODS: A retrospective analysis of outpatient gastroenterology (GI) visits were conducted General demographic information, labs, imaging, interpreter use, duration visit, medications, endoscopic procedures were collected Statistical analysis was performed using STATA software V 16 RESULTS: In a total sample size of 151 patients, the mean age was 51 ± 13 5 years with 74 males and 77 females The majority of the patients were Hispanics (n = 101), followed by Asians (n = 33), White (n = 10) and African American (n = 7) 26% patients were unable to reach (n = 26), 1% died of COVID19 (n = 3) The mean duration of telehealth conversation was 20 minutes The most common diagnosis of GI visit were dyspepsia (n = 42), followed by cirrhosis (n = 15), IBD (n = 11), PUD (n = 9), dysphagia (n = 8) and GI bleeding (n = 7) The patients received various drug treatments based on their clinical condition including PPI (n = 31);H2-blockers (n = 8);5-ASA (n = 7);diuretics (n = 6);Biologic therapy (n = 5);beta-blockers (n = 5);lactulose (n = 3);and rifaximin (n = 3) ± patients were unable to get the refill of their medications and 8 patients were afraid to get the refill (Figure 1) 34% patients missed blood work for their follow-up (n = 51) and 15% patients had delay in getting imaging as diagnostic and screening (n = 23) 59 patients needed to have procedures, 3% urgent (n = 4), 9% time essential (n = 14), and 26% required routine screening (n = 40) (Figure 2) Lastly, there was 3 patients who had confirmed COVID19 and required hospitalization with good recovery CONCLUSION: Despite a dramatic shift in the outpatient care to telehealth medicine, many clinicians expect future roles in telehealth There are many barriers to outpatient care especially in this pandemic, summarized by a delay in getting blood work, medications and fear of approaching hospitals for medication refill (Table Presented)

Despite modern investigative innovations in the cutting edge field of gastroenterology, we are reminded of our contemporary limitations when we encounter the ever evasive Dieulafoy's lesion (DL). Ever since it has been initially described in 1884, its rare but frustrating presence creates a calamitous situation. Even more so when it presents atypically, much like it did in our patient. This review of DL delves into the history, epidemiology, characteristics, the most current and innovative diagnostic measures available, as well as treatment and prevention of recurrence of these obscure gastrointestinal (GI) bleeding sources.

INTRODUCTION: COVID-19 pandemic has created chaos in the healthcare system and widely impacted our personal and academic life We conducted a survey questionnaire for gastroenterology trainees to understand the educational, psychological, physical and social impact of this crisis METHODS: National based survey questionnaires were securely sent to program coordinators and distributed to all gastroenterology fellows from various parts of the United States, via email over 3 weeks period RESULTS: A total of 246 GI fellows participated (153 males & 93 females), with a mean age of 35 ± 5 years 67% were married (n = 165) and 31% had children (n = 76) (Figure 1) Majority of the trainees are American graduates (69%) Our sample consisted of 212 fellows from university program and 34 from community program The year of fellowship was evenly distributed between 1st (n = 88), 2nd (n = 77) and 3rd year (n = 75) of training During the pandemic, 91% fellows participated in telehealth visits (n = 224) and only 5 fellows reported lack of supervisors in this situation Majority of the fellows continued practicing GI related issues (N = 227) and on top of that, 22 4% were deployed covering medicine wards (n = 56), 9% covering ICU (n = 22), and only one fellow covered ED 121 fellows reporting COVID19 severely impacted their GI practice, followed by 87 fellows reporting moderate to severe effects and 38 experiencing mild to moderate impacts 41% of fellows were not following social distancing mainly due to lack of space to sit 6 feet apart and also since they were wearing a mask 22 4% (n = 54) of fellows felt that they would not have sufficient procedural volume and/or training to be a practicing gastroenterologist but only 3 7% (n = 9) wanted to extend the fellowship The fellows wanted more procedural training in colonoscopy (45%) with polypectomy (52 4%) and hemostasis (38 6%) In order to minimize COVID19 exposure, many hospitals allowed only attending to perform procedures The majority of the fellows disagreed with this new practice (46%;n = 115) (Figure-2) Finally, 4 9% fellows acquired COVID-19 (n = 12) and only one was admitted (4 of those fellows did not have proper PPE) CONCLUSION: COVID-19 pandemic has a major impact affecting the learning process in GI fellowship programs The fear among many trainees is mainly due to the lack of performing GI procedures and the impact on their skill in the future (Table Presented)

