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Objective: There is paucity of data on lower gastrointestinal bleed (LGIB) in the pediatric population. We aimed to retrospectively review the endoscopy findings in patients younger than 18 years, presenting with lower gastrointestinal (GI) bleed and undergoing colonoscopy. Materials and Methods: Retrospective review of the endoscopy database at the department of gastroenterology at a tertiary care center from Western India was conducted between June 2017 until December 2021. Patients ≤18 years with LGIB, who underwent colonoscopy within 7 days of onset of bleed, were included in the study. Demographic details, endoscopic findings, and complications were noted. Results: In all, 55 patients were included in study (65% males; median age: 13 years [range: 1–18 years]). The most common endoscopic findings were polyps in 26 (47.2%) patients, colitis in 15 (27.2%) patients, solitary rectal ulcer syndrome (SRUS) in 6 (11.3%) patients, and hemorrhoids in 3 (5.4%) patients. Five (9%) patients had normal colonoscopy in whom the cause remained unidentified on further evaluation. However, no repeat episode was documented on a follow-up of 30 days. The most common location of a polyp was the rectum (64%). Two patients had multiple polyps (2 each). All the patients underwent a successful polypectomy. Pathology reported juvenile polyps in 25 biopsies. Four were diagnosed as inflammatory bowel disease (IBD), while 11 had acute infective colitis. Patients with infectious colitis as compared to IBD had higher incidence of fever (55 vs. 0%) and lesser incidence of previous similar events (22 vs. 66%). Those with polyps were younger than those without polyps (9.1 vs. 14.3 years; p = 0.000). Polyps were significantly more common in boys (84%; 22/26; p = 0.014) than in girls. No complications occurred in this cohort of patients. Conclusions: Polyps are the most common cause of LGIB in patients ≤18 years, followed by colitis. Polyps were more common in younger males. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) is the workhorse for biliary and pancreatic ductal interventions. Despite advances in both endoscopes and accessories for ERCP, it still has limitations in the presence of altered anatomy, luminal obstruction hindering access to the papilla, and proximal duct obstructions by tight stricture, calculi or intraductal growth. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and EUS-guided pancreatic duct drainage (EUS-PDD) have expanded the rescue procedures after failed ERCP. This review discusses the techniques and results of various EUS-BD procedures, as well as EUS-PDD. [ABSTRACT FROM AUTHOR]

Endoscopic resection techniques like endoscopic mucosal resection and endoscopic submucosal dissection have become the cornerstone for the management of early cancers of the gastrointestinal tract. Risks associated with endoscopic resection may be exacerbated by the presence of background cirrhosis with its attendant complications. With complex alterations in hemostasis in patients with cirrhosis, management of patients undergoing endoscopic resection is more challenging. In this article we discuss a case of early gastric cancer in a patient with background chronic liver disease and thrombocytopenia managed using endoscopic submucosal dissection. [ABSTRACT FROM AUTHOR]

Aim of the study: Endoscopic ultrasound (EUS)-guided liver biopsy (LB) has become an increasingly popular method of tissue acquisition for evaluating liver diseases. Despite its advantages, EUS-LB has not been widely adopted in clinical practice due to concerns regarding efficacy and safety. Present data on EUS-LB from India are scarce. We aimed to study the diagnostic outcome and safety of EUS-guided liver biopsy. Material and methods: This is a retrospective analysis of prospectively maintained data from January 2021 to October 2022 of consecutive patients undergoing EUS-LB at four tertiary care centers in India. The primary outcome was sample adequacy, while secondary outcomes were rate of successful pathological diagnoses and incidence of adverse events (AE). Results: A total of 74 patients (median age: 44.5 years, 50.0% males) were included. The majority of the patients underwent left-lobe biopsy (62/74, 83.7%), and a 19-G Franseen FNB needle was most commonly used (61/74, 82.4%). Wet heparin suction was used in most cases (60/74, 81.1%). There were five mild AEs observed (one case of self-limited bleeding and four cases of post-procedural pain). Adequate and optimal samples were obtained in 71 (95.9%) and 49 (66.2%) cases, with a conclusive diagnosis being made in 97.3% (72/74) of the patients. On multivariate analysis, the presence of ascites was a negative predictor of optimal sample (odds ratio [OR] = 0.128, 95% CI: 0.017-0.96). Conclusions: EUS-LB is a safe and viable alternative to percutaneous liver biopsy, achieving diagnosis in > 95% of cases. EUS-LB can be performed safely even in patients with mild ascites, although ascites reduces the chances of getting an optimal sample. [ABSTRACT FROM AUTHOR]

