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Background Secondary sclerosing cholangitis (SSC) is a rare disease with poor prognosis. Cases of SSC have been reported following coronavirus disease 2019 (COVID-SSC). The aim of this study was to compare COVID-SSC to SSC in critically ill patients (SSC-CIP) and to assess factors influencing transplant-free survival. Methods In this retrospective, multicenter study involving 127 patients with SSC from 9 tertiary care centers in Germany, COVID-SSC was compared to SSC-CIP and logistic regression analyses were performed investigating factors impacting transplant-free survival. Results Twenty-four patients had COVID-SSC, 77 patients SSC-CIP, and 26 patients other forms of SSC. COVID-SSC developed after a median of 91 days following COVID-19 diagnosis. All patients had received extensive intensive care treatment (median days of mechanical ventilation, 48). Patients with COVID-SSC and SSC-CIP were comparable in most of the clinical parameters and transplant-free survival was not different from other forms of SSC (P = .443, log-rank test). In the overall cohort, the use of ursodeoxycholic acid (UDCA) (odds ratio [OR], 0.36 [95% confidence interval {CI}, .16–.80], P = .013; log-rank P < .001) and high serum albumin levels (OR, 0.40 [95% CI, .17–.96], P = .040) were independently associated with an increased transplant-free survival, while the presence of liver cirrhosis (OR, 2.52 [95% CI, 1.01–6.25], P = .047) was associated with worse outcome. Multidrug-resistant organism (MDRO) colonization or infection did not impact patients’ survival. Conclusions COVID-SSC and CIP-SSC share the same clinical phenotype, course of the disease, and risk factors for its development. UDCA may be a promising therapeutic option in SSC, though future prospective trials are needed to confirm our findings.

International audience; Background: Ampullary lesions are rare and can be locally treated either with endoscopic papillectomy or transduodenal surgical ampullectomy. Management of local recurrence after a first-line treatment has been poorly studied.Methods: Patients with a local recurrence of an ampullary lesion initially treated with endoscopic papillectomy or transduodenal surgical ampullectomy were retrospectively included from a multi-institutional database (58 centers) between 2005 and 2018.Results: A total of 103 patients were included, 21 (20.4%) treated with redo endoscopic papillectomy, 14 (13.6%) with transduodenal surgical ampullectomy, and 68 (66%) with pancreaticoduodenectomy. Redo endoscopic papillectomy had low morbidity with 4.8% (n = 1) severe to fatal complications and a R0 rate of 81% (n = 17). Transduodenal surgical ampullectomy and pancreaticoduodenectomy after a first procedure had a higher morbidity with Clavien III and more complications, respectively, 28.6% (n = 4) and 25% (n = 17); R0 resection rates were 85.7% (n = 12) and 92.6% (n = 63), both without statistically significant difference compared to endoscopic papillectomy (P = .1 and 0.2). Pancreaticoduodenectomy had 4.4% (n = 2) mortality. No deaths were registered after transduodenal surgical ampullectomy or endoscopic papillectomy. Recurrences treated with pancreaticoduodenectomy were more likely to be adenocarcinomas (79.4%, n = 54 vs 21.4%, n = 3 for transduodenal surgical ampullectomy and 4.8%, n = 1 for endoscopic papillectomy, P < .0001). Three-year overall survival and disease-free survival were comparable.Conclusion: Endoscopy is appropriate for noninvasive recurrences, with resection rate and survival outcomes comparable to surgery. Surgery applies more to invasive recurrences, with transduodenal surgical ampullectomy rather for carcinoma in situ and early cancers and pancreaticoduodenectomy for more advanced tumors.

