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Background Treatment of Zenker’s diverticulum has evolved from open surgery to endoscopic techniques, including flexible and rigid endoscopic septotomy, and more recently, peroral endoscopic myotomy (Z-POEM). This study compared the effectiveness of flexible and rigid endoscopic septotomy with that of Z-POEM. Methods Consecutive patients who underwent endoscopic septotomy (flexible/rigid) or Z-POEM for Zenker’s diverticulum between 1/2016 and 9/2019 were included. Primary outcomes were clinical success (decrease in Dakkak and Bennett dysphagia score to ≤ 1), clinical failure, and clinical recurrence. Secondary outcomes included technical success and rate/severity of adverse events. Results 245 patients (110 females, mean age 72.63 years, standard deviation [SD] 12.37 years) from 12 centers were included. Z-POEM was the most common management modality (n = 119), followed by flexible (n = 86) and rigid (n = 40) endoscopic septotomy. Clinical success was 92.7 % for Z-POEM, 89.2 % for rigid septotomy, and 86.7 % for flexible septotomy (P = 0.26). Symptoms recurred in 24 patients (15 Z-POEM during a mean follow-up of 282.04 [SD 300.48] days, 6 flexible, 3 rigid [P = 0.47]). Adverse events occurred in 30.0 % rigid septotomy patients, 16.8 % Z-POEM patients, and 2.3 % flexible septotomy patients (P Conclusions There was no difference in outcomes between the three treatment approaches for symptomatic Zenker’s diverticulum. Rigid endoscopic septotomy was associated with the highest rate of complications, while flexible endoscopic septotomy appeared to be the safest. Recurrence following Z-POEM was similar to flexible and rigid endoscopic septotomy. Prospective studies with long-term follow-up are required.

Background & Aims Endoscopic ultrasound-guided placement of LAMS has emerged as an effective treatment for WON following acute necrotizing pancreatitis, but a standardized management protocol has not yet emerged. We sought to characterize practice variations in the use of lumen-apposing metal stents (LAMS) for the treatment of walled-off pancreatic necrosis (WON). Methods A 30-question survey was sent to 341 endoscopists in the United States to collect information on practitioner demographics, procedural practices, necrosectomy practices, and LAMS-related adverse events. Results A total of 69 of the 341 surveys were completed for a response rate of 20.2%. Almost all reported using LAMS placement as the primary method of WON treatment (92.5%). At the time of LAMS placement, almost half of respondents perform balloon dilation (45.2%), and a minority place pigtail stents through the LAMS channel (15.0%). Necrosectomy is performed by less than half during index LAMS placement procedure (46.8%). Approximately half never use hydrogen peroxide lavage (52.4%). Most respondents reported experiencing adverse events at some point. About half reported a stent indwell time of the greater than 1 month. Conclusion A convergence of practice patterns when using LAMS to treat WON has not been demonstrated. Considerable variability exists in certain aspects of LAMS use including placement technique, necrosectomy practices, follow-up treatment, and stent removal. Further investigation is necessary to standardize this procedure to effectively and safely treat WON.

Background In stable patients, video capsule endoscopy (VCE) is the recommended first test for patients presenting with suspected small bowel bleeding (SSB). The aim of this study is to develop a scoring system to aid clinicians in deciding which patients with SSB would benefit from VCE. A multicenter database of patients who underwent VCE for SSB was created. Methods A multivariable logistic regression analysis was utilized on a developmental cohort to determine independent predictors of a positive diagnosis on VCE and develop the scoring system. Receiver operating characteristic analysis compared the performance of the scoring system between the developmental cohort and the validation cohort. Results Three hundred fourteen patients underwent VCE for SSB. Multivariable analysis revealed 3 variables—age less than 54 years old (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.11-0.58), inpatient status with overt bleeding (OR 2.38, 95% CI 1.05-5.39), and hemoglobin less than 6.4 g/dL (OR 2.68, 95% CI 1.11-6.48) as independent predictors of a diagnosis on VCE. The performance of the scoring system in the developmental cohort (C-statistic 0.70; 95% CI 0.62-0.77) and the validation cohort (C-statistic 0.69; 95% CI 0.61-0.75) was not significantly different (P = 0.91). Conclusions For patients with suspected small bowel bleeding, age older than 54 years, hemoglobin