Chronic pancreatitis (CP) is a known risk factor for pancreatic cancer. CP may present with an inflammatory mass, and differentiation from pancreatic cancer is often difficult. Clinical suspicion of malignancy dictates a need for further evaluation for underlying pancreatic cancer. Imaging modalities remain the mainstay of evaluation for a mass in background CP; however, they have their shortcomings. Endoscopic ultrasound (EUS) has become the go-to investigation. Adjunct modalities such as contrast-harmonic EUS and EUS elastography, as well as EUS-guided sampling using newer-generation needles are useful in differentiating inflammatory from malignant masses in the pancreas. Paraduodenal pancreatitis and autoimmune pancreatitis often masquerade as pancreatic cancer. In this narrative review, we discuss the various modalities used to differentiate inflammatory from malignant masses of the pancreas. [ABSTRACT FROM AUTHOR]

Background Rapid on-site examination (ROSE) during endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) has been a subject of debate. We compared the yield of EUS-FNB with adequacy assessed using macroscopic on-site evaluation (MOSE), and smear cytology with adequacy confirmed by ROSE, acquired using the same needle. Methods Consecutive patients with solid pancreatic lesions (SPLs) who underwent EUS-FNB of pancreatic solid lesions between January 2021 and July 2022 were included. Demographic details, site and size of lesion, number of passes, and the diagnosis by cytology and histopathology of core tissue were noted. The first pass was used for ROSE adequacy assessment and was subsequently sent for cytological assessment. Additional passes were taken subsequently to acquire core tissue. Adequacy was confirmed by MOSE (whitish core of more than 4 mm). Final cytology and histopathology (HPE) were compared for diagnostic accuracy. Results One hundred fifty-five patients were included in the analysis during the study period (mean age 55.1+12.9 years; 60% male; 77% in pancreatic head; median size 3.7 cm). The final diagnosis was malignancy in 129, while 26 were negative for malignancy. Sensitivity and specificity for ROSE with cytology in detecting malignant SPLs were 96.9% and 100%, respectively. HPE with MOSE had sensitivity and specificity of 96.1% and 100%, respectively. A comparison of diagnostic accuracy showed no significant difference (P>0.99) between HPE with MOSE and ROSE with cytology, using an FNB needle. Conclusion MOSE is as good as ROSE in terms of diagnostic yield for solid pancreatic lesions sampled using newer-generation EUS biopsy needles. [ABSTRACT FROM AUTHOR]

Aim of the study: Endoscopic ultrasound (EUS)-guided liver biopsy (LB) has become an increasingly popular method of tissue acquisition for evaluating liver diseases. Despite its advantages, EUS-LB has not been widely adopted in clinical practice due to concerns regarding efficacy and safety. Present data on EUS-LB from India are scarce. We aimed to study the diagnostic outcome and safety of EUS-guided liver biopsy. Material and methods: This is a retrospective analysis of prospectively maintained data from January 2021 to October 2022 of consecutive patients undergoing EUS-LB at four tertiary care centers in India. The primary outcome was sample adequacy, while secondary outcomes were rate of successful pathological diagnoses and incidence of adverse events (AE). Results: A total of 74 patients (median age: 44.5 years, 50.0% males) were included. The majority of the patients underwent left-lobe biopsy (62/74, 83.7%), and a 19-G Franseen FNB needle was most commonly used (61/74, 82.4%). Wet heparin suction was used in most cases (60/74, 81.1%). There were five mild AEs observed (one case of self-limited bleeding and four cases of post-procedural pain). Adequate and optimal samples were obtained in 71 (95.9%) and 49 (66.2%) cases, with a conclusive diagnosis being made in 97.3% (72/74) of the patients. On multivariate analysis, the presence of ascites was a negative predictor of optimal sample (odds ratio [OR] = 0.128, 95% CI: 0.017-0.96). Conclusions: EUS-LB is a safe and viable alternative to percutaneous liver biopsy, achieving diagnosis in > 95% of cases. EUS-LB can be performed safely even in patients with mild ascites, although ascites reduces the chances of getting an optimal sample. [ABSTRACT FROM AUTHOR]

Background: No large studies have addressed the role of endoscopic-ultrasound biliary drainage (EUS-BD) as preoperative biliary drainage (PBD) for malignant extrahepatic biliary obstruction (MEBO). We aimed to discuss the outcomes of EUS antegrade stent placement (EUS-AG) in the preoperative and palliative setting. Methods: Retrospective review of patients who underwent EUS-AG for MEBO between December 2019 and December 2021 was done. Primary outcome measures were technical success and clinical success. Secondary outcome measures were number of days of hospitalization postprocedure, adverse events related to EUS-AG procedure, morbidity related to surgery, and 3-month mortality after surgery. Results: 54 patients underwent attempt for EUS-AG (mean age 54.8 ± 12.1 years; female 44.4%). Most common primary cancer was pancreatic cancer in 42.1% (23/54) patients. Indication was palliative in 34 (62.9%) patients and PBD in 20 (37%) patients. Level of block was distal in 35 (64.8%) and proximal in 19 (35.1%) patients. Technical success of EUS-AG was 88.7% (47/53). Clinical success was seen in 95.7% (45/47) patients. Median number of days of hospitalization postprocedure was 1 day. No procedure-related severe adverse events were seen. Of 20 patients who underwent EUS-AG as PBD, 19 had technical success (95%) with clinical success in 94.5% (18/19). Surgery was performed in 11 patients, of whom 10 patients underwent successful PPPD (one intraoperative liver metastasis). Two patients had Clavein–Dindo III/IV complication post-PPPD, with one mortality within 30 days of surgery. Conclusion: EUS-AG is safe and effective after failed ERCP in both preoperative and palliative setting. [ABSTRACT FROM AUTHOR]