Main recommendationsObesity is a chronic, relapsing, degenerative, multifactorial disease that is associated with many co-morbidities. The global increasing burden of obesity has led to calls for an urgent need for additional treatment options. Given the rapid expansion of bariatric endoscopy and bariatric surgery across Europe, the European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. This curriculum is set out in terms of the prerequisites prior to training, minimum number of procedures, the steps for training and quality of training, and how competence should be defined and evidenced before independent practice. 1 ESGE recommends that every endoscopist should have achieved competence in upper gastrointestinal endoscopy before commencing training in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. 2 Trainees in bariatric endoscopy and the endoscopic treatment of the complications of bariatric surgery should have basic knowledge of the definition, classification, and social impact of obesity, its pathophysiology, and its related co-morbidities. The recognition and management of gastrointestinal diseases that are more common in patients with obesity, along with participation in multidisciplinary teams where obese patients are evaluated, are mandatory. 3 ESGE recommends that competency in bariatric endoscopy and the endoscopic treatment of the complications of bariatric surgery can be learned by attending validated training courses on simulators initially, structured training courses, and then hands-on training in tertiary referral centers.

Die akute Pankreatitis (AP) stellt eine haufige gastrointestinale Erkrankung dar. Bei etwa 80 % der Patienten verlauft sie mild, eine konservative Therapie ist ausreichend. Bei etwa 20 % tritt eine schwere Verlaufsform mit lokalen und systemischen Komplikationen auf. Der vorliegende Beitrag soll einen Uberblick uber das aktuell empfohlene endoskopische Management der schweren AP geben. Einteilung der AP anhand der revidierten Atlanta-Klassifikation und des Auftretens lokaler sowie systemischer Komplikationen. Darstellung der aktuellen Evidenz hinsichtlich des endoskopischen Managements. Sichtung aktueller Literatur aus fachrelevanten Journalen und Leitlinien. Die AP wird in eine milde, moderate und schwere Verlaufsform eingeteilt. Die Einordnung richtet sich nach dem Auftreten von systemischen (Kreislaufdepression, Nierenversagen, Lungenversagen) und/oder lokalen Komplikationen (akute peripankreatische Flussigkeitskollektionen [APFC], peripankreatische Pseudozysten [PPZ], akute nekrotische Kollektionen [ANC] und „walled-off necrosis“ [WON]). In den letzten Jahren hat sich die stufenweise endoskopische Therapie bei infizierter ANC, WON und PPZ etabliert. Zunachst erfolgt eine mit endoskopischem Ultraschall gestutzte Punktion und Drainageanlage mit Plastik- oder lumenadaptierenden Metallstent. Bei soliden Anteilen bzw. nicht ausreichender Drainage wird eine endoskopische transgastrische Nekrosektomie durchgefuhrt. Die Therapie der schweren AP erfordert ein interdisziplinares Management in Zentren mit entsprechender Expertise und eine regelmasige Reevaluation der Therapiefortschritte. Die interventionelle Endoskopie hat sich als Standard bei der Therapie der schweren AP etabliert.

Background The COVID-19 pandemic has created unprecedented challenges in all fields of society with social, economic, and health-related consequences worldwide. In this context, gastroenterology patients and healthcare systems and professionals have seen their routines changed and were forced to adapt, adopting measures to minimize the risk of infection while guaranteeing continuous medical care to chronic patients. Objective At this point, it is important to evaluate the impact of the pandemic on this field to further improve the quality of the services provided in this context. Methods/results/conclusion We performed a literature review that summarizes the main aspects to consider in gastroenterology, during the pandemic crisis, and includes a deep discussion on the main changes affecting gastroenterology patients and healthcare systems, anticipating the pandemic recovery scenario with future practices and policies.