Increasing utilization of colonoscopy and improvements in colon cancer screening modalities have led to increased detection of advanced adenomas and early-stage colon cancers. In the USA, many large, laterally spreading adenomatous colon polyps and early-stage colon cancers detected at the time of colonoscopy have traditionally been referred for surgical resection. However, with the advent and widespread adoption of endoscopic mucosal resection (EMR) over the past decade, endoscopic management of these lesions has increasingly provided a cost-effective and less invasive treatment. Nevertheless, EMR is challenging for lesions that demonstrate a non-lifting sign due to malignant submucosal invasion, fibrosis, or prior manipulation. EMR is also less suitable for polyps that may contain carcinoma since it often removes larger lesions in a piecemeal fashion, which results in difficulty to assess lateral and deep margins and significant rates of lesion persistence or recurrence. These EMR shortcomings have led in recent years to increased utilization of endoscopic submucosal dissection (ESD) for removal of colonic lesions (mainly in Asia, where ESD was invented in the late 1990s for resection of early gastric cancer). ESD offers high en bloc, R0 curative resection rates for lesions that contain carcinoma and/or demonstrate poor lifting due to fibrosis or prior manipulation including very large lesions. ESD also compares favorably to hybrid resection techniques such as combined endo-laparoscopic surgery (CELS) for colonic lesions and surgical resection techniques such as transanal endoscopic microsurgery (TEM) for rectal lesions. Unfortunately, adoption of ESD in the Western world has been relatively slow due to reimbursement and training barriers. We review here indications, techniques, and outcomes of EMR and ESD including comparative data between these two techniques and surgical techniques.

Heller's myotomy (HM) is one of the most effective treatments for esophageal achalasia. However, failures do exist, and the success rate tends to decrease with time. The efficacy of rescue treatments for patients with failed HM is limited. A few small-scale studies have reported outcomes of per-oral endoscopic myotomy (POEM) in these patients. We conducted this study to systematically assess feasibility, safety, and efficacy of POEM on patients who have had HM.Patients at least 3 months out from POEM were selected from our prospective database: 318 consecutive POEMs performed from October 2009 to October 2016. The efficacy and safety of POEM were compared between the 46 patients with prior HM and the remaining 272 patients.Patients with prior HM had longer disease history, more advanced disease, more type I and less type II achalasia, lower before-POEM Eckardt scores, and lower before-POEM lower esophageal sphincter (LES) pressure (all P .01). Procedure parameters and follow-up results (clinical success rate, Eckardt score, LES pressure, GERD score, esophagitis, and pH testing) showed no significant difference between the 2 groups. For the 46 HM-POEM patients, no clinically significant perioperative adverse events occurred. Their overall clinical success rate (Eckardt score ≤3 and no other treatment needed) was 95.7% at a median follow-up of 28 months.POEM as a rescue treatment for patients with achalasia who failed HM is feasible, safe, and highly effective. It should be the treatment of choice in managing these challenging cases at centers with a high level of experience with POEM.

Extraintestinal Clostridium difficile is rare. A 74-year-old man with a history of ulcerative colitis presented after a fall. Trauma work-up showed liver cirrhosis. Two days later he developed abdominal pain, distension, diarrhoea and leucocytosis. Stool tested positive for C. difficile. CT abdomen showed pancolitis with toxic megacolon. Total abdominal colectomy and ileostomy with a rectal stump was performed. He was discharged, but was readmitted with sepsis. CT abdomen showed a 10.4×7.2 cm fluid collection in the pelvis. C. difficile stool was negative. CT-guided abscess drainage grew C. difficile. Barium enema was negative for communication from the rectal stump to the abscess. The patient was treated with metronidazole for 2 weeks. In summary, extraintestinal C. difficile can develop from recent antibiotics use, gastrointestinal surgery and microperforations from toxic megacolon. We recommend abscess drainage, concomitant treatment with metronidazole and or vancomycin, and reimaging of abscess location 2–4 weeks after cessation of antibiotics.