Introduction Colonic self-expanding metal stent (SEMS) placement is the preferred method for palliation of malignant colonic obstruction. We analyzed outcomes of patients who underwent colonic SEMS placement for palliation at a tertiary care oncology center in Western India. Methods Retrospective review of the endoscopy database was done for patients who underwent colonic SEMS placement at our center between January 2013 and September 2021. Demographic details, intent of stent placement, site of obstruction, length of stricture, technical success of stenting, clinical success, and complications (both immediate and long term) were noted. Results Sixty-one patients underwent colonic SEMS placement during the study period (mean age 53.6 years, 50.7% men). Obstruction was due to primary colonic malignancy in 43 (70.5%) patients and extracolonic malignancies in 18 (29.5%) patients. Most common extracolonic malignancy was gallbladder cancer in 8 (44.4%) patients. Most common site of obstruction was sigmoid colon in 18 (29.5%) patients. Proximal colonic obstruction was seen in 17 (27.9%) patients. Peritoneal metastases were seen in 26 (42.6%) patients. Colonoscopy revealed an impassable stenosis in 58 (95.1%) patients. Median length of stricture was 5 cm (range 2–9 cm). Technical success was achieved in 98.3% (60/61). Clinical success was achieved in 51 (86.4%) patients. Perforation during colonic SEMS placement was seen in 2 (3.4%) patients. Stent migration was seen in 3 (5.9%) patients, needing surgery for retrieval in all 3 patients. Over a median follow-up of 9 months (0–21 months), stent block was seen in 7 (13.7%) patients. Stent block developed after a median period of 6 months. Of these patients, three patients underwent SEMS placement within the SEMS and the other four patients underwent surgery. Conclusion Colonic SEMS placement achieves good palliation of malignant colonic obstruction in approximately 87% patients. Long-term complications like obstruction occur in a few patients after a median duration of 6 months. [ABSTRACT FROM AUTHOR]

Aim of the study: Significant fibrosis is an indication for treatment in hepatitis B patients with normal transaminase levels. The present study was aimed at analyzing the factors associated with significant fibrosis in incidentally detected asymptomatic hepatitis B subjects (IDAHS) and developing a model for fibrosis prediction for use in low-resource settings. Material and methods: This is a single-center retrospective analysis of data on IDAHS who had undergone FibroScan. The variables associated with significant fibrosis in the derivation cohort were subjected to multivariate analysis by logistic regression. The model was applied to the validation cohort for fibrosis prediction. Results: A total of 299 patients (mean age: 42.6 years, males: 63.2%) were included in the model derivation. Significant fibrosis was found in 27.4% (82/299) of the patients and 16.8% (30/178) of those with normal transaminase. On multivariate analysis, age, lower platelet count, and presence of diabetes were associated with fibrosis. Serum glutamic pyruvic transaminase (SGPT) was included in the model as it was nearing towards in multivariate analysis. The DAPS (diabetes, age, platelet count, SGPT) score was proposed with equal weightage to each variable. Based on the cumulative score, patients were categorized as having low risk (DAPS score 0-2) or high risk (DAPS score 3-4). The specificity of the model in derivation and validation cohorts was 98.2% and 97.6%, respectively, while the accuracy was 83.6% and 80%, respectively. Conclusions: Approximately 17% of IDAHS with normal transaminase have significant fibrosis. The DAPS score can be used easily as a bedside tool for assessment of significant fibrosis in IDAHS with excellent specificity. [ABSTRACT FROM AUTHOR]

Background: Patients with moderate–severe cholangitis require urgent/early biliary drainage and failed endoscopic retrograde cholangiopancreatography (ERCP) warrants use of percutaneous drainage. While endoscopic ultrasound-guided biliary drainage (EUS-BD) has evolved as an effective salvage modality but its safety and efficacy data in moderate–severe cholangitis are limited. Patients and methods: All consecutive moderate–severe cholangitis patients, with failed/technically non-feasible ERCP requiring EUS-BD in two tertiary care centers were included. Baseline laboratory and demographic parameters were documented. Technical and clinical success were primary outcome measures. Additionally, effective biliary drainage, adverse events due to procedure, hospital stay, ICU stay, and mortality were noted. Results: Of the 49 patients (23 male; 46.9%) presenting with moderate/severe cholangitis, 23 (46.9%) had severe cholangitis. The median Charleston comorbidity index was 7.0 (IQR 2.0). Majority had malignant disease (87.8%) and 25 (51.0%) had inaccessible papilla. Technical success was achieved in 48 cases (98.0%), while clinical success with improvement of cholangitis was noted in 44 of 48 cases (91.7%). Effective biliary drainage was noted in 85.4% (41/48) cases. Adverse events in the form of mostly bleeding and bile leak were noted in 5 cases (10.2%) but managed conservatively. Distal obstruction exhibited significantly better clinical success (100% vs. 78.9%; p = 0.02) than hilar obstruction. Severe cholangitis had significantly lower clinical success (81.8% vs. 100%; p = 0.04) than moderate cholangitis. Conclusion: EUS-BD can be a safe and effective alternative option for patients with moderate to severe cholangitis, even with significant pre-morbid conditions, with acceptable adverse events rate. [ABSTRACT FROM AUTHOR]