Das endoskopische Management von Polypen des unteren Gastrointestinaltrakts (uGIT) hat sich in den letzten Jahren durch zahlreiche technische Neuerungen deutlich erweitert und setzt eine ausgewiesene Expertise sowie Erfahrung des Untersuchers voraus. Darstellung neuer und etablierter Techniken und Vorgehensweisen zur Charakterisierung und Resektion von Polypen im uGIT. Aktuelle Literatur aus fachrelevanten Journalen und Leitlinien. Die hochauflosende Endoskopie sollte den Standard bei der Untersuchung des Kolorektums darstellen. Eine (virtuelle) Chromoendoskopie ist bei Detektion und Charakterisierung von Polypen hilfreich, allerdings erfordern die Techniken eine spezielle Expertise sowie Erfahrung bei der Befundinterpretation. Der Einsatz sogenannter Computer-aided-diagnosis(CAD)-Systeme kann in Zukunft ggf. unterstutzend angewendet werden. Gestielte Polypen sollten mittels Diathermieschlinge entfernt werden. Kleinere flache Polypen lassen sich mittels Kaltschlinge oder Jumbopolypektomiezange entfernen. Grose nichtgestielte Polypen sollten in einem Zentrum mit ausgewiesener Expertise interdisziplinar in Abhangigkeit von ihrem Malignitatspotenzial therapiert werden. Bei vollstandig abgetragenen kleinen Adenomen ohne hohergradige intraepitheliale Neoplasie (IEN) ist meist eine Kontrolle nach 5–10 Jahren ausreichend, bei groseren Adenomen bzw. Adenomen mit hochgradigen IEN sollte diese nach 3 Jahren und bei multiplen Adenomen noch zeitiger erfolgen. Patienten mit unvollstandig oder in Piecemeal-Technik abgetragenen Polypen bedurfen ebenso wie Patienten mit unzureichender Darmreinigung einer zeitnahen Wiedervorstellung. Adaquate Charakterisierung und Therapie sind fur ein korrektes Polypenmanagement des uGIT entscheidend.

ObjectiveThis study aimed to develop and validate a patient-reported outcome measure (PROM) in acute pancreatitis (AP) as an endpoint centred on the patient.DesignA PROM instrument (PAtieNt-rePoRted OutcoMe scale in acute pancreatItis, an international proSpEctive cohort study, PAN-PROMISE scale) was designed based on the opinion of patients, professionals and an expert panel. The scale was validated in an international multicentre prospective cohort study, describing the severity of AP and quality of life at 15 days after discharge as the main variables for validation. The COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) methodology was applied. Both the design and validation stages considered the content and face validity of this new instrument; the metric properties of the different items, reliability (reproducibility and internal consistence), the construct, structural and criterion validity, responsiveness and interpretability of this scale.ResultsPAN-PROMISE consists of a seven-item scale based on the symptoms that cause the most discomfort and concern to patients with AP. The validation cohort involved 15 countries, 524 patients. The intensity of symptoms changed from higher values during the first 24 hours to lower values at discharge and 15 days thereafter. Items converged into a unidimensional ordinal scale with good fit indices. Internal consistency and split-half reliability at discharge were adequate. Reproducibility was confirmed using test–retest reliability and comparing the PAN-PROMISE score at discharge and 15 days after discharge. Evidence is also provided for the convergent-discriminant and empirical validity of the scale.ConclusionThe PAN-PROMISE scale is a useful tool to be used as an endpoint in clinical trials, and to quantify patient well-being during the hospital admission and follow-up.Trial registration numberNCT03650062

Secondary sclerosing cholangitis (SSC) is a rare disease with poor prognosis. Cases of SSC have been reported following coronavirus disease 2019 (COVID-19), COVID-SSC.Aim of this study was to compare COVID-SSC to SSC in critically ill patients (SSC-CIP) and to assess factors influencing transplant-free survival.In this retrospective, multicenter study involving 127 patients with SSC from 9 tertiary care centers in Germany, COVID-SSC was compared to SSC-CIP and logistic regression analyses were performed investigating factors impacting transplant-free survival.24 patients had COVID-SSC, 77 patients SSC-CIP and 26 patients had other forms of SSC. COVID-SSC developed after a median of 91 days following COVID-19 diagnosis. All patients had received extensive intensive care treatment (median days of mechanical ventilation 48). Patients with COVID-SSC and SSC-CIP were comparable in most of the clinical parameters and transplant-free survival was not different from other forms of SSC (P = 0.443 in log-rank test). In the overall cohort, the use of ursodeoxycholic acid (UDCA, OR 0.36, 95%-CI 0.16-0.80, P = 0.013; P 0.001 in log-rank test) and high serum albumin levels (OR 0.40, 95%-CI 0.17-0.96, P = 0.040) were independently associated with an increased transplant-free survival, while the presence of liver cirrhosis (OR 2.52, 95%-CI 1.01-6.25, P = 0.047) was associated with worse outcome. MDRO colonization or infection did not impact patients' survival.COVID-SSC and CIP-SSC share the same clinical phenotype, course of the disease and risk factors for its development. UDCA may be a promising therapeutic option in SSC, though future prospective trials need to confirm our findings.