Backgrounds Endoscopic ultrasound (EUS)-guided placement of lumen-apposing metal stents (LAMSs) has gained popularity for the treatment of pancreatic walled-off necrosis (WON). We compared the 20-mm and 15-mm LAMSs for the treatment of symptomatic WON in terms of clinical success and adverse events. Methods We conducted a retrospective, case-matched study of 306 adults at 22 tertiary centers from 04/2014 to 10/2018. A total of 102 patients with symptomatic WON who underwent drainage with 20-mm LAMS (cases) and 204 patients who underwent drainage with 15-mm LAMS (controls) were matched by age, sex, and drainage approach. Conditional logistic regression analysis was performed to compare clinical success (resolution of WON on follow-up imaging without reintervention) and adverse events (according to American Society for Gastrointestinal Endoscopy criteria). Results Clinical success was achieved in 92.2 % of patients with 20-mm LAMS and 91.7 % of patients with 15-mm LAMS (odds ratio 0.92; P = 0.91). Patients with 20-mm LAMS underwent fewer direct endoscopic necrosectomy (DEN) sessions (mean 1.3 vs. 2.1; P Conclusions The 20-mm LAMS showed comparable clinical success and safety profile to the 15-mm LAMS, with the need for fewer DEN sessions for WON resolution.

Treatment options for malignant bowel obstruction are limited, particularly in poor surgical candidates. Standard percutaneous endoscopic gastrostomy (PEG) tubes used for venting are of small caliber, limiting success. This study examines outcomes in patients who received larger-caliber 30-Fr PEGs for treatment of malignant bowel obstruction.Retrospective chart review for all patients who received a large-caliber venting PEGs for malignant bowel obstruction in a series of patients at a single institution.Thirty-six patients were included. The most common primary cancer diagnoses were ovarian (22%), mucinous appendiceal (19%), and colorectal (17%). Symptom relief was achieved in all patients (100%). Four patients (11%) sought medical care for recurrent symptoms due to an incorrect venting technique. Large-caliber venting PEGs were placed on the first admission for obstruction in 17 patients (47%), and were used to replace standard caliber PEGs in 8 patients because of persistent symptoms (22%). Significant ascites was observed in 12 patients (33%), but paracenteses were performed in only 3 of these patients prior to PEG placement. Most large-caliber venting PEGs were placed during hospital admission (34/36, 94%), and facilitated hospital discharge (33/34, 97%). Two significant (6%) and 2 minor adverse events (6%) occurred.This study demonstrates the efficacy and safety of large-caliber venting PEGs for malignant bowel obstruction. This facilitated hospital discharge in almost all patients and prevented readmissions when a correct venting technique was utilized; these PEGs were also effective in patients who had failed standard PEG tube venting.

BACKGROUND Many communities face a shortage of qualified endoscopists. Training physician assistants (PAs) to perform colonoscopies can expand the availability of colorectal cancer screening. This study examined screening colonoscopy metrics and quality indicators among gastroenterologists, supervised PAs, and gastroenterology fellows. METHODS Consecutive patients undergoing average-risk screening colonoscopy were stratified into one of three groups by endoscopist type. Procedure and pathology reports were reviewed for the technical performance and quality metrics of the providers. RESULTS PAs performed comparably to gastroenterologists in technical performance and quality metrics, and demonstrated higher cecal intubation rates than their gastroenterologist colleagues. Comparisons of attending physicians and PAs grouped by years of experience also did not show notable differences in performance. CONCLUSIONS In a supervised practice, PAs performed on par with their gastroenterology colleagues on established colonoscopy quality indicators. Following proper training, PAs can be employed in the provision of screening colonoscopy.

Background and Aims Certain pancreaticobiliary conditions remain challenging to treat using standard endoscopic techniques. Examples include difficult-to-remove gallstones and foreign objects in the bile ducts. Two tools designed for these purposes are the SpyGlass retrieval basket and the SpyGlass retrieval snare, which are passed through the cholangioscope channel for use under direct visualization. We present 3 cases in which these tools were used successfully. Methods Three cases using the SpyGlass retrieval basket and retrieval snare were reviewed for efficacy. Results Patient 1 had hepatitis C cirrhosis and underwent liver transplantation with T tube placement at the site of biliary anastomosis. Image-guided T tube removal by interventional radiology was unsuccessful. Endoscopic removal with the SpyGlass retrieval snare was completed. Patient 2 presented with cholangitis from an impacted common bile duct stone. Fragmentation with electrohydraulic lithotripsy was performed, and the fragments were removed with the SpyGlass retrieval basket. Patient 3 presented for removal of a migrated biliary stent. The stent was placed a year prior during an ERCP for treatment of choledocholithiasis. Initial removal attempt at an area hospital failed, so the patient was referred to our center, where the Spyglass retrieval snare was used to remove the biliary stent. Conclusions This case series demonstrates initial successes treating biliary pathologic conditions with the SpyGlass retrieval basket and retrieval snare, 2 tools designed for use under direct visualization with the cholangioscope.

Outbreaks of infections related to duodenoscope use have brought attention to the important topic of endoscope reprocessing. Much work has been done to understand why these outbreaks occurred and how to prevent them; however, the adequacy of duodenoscope reprocessing has not been ensured to date. This review summarizes current techniques in duodenoscope reprocessing and future directions to eradicate endoscopically transmitted infections.