Aim of the study: Endoscopic variceal ligation (EVL) is important for emergency as well as prophylactic management of esophageal varices. Early bleeding after EVL is associated with significant morbidity and mortality. Assessing the likelihood of early post-EVL bleeding and its determinants can help deciding therapeutic strategies for high-risk patients. The aim of the present meta-analysis was to identify predictors of early bleeding after EVL. Material and methods: A comprehensive search of the literature was conducted from 2000 to November 2021 for studies evaluating the incidence, predictors and outcome of post-EVL bleeding. Pooled odds ratios (OR), mean difference (MD) and their 95% confidence intervals (CI) were calculated for prognostic variables. Results: A total of 16 studies with data on 13,378 patients were included in the meta-analysis. Among 34 parameters, 14 parameters were assessed for association with early bleeding after EVL. Lower hemoglobin at admission (MD = 1.11, 95% CI: -1.91 to -0.31), higher MELD score (MD = 2.00, 95% CI: 0.51-3.50), associated gastric varices (OR = 5.99, 95% CI: 1.06-33.90), higher number of bands (MD = 0.49, 95% CI: 0.02-0.97), and peptic esophagitis (OR = 11.38, 95% CI: 1.21-106.81) were significantly associated with increased risk of bleeding. However, there was significant heterogeneity among the studies with respect to all the analyzed parameters. Conclusions: Major predictors for early post-EVL bleeding in cirrhosis are admission hemoglobin level and MELD score, associated gastric varices, number of bands deployed during EVL, and peptic esophagitis on follow-up endoscopy. These risk factors may be useful for risk stratification after EVL in cirrhotics. [ABSTRACT FROM AUTHOR]

Background/Aims: Pancreatic strictures in chronic pancreatitis are treated using endoscopic retrograde cholangiopancreatography (ERCP) with plastic stent placement. The management of recalcitrant strictures remains a challenge, with the use of a Soehendra stent retriever or a needle knife described in case reports. Here, we discuss our experience with dilation of dominant pancreatic strictures with a 6-Fr cystotome. Methods: A retrospective review of an endoscopy database was performed to search for patients with pancreatic strictures recalcitrant to conventional methods of dilation in which a cystotome was used. Technical success was defined as the successful dilation of the stricture with plastic stent placement. Functional success was defined as substantial pain relief or resolution of pancreatic fistulae. Results: Ten patients (mean age, 30.8 years) underwent dilation of a dominant pancreatic stricture secondary to chronic pancreatitis, with a 6-Fr cystotome. Seven patients presented with pain. Three patients had pancreatic fistulae (two had pancreatic ascites and one had a pancreaticopleural fistula). The median stricture length was 10 mm (range, 5-25 mm). The head of the pancreas was the most common location of the stricture (60%). Technical and functional success was achieved in all patients. One patient had self-limiting bleeding, whereas another patient developed mild post-ERCP pancreatitis. Conclusions: The use of a 6-Fr cystotome (diathermy catheter) can be an alternative method for dilation of recalcitrant pancreatic strictures after the failure of conventional modalities. [ABSTRACT FROM AUTHOR]

Thiopurines (azathioprine [AZA] and 6-mercaptopurine [6-MP]) are one of the main therapies for the management of inflammatory bowel disease (IBD), commonly being used as steroid-sparing agents for the maintenance of remission [[1]]. Reply We appreciate the interest expressed by Giri et al. in our recent work evaluating the long-term effectiveness and safety of first-line low-dose azathioprine-allopurinol co-therapy (LDAA) in 166 patients with inflammatory bowel disease (IBD) [[3]]. [Extracted from the article]

Background/Aims: Bile leak is a common complication of cholecystectomy, and it is also observed in other conditions such as ruptured liver abscess, hydatid cyst, and trauma. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management for such conditions. However, studies on the outcomes of endoscopic management for bile leaks with etiologies other than post-cholecystectomy injury are extremely limited. Methods: We conducted a retrospective review of patients with symptomatic bile leak who were referred to a tertiary care center and who underwent ERCP between April 2016 and April 2019. The primary outcome was complete symptomatic resolution without extravasation of the contrast medium during the second ERCP conducted after 6 weeks. Results: In total, 71 patients presented with symptomatic bile leak. The etiologies of bile leak were post-cholecystectomy injury in 34 (47.8%), liver abscess in 20 (28.1%), and post-hydatid cyst surgery in 11 (15.4%) patients. All patients were managed with ERCP, sphincterotomy, and stent placement for 6 weeks, except for one who underwent surgery. The primary outcome was achieved in 65 (91.5%) of 71 patients. There was no significant difference in terms of outcome in relation to the interval between the diagnosis of bile leak and ERCP. Conclusions: Most patients with bile leak can be successfully managed with ERCP even when performed on an elective basis [ABSTRACT FROM AUTHOR]