Acute pancreatitis (AP) represents a frequent gastrointestinal diseases. Approximately 80% of patients have a mild course of the disease and conservative treatment is sufficient; however, 20% of patients develop a severe AP with local and systemic complications. This article focuses on the currently recommended endoscopic management of severe AP.Classification of AP by the revised Atlanta classification and the occurrence of local or systemic complications. Summary of current evidence with respect to endoscopic management.Inspection of the current literature from specialist journals and current guidelines.The AP is classified as mild, moderate or severe based on systemic (hypotension, renal failure, lung failure) and/or local complications, such as acute peripancreatic fluid collections (APFC), peripancreatic pseudocysts (PPC), acute necrotic collections (ANC) and walled-off necrosis (WON). In recent years the staged endoscopic treatment of infected ANC, WON and PPC has become established. The initial step is the endoscopic ultrasound-guided puncture and drainage with plastic or lumen-apposing metal stents. For solid components or insufficient drainage, a transgastric endoscopic necrosectomy is recommended. The treatment of severe AP requires an interdisciplinary management in specialized centers and regular re-evaluation of the therapeutic efficacy.Interventional endoscopy has become established as the standard for treatment of severe AP.HINTERGRUND: Die akute Pankreatitis (AP) stellt eine häufige gastrointestinale Erkrankung dar. Bei etwa 80 % der Patienten verläuft sie mild, eine konservative Therapie ist ausreichend. Bei etwa 20 % tritt eine schwere Verlaufsform mit lokalen und systemischen Komplikationen auf. Der vorliegende Beitrag soll einen Überblick über das aktuell empfohlene endoskopische Management der schweren AP geben.Einteilung der AP anhand der revidierten Atlanta-Klassifikation und des Auftretens lokaler sowie systemischer Komplikationen. Darstellung der aktuellen Evidenz hinsichtlich des endoskopischen Managements.Sichtung aktueller Literatur aus fachrelevanten Journalen und Leitlinien.Die AP wird in eine milde, moderate und schwere Verlaufsform eingeteilt. Die Einordnung richtet sich nach dem Auftreten von systemischen (Kreislaufdepression, Nierenversagen, Lungenversagen) und/oder lokalen Komplikationen (akute peripankreatische Flüssigkeitskollektionen [APFC], peripankreatische Pseudozysten [PPZ], akute nekrotische Kollektionen [ANC] und „walled-off necrosis“ [WON]). In den letzten Jahren hat sich die stufenweise endoskopische Therapie bei infizierter ANC, WON und PPZ etabliert. Zunächst erfolgt eine mit endoskopischem Ultraschall gestützte Punktion und Drainageanlage mit Plastik- oder lumenadaptierenden Metallstent. Bei soliden Anteilen bzw. nicht ausreichender Drainage wird eine endoskopische transgastrische Nekrosektomie durchgeführt. Die Therapie der schweren AP erfordert ein interdisziplinäres Management in Zentren mit entsprechender Expertise und eine regelmäßige Reevaluation der Therapiefortschritte.Die interventionelle Endoskopie hat sich als Standard bei der Therapie der schweren AP etabliert.

Main Recommendations 1 ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7–9 g/dL is desirable.Strong recommendation, low quality evidence. 4 ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5 ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9 ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10 ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.