Background & objectives: Screening for hepatitis B prior to the initiation of chemotherapy in patients with cancer is recommended by all major hepatology and oncology societies. This study was aimed to determine the screening practices for hepatitis B among oncologists from India and their experience with hepatitis B reactivation. Methods: A questionnaire-based survey was conducted among oncologists attending the Evidence-Based Medicine Conference at Tata Memorial Centre, Mumbai, India. The questionnaire was developed in keeping with the recent guidelines for hepatitis B reactivation on chemotherapy, with questions regarding demographics, years in practice and hepatitis B screening practices and management. There was 78 per cent response rate to the questionnaire. Results: Most respondents were <35 yr of age (69%), with

Removal of migrated biliary stent by use of an enteral stent in a patient with gastric outlet obstruction caused by nonresectable pancreatic adenocarcinoma with prior loop gastrojejunostomy. After successful retrieval of the plastic stent, the PTBD catheter was internalized and a 10 × 80-mm self-expanding metal stent (Niti-S; Taewoong Medical, Seoul, South Korea) was placed in the CBD (Fig. A 57-year-old man with metastatic periampullary carcinoma and a history of previous endoscopic retrograde cholangiopancreatography (ERCP) and placement of a double-pigtail plastic stent for distal common bile duct (CBD) obstruction presented with severe cholangitis and blockage of the stent. [Extracted from the article]

Autoimmune pancreatitis (AIP) is a known autoimmune disorder of the pancreas, with a clinical presentation similar to that of carcinoma of the pancreas. CA19-9 levels can be the distinguishing feature between the two disorders. In rare instances, CA19-9 may be elevated in AIP. Elevation of levels of more than 1,000 U/mL has been reported in only one case series previously. Here we report a rare instance of CA19-9 more than 1,000 U/mL in a case of AIP and its subsequent management. [ABSTRACT FROM AUTHOR]

Gastrointestinal (GI) endoscopy is among the highest waste generator in healthcare facilities. The major reasons include production of large‐volume non‐renewable waste, use of single‐use devices, and reprocessing or decontamination processes. Single‐use endoscopic accessories have gradually replaced reusable devices over last two decades contributing to the rising impact of GI endoscopy on ecosystem. Several reports of infection outbreaks with reusable duodenoscopes raised concerns regarding the efficacy and adherence to standard disinfection protocols. Even the enhanced reprocessing techniques like double high‐level disinfection have not been found to be the perfect ways for decontamination of duodenoscopes and therefore, paved the way for the development of single‐use duodenoscopes. However, the use of single‐use endoscopes is likely to amplify the net waste generated and carbon footprint of any endoscopy unit. Moreover, single‐use devices challenge one of the major pillars of sustainability, that is, "reuse." In the era of climate change, a balanced approach is required taking into consideration patient safety as well as financial and environmental implications. The possible solutions to provide optimum care while addressing the impact on climate include selective use of disposable duodenoscopes and careful selection of accessories during a case. Other options include use of disposable endcaps and development of effective high‐level disinfection techniques. The collaboration between the healthcare professionals and the manufacturers is paramount for the development of environmental friendly devices with low carbon footprint. [ABSTRACT FROM AUTHOR]

Endoscopy UCTN Code TTT 1AO 2AI Endoscopy E-Videos I Endoscopy E-Videos i is an open access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. 2 Upper gastrointestinal endoscopy showing dehiscence at the anastomotic site, approx. 1 cm in size. Computed tomography (CT) of the chest showed a leak from the anastomotic site tracking into the right pleura (Fig. [Extracted from the article]

Intussusception is a rare cause of colonic obstruction, with the colon accounting for 5 % of all instances of intussusception [1]. 4 Plain radiograph of the abdomen post-stent placement showing the expanded colonic stent and no evidence of bowel dilatation, with a biliary self-expanding metal stent also visible. In adults, about half of bowel intussusceptions result from malignancy, with surgical resection being required in 72 % of patients [2]. [Extracted from the article]

Background  The majority of foreign bodies entering the small intestine are passed spontaneously. However, in case of a sharp object, its removal is an urgency due to a higher risk of intestinal perforation, and endoscopic intervention is an appropriate management strategy as surgery is associated with greater morbidity. Although enteroscopy is the standard practice for the removal of a foreign body in the small intestine, gastroduodenoscopy may be used for small intestinal foreign body removal. Case Presentation  We describe here the case of a 21-month-old child in whom a 5-cm, sharp-pointed nail in the midjejunum was removed successfully by a gastroduodenoscopy. This case highlights the difficulties in the removal of a sharp foreign body in a pediatric patient and the use of push enteroscopy. Conclusion  Gastroduodenoscopy can be used for the removal of a foreign body in the small intestine in pediatric population in a resource-limited setup by performing push enteroscopy. [ABSTRACT FROM AUTHOR]