Background Digital single-operator pancreatoscopy (DSOP)-guided lithotripsy is a novel treatment modality for pancreatic endotherapy, with demonstrated technical success in retrospective series of between 88 % and 100 %. The aim of this prospective multicenter trial was to systematically evaluate DSOP in patients with chronic pancreatitis and symptomatic pancreatic duct stones. Methods Patients with symptomatic chronic pancreatitis and three or fewer stones ≥ 5mm in the main pancreatic duct (MPD) of the pancreatic head or body were included. The primary end point was complete stone clearance (CSC) in three or fewer treatment sessions with DSOP. Current guidelines recommend extracorporeal shock wave lithotripsy (ESWL) for MPD stones > 5 mm. A performance goal was developed to show that the CSC rate of MPD stones using DSOP was above what has been previously reported for ESWL. Secondary end points were pain relief measured with the Izbicki pain score (IPS), number of interventions, and serious adverse events (SAEs). Results 40 chronic pancreatitis patients were included. CSC was achieved in 90 % of patients (36/40) on intention-to-treat analysis, after a mean (SD) of 1.36 (0.64) interventions (53 procedures in total). The mean (SD) baseline IPS decreased from 55.3 (46.2) to 10.9 (18.3). Overall pain relief was achieved in 82.4 % (28/34) after 6 months of follow-up, with complete pain relief in 61.8 % (21/34) and partial pain relief in 20.6 % (7/34). SAEs occurred in 12.5 % of patients (5/40), with all treated conservatively. Conclusion DSOP-guided endotherapy is effective and safe for the treatment of symptomatic MPD stones in highly selected patients with chronic pancreatitis. It significantly reduces pain and could be considered as an alternative to standard ERCP techniques for MPD stone treatment in these patients.

Aims The unprecedented situation caused by the COVID-19 pandemic has profoundly affected endoscopic practice inregard to access, volume, and workflow. We aimed to assess the potential changes in the technical outcomes of ERCPprocedures carried out in patients with confirmed SARS-CoV-2 infection. Methods We conducted an international, multicenter, retrospective, matched case-control study of ERCP procedures carriedout in patients with confirmed COVID-19. The main outcome was technical success of the procedure as assessed by theendoscopist, and the secondary outcome was the development of procedure-related adverse events. Each case wasmatched in a 1:4 ratio with controls extracted from each center's database in order to identify relevant changes in outcomemeasures compared to the pre-pandemic era. Results Eighteen procedures performed in 16 COVID-19 patients (14 men, 65 years (9-82)) between the 15th of Marchand the 1st of July 2020 and 67 matched controls were included in the final analysis. Technical success was achieved in14/18 procedures in COVID-19 cases, which was significantly lower as compared to the control group (14/18 vs. 64/67, p=0.034), with an endoscopic reintervention required in 9/18 cases. However, the rate of procedure-related adverse eventswas low in both groups (1/18 vs. 10/67, p=0.44). On multivariable analysis COVID-19 status remained the only risk factorfor technical failure of the procedure (OR of 19.9 (95 %CI 1.4-269)).

Aims An outbreak of coronavirus disease 19 (COVID-19) has altered the dynamic of endoscopic practices. Many guidelines, questionnaires have been published addressing service resumption during the pandemic. Curious about the situation indifferent endoscopic units across the globe, the study was designed to evaluate different aspects of practice resumptionworldwide and their adherence to guidelines. Methods An online questionnaire was created and distributed by national/regional representatives and societies. Redcapplatform was used as the interface;afterwards, Microsoft Excel 2016 and Prism 5 were utilized for data analysis. Results From a total of 307 responses from 47 countries/regions was collected, 290 valid answers were analyzed. Almosthalf (47 %) were in post-peak period by August, 2020. Many units were not designated to be COVID-oriented facility. About15.5 % of centers remained unrecovered, mainly in North and South America;those were recovered, training was still withheld significantly. Nevertheless, opened centers kept safety measurements strictly. Patient load was decreased by 37 %,but waiting list was increased 0-25 %. Among many surveillance methods, body temperature, PCR and chest CT were themost common. 74.8 % increased post-procedural disinfection time and 68.2 % increase in per-case inspection were noted.PPE usage was implemented highly and shortage of these posed as one of the resumption barriers. Post-procedural patientsurveillance was not reinforced. Conclusions The study represented real-time global endoscopic service's adaptation to COVID-19 pandemic. Previouslypublished barriers upon practice resumption remained. Despite Delphi consensus' emphasis on post-procedural surveillance, application was not widely reinforced, raising concerns in disease control.