TJRB is the alternative to percutaneous biopsy in high-risk patients with ascites and thrombocytopenia [1]. Transjugular renal biopsy (TJRB) was advised after nephrology consultation, due to the ascites with thrombocytopenia, but the patient was not willing to undergo this procedure. B Video 1 b Endoscopic ultrasound-guided kidney biopsy from the lower pole of the left kidney for evaluation of nephrotic syndrome. [Extracted from the article]

Background: Concerned studies with respect to the outcome of pregnant patients with non-cirrhotic portal hypertension are limited. Thus, a systematic review and meta-analysis of the available literature was conducted. Methods: A literature search was conducted from 1999 to December 2021 for studies evaluating pregnancy outcomes in patients with non-cirrhotic portal hypertension. Results: Twelve studies were included in the meta-analysis. The pooled rate of variceal bleeding, ascites and severe anemia requiring blood transfusion were 9.6%, 2.3%, and 14.9%, respectively. The pooled rate of spontaneous miscarriage, gestational hypertension, delivery by cesarean section, and postpartum hemorrhage were 11.9%, 4.5%, 36.7%, and 4.7%, respectively. The pooled stillbirth rate was 2.5% and among the live births, the pooled rates of preterm birth, low birth weight, intensive care unit admission, and neonatal mortality were 21.6%, 18.7%, 15.5%, and 1.8%, respectively. Conclusion: Pregnancy in patients with non-cirrhotic portal hypertension is associated with increased maternal & fetal morbidity but mortality remains low. [ABSTRACT FROM AUTHOR]

Colonic self-expanding metal stent (SEMS), although associated with high technical and functional success in malignant colonic obstruction, may be associated with complications such as migration. Furthermore, fistulous tract formation with SEMS in situ has been reported only in few case reports previously. Here, we present a case of colonic SEMS migrating through a gastrocolic fistula into the stomach. There are no previous reports of migration of a colonic SEMS into a proximal segment of the gastrointestinal tract. [ABSTRACT FROM AUTHOR]

Famularo et al.[1] recently published the findings of their retrospective study on impact of post-operative ascites (POA) after hepatectomy on long-term outcomes and survival. Post-operative Ascites After Hepatectomy - Not More Than What Meets the Eyes While calculating the proportion of patients developing grade 3/4 Clavien-Dindo complications, the authors should have included only patients who developed complications 83/560 (14%) in the NO-POA cohort. [Extracted from the article]

Purpose: Most studies identifying risk factors for post-hepatectomy biliary leaks (PHBLs) have relatively small proportions of major hepatectomies. A simplified predictive score to identify high risk patients is necessary in order to investigate the efficacy of mitigation strategies. Methods: A retrospective analysis of a prospectively maintained database of liver resections from a high-volume cancer center was performed. Multivariate regression was utilized for identification of risk factors and development of the predictive score. Results: A total of 862 patients underwent a curative hepatic resection over 10 years, of whom 146 (16.9%) developed a biliary leak; 85 (9.86%), 52 (6.03%), and 9 (1.04%) patients had a grade A, B, and C leak respectively. A biliary-enteric anastomosis [OR 5.1 (95% CI 2.45–10.58); p < 0.001], a central [OR 4.33 (95% CI 1.25–14.95); p = 0.021] or an extended hepatectomy [OR 4.29 (95% CI 1.52–12.12); p = 0.006], liver steatosis [OR 2.28 (95% CI 1.09–4.77); p = 0.027], and blood loss of ≥ 2000 mL [OR 2.219 (95% CI 1.15–4.27); p = 0.017] were identified as independent predictors of a clinically significant biliary leak and were assigned 1 point each to develop the biliary leak score. Clinically significant biliary leaks were seen in 11 (2.79%), 20 (6.38%), 19 (15.4%), 9 (56.3%), and 1 (100%) patients with scores of 0, 1, 2, 3, and 4 respectively (p < 0.001). Conclusion: A biliary-enteric anastomosis, a central or extended hepatectomy, liver steatosis, and blood loss ≥ 2L combined result in a simple predictive score for clinically significant biliary leaks. [ABSTRACT FROM AUTHOR]

The authors declare that they have no conflict of interest. letter Studies have shown that trainee involvement in endoscopic retrograde cholangiopancreatography (ERCP) procedures results in increased time to cannulation and requirement for advanced cannulation techniques such as precut sphincterotomy [1]. Although the protocol defined that trainees performed about 20 procedures on sphincterotomized papillae prior to attempts at cannulating native papillae, trainees who had performed a higher number of procedures were more likely to be better skilled [4]. The European Society of Gastrointestinal Endoscopy proposed the 5-5-1 criteria for difficult biliary cannulation: > 5 minutes attempting to cannulate, > 5 contacts with the papilla during cannulation attempts, > 1 unintended pancreatic duct guidewire cannulation or opacification [2]. [Extracted from the article]