Die metaplastische Barrett-Schleimhaut stellt eine pramaligne Lasion fur die Entstehung eines Adenokarzinoms des Osophagus dar. Neben der bioptischen Sicherung stehen neuere Verfahren der (virtuellen) Chromoendoskopie (Essigsaure, NBI, i-Scan, FICE u. a.) zur Verfugung, um intraepitheliale Neoplasien (IEN, Dysplasien) besser zu detektieren. In Abhangigkeit des Vorhandenseins von IEN wird eine Barrett-Schleimhaut entweder endoskopisch im Verlauf kontrolliert oder mittels endoskopischer Mukosaresektion (EMR), endoskopischer Submukosadissektion (ESD) bzw. Radiofrequenzablation (RFA) therapiert. In diesem Kapitel wird der Stellenwert diagnostischer und therapeutischer Verfahren diskutiert sowie praktische Handlungsanleitungen nach aktuellen Leitlinien vorgestellt.

Background:The unprecedented situation caused by the coronavirus disease 2019 (COVID-19) pandemic has profoundly affected endoscopic practice in regard to access, volume, and workflow. We aimed to assess the potential changes in the technical outcomes of endoscopic retrograde cholangiopancreatography (ERCP) procedures carried out in patients with confirmed SARS-CoV-2 infection.Methods:We conducted an international, multicenter, retrospective, matched case-control study of ERCP procedures carried out in patients with confirmed COVID-19. The main outcome was technical success of the procedure as assessed by the endoscopist, and the secondary outcome was the development of procedure-related adverse events. Each case was matched in a 1:4 ratio with controls extracted from each center’s database in order to identify relevant changes in outcome measures compared with the pre-pandemic era.Results:Eighteen procedures performed in 16 COVID-19 patients [14 men, 65 years (9–82)] and 67 controls were included in the final analysis. Technical success was achieved in 14/18 COVID-19 cases, which was significantly lower as compared with the control group (14/18 versus 64/67, p = 0.034), with an endoscopic reintervention required in 9/18 cases. However, the rate of procedure-related adverse events was low in both groups (1/18 versus 10/67, p = 0.44). On multivariable analysis, COVID-19 status remained the only risk factor for technical failure of the procedure [odds ratio of 19.9 (95% confidence interval 1.4–269.0)].Conclusions:The COVID-19 pandemic has affected the volume and practice of ERCP, resulting in lower technical success rates without significantly impacting patient safety. Prioritizing cases and following recommendations on safety measures can ensure good outcome with minimal risk in dedicated centers.

Ampullary lesions (ALs) can be treated by endoscopic (EA) or surgical ampullectomy (SA) or pancreaticoduodenectomy (PD). However, EA carries significant risk of incomplete resection while surgical interventions can lead to substantial morbidity. We performed a systematic review and meta-analysis for R0, adverse-events (AEs) and recurrence between EA, SA and PD. Electronic databases were searched from 1990 to 2018. Outcomes were calculated as pooled means using fixed and random-effects models and the Freeman-Tukey-Double-Arcsine-Proportion-model. We identified 59 independent studies. The pooled R0 rate was 76.6% (71.8–81.4%, I2 = 91.38%) for EA, 96.4% (93.6–99.2%, I2 = 37.8%) for SA and 98.9% (98.0–99.7%, I2 = 0%) for PD. AEs were 24.7% (19.8–29.6%, I2 = 86.4%), 28.3% (19.0–37.7%, I2 = 76.8%) and 44.7% (37.9–51.4%, I2 = 0%), respectively. Recurrences were registered in 13.0% (10.2–15.6%, I2 = 91.3%), 9.4% (4.8–14%, I2 = 57.3%) and 14.2% (9.5–18.9%, I2 = 0%). Differences between proportions were significant in R0 for EA compared to SA (p = 0.007) and PD (p = 0.022). AEs were statistically different only between EA and PD (p = 0.049) and recurrence showed no significance for EA/SA or EA/PD. Our data indicate an increased rate of complete resection in surgical interventions accompanied with a higher risk of complications. However, studies showed various sources of bias, limited quality of data and a significant heterogeneity, particularly in EA studies.