We read with great interest the scientific review by Nahshon et al., titled 'Hazardous Postoperative Outcomes of Unexpected COVID-19 Infected Patients: A Call for Global Consideration of Sampling all Asymptomatic Patients Before Surgical Treatment' [[1]]. It also seems worth looking into, that of the vast volumes of the literature available regarding COVID-19, and with over 6 million people being affected with it worldwide as of 30 of May, the peri-operative outcomes from these 64 patients might not reflect the global reality. [Extracted from the article]

Background In clinical practice, decision about management of choledocholithiasis is driven by availability of resources and expertise, patients and healthcare professional preferences. This survey is aimed to describe the approach of physicians and surgeons for the management of choledocholithiasis. Method A 36-question online survey was conducted using Google Forms on various aspects of management of choledocholithiasis. Results The responses from 323 participants were included, of which 202 (62.54%) were physicians and 121 (37.46%) were surgeons. The proportion of responders who do not follow American or European Society of Gastrointestinal Endoscopy guidelines is associated with increasing age and experience of responders (p = 0.0001), while place of work (private vs. teaching) and broad specialty (physician vs surgeon) are not associated (p >0.05). For patients with high likelihood of choledocholithiasis, 123 (38.1%) participants prefer to do endoscopic ultrasound/magnetic resonance cholangiopancreatography (EUS/MRCP) rather than directly performing endoscopic retrograde cholangiopancreatography/intraoperative cholangiography (ERCP/IOC). For intermediate likelihood, MRCP is more commonly preferred compared with EUS, due to local availability (44%), expertise (39.6%), healthcare professionals preference (30.7%), and patients preference (17.3%). For difficult common bile duct (CBD) stones, short biliary sphincterotomy with large balloon sphincteroplasty (59.4%), followed by laparoscopic CBD exploration are commonly used approaches. Prophylactic CBD stent placement after ERCP and CBD clearance is common practice. Preoperative ERCP followed by cholecystectomy is more preferred approach than cholecystectomy and CBD exploration. Conclusion There is considerable variability in the management of choledocholithiasis. The practices such as use of EUS/MRCP for high likelihood group, use of prophylactic CBD stent placement after ERCP and CBD clearance, and use of single stage approach especially in patient with intermediate likelihood group should be addressed in future studies. [ABSTRACT FROM AUTHOR]

Increasing incidence of hepatocellular carcinoma (HCC) in India is a matter of concern and need for adequate profiling and streamlining management strategies cannot be over-emphasized. This is a prospective multi-centric observational cohort study comprising of an oncology center, one university tertiary hospital with specialized hepatology service, one public hospital with gastroenterology service, and a private liver transplant center located within a 3-km radius. The demographic and clinical parameters were recorded on a prospectively maintained database. The clinical profile, demographics, characteristics of HCC and the allocated treatment were noted and compared among the four centers. In total, 672 patients were enrolled from June 2016 till January 2020. Abdominal pain (64.3%) and weight loss (47.3%) were the most common symptoms. Most common identified etiology was hepatitis B (39%). The cancer center received lesser patients with hepatitis C and those with advanced stage of HCC. The private transplant center reported the highest proportion of NASH, which was also significantly higher in those belonging to higher socioeconomic strata, and lowest proportion of alcoholic cirrhosis. Metastasis was seen in almost one-fifth (19%) cases at diagnosis. Portal vein thrombosis was evident in 40%. Adherence to treatment guidelines was seen in three-fourth cases (76%). Hepatitis B is the most common underlying cause for HCC, whereas other causes like NASH are on the rise. Etiologic profile may vary with selective specialization of centers catering to patients with HCC. Adherence to guideline while allocating treatment was high among all centers with highest non-adherence in BCLC A. [ABSTRACT FROM AUTHOR]

The authors declare that they have no conflict of interest. letter Kylänpää et al. recently published the results of a multicenter randomized controlled trial that compared a double-guidewire (DGW) technique with transpancreatic biliary sphincterotomy (TPBS) for patients with difficult biliary cannulation, and evaluated the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) after use of these techniques [1]. As mentioned by Kylänpää et al., in patients with failed DGW technique, TPBS was used in 90 % with successful cannulation in 77.8 %; hence, in patients with failed DGW, TPBS may be considered an alternative. The need to perform an additional pancreatic sphincterotomy in patients with biliary pathology is overtreatment and is associated with a risk of long-term complications. [Extracted from the article]

Sumi et al.2 recently published their findings of ARMS in a retrospective series of 109 patients with PPI refractory GERD. Endoscopic therapies have evolved significantly over the last decade as minimally invasive therapies for GERD.1 Antireflux mucosectomy (ARMS) was first described in 2003, however the pilot series was reported in refractory GERD in 2014. [Extracted from the article]

This review article examines the evidence-based management of colorectal cancers, focusing on topics characterized by ongoing debates and evolving evidence. To contribute to the scientific discourse, we intentionally exclude subjects with established guidelines, concentrating instead on areas where the current understanding is dynamic. Our analysis encompasses a thorough exploration of critical themes, including the evidence surrounding complete mesocolic excision and D3 lymphadenectomy in colon cancers. Additionally, we delve into the evolving landscape of perioperative chemotherapy in both colon and rectal cancers, considering its nuanced role in the context of contemporary treatment strategies. Advancements in surgical techniques are a pivotal aspect of our discussion, with an emphasis on the utilization of minimally invasive approaches such as laparoscopy and robotic surgery in both colon and rectal cancers, including advanced rectal cases. Moving beyond conventional radical procedures, we scrutinize the feasibility and implications of endoscopic resections for small tumors, explore the paradigm of organ preservation in locally advanced rectal cancers, and assess the utility of total neoadjuvant therapy in the current treatment landscape. Our final segment reviews pivotal trials that have significantly influenced the management of colorectal liver and peritoneal metastasis. [ABSTRACT FROM AUTHOR]

Background: Tissue acquisition from a thickened gastric wall using biopsy forceps may not always lead to diagnosis, given the submucosal location of the pathology. Endoscopic ultrasound (EUS)-guided tissue acquisition (TA) may serve as a minimally invasive diagnostic tool in such cases. Hence, we aimed to assess the diagnostic outcome and safety of EUS-TA from thickened gastric walls. Methods: Data from patients with gastric wall thickening undergoing EUS-TA at 5 tertiary care centers from August 2020 to August 2022 were retrospectively analyzed. These data were pooled with studies obtained from a comprehensive search of Medline, Embase and Scopus from January 2000 to November 2022 and a meta-analysis was performed. Pooled event rates were calculated using an inverse variance model. Results: The search strategy yielded 13 studies that were combined with data from 30 patients from our centers; a total of 399 patients were included in the analysis. The pooled rate of sample adequacy was 94.1% (95% confidence interval [CI] 90.0-98.2), while the pooled rate of diagnostic accuracy was 91.3% (95%CI 87.0-95.5). The pooled sensitivity and specificity for diagnosing malignant lesions with EUS-TA from gastric wall thickening were 94.8% (95%CI 91.3-97.2) and 100% (95%CI 93.6-100), respectively. There were no reported adverse events in any of the studies. Conclusions: EUS-TA offers a safe and accurate diagnostic modality for the etiological diagnosis of thickened gastric walls. Further research is required to identify the needle type and optimal technique for improving outcomes. [ABSTRACT FROM AUTHOR]

Background: Lumen apposing metal stents (LAMSs) have a higher clinical success rate for managing pancreatic fluid collections. But they are associated with adverse events (AEs) like bleeding, migration, buried stent, occlusion, and infection. It has been hypothesized that placing a double pigtail stent (DPS) within LAMS may mitigate these AEs. The present systematic review and meta-analysis were conducted to compare the outcome and AEs associated with LAMS with or without a coaxial DPS (LAMS-DPS). Methods: A comprehensive literature search of three databases from January 2010 to August 2022 was conducted for studies comparing the outcome and AEs of LAMS alone and LAMS-DPS. Pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated for all the dichotomous outcomes. Results: Overall, eight studies (n = 460) were included in the final analysis. The clinical success rate (RR 1.00, 95% CI: 0.87–1.14) and the risk of overall AEs (RR 1.60, 95% CI: 0.95–2.68) remained comparable between both groups. There was no difference in the risk of bleeding between LAMS alone and LAMS-DPS (RR 1.80, 95% CI: 0.83–3.88). Individual analysis of other AEs, including infection, stent migration, occlusion, and reintervention, showed no difference in the risk between both procedures. Conclusion: The present meta-analysis shows that coaxial DPS within LAMS may not reduce AE rates or improve clinical outcomes. Further larger studies, including patients with walled-off necrosis, are required to demonstrate the benefit of coaxial DPS within LAMS. [ABSTRACT FROM AUTHOR]

Background Lumen-apposing metal stents (LAMS) are an evolving option for the management of benign gastrointestinal (GI) strictures. Multiple studies have reported on the efficacy and safety of LAMS for benign GI strictures, but were limited by their small sample size. Hence, we conducted this meta-analysis to assess the critical role of LAMS for the management of benign GI strictures. Methods: A literature search of various databases from inception until October 2022 was conducted for studies evaluating the outcome of LAMS in patients with benign GI strictures. The outcomes assessed included technical and clinical success, adverse events including stent migration, and reintervention. Pooled event rates across studies were expressed with summative statistics. Results: A total of 18 studies (527 patients) were included in the present analysis. The pooled event rates for technical, short-term and long-term clinical success were 99.9% (95% confidence interval [CI] 99.1-100.0), 93.9% (95%CI 90.7-100.0), and 72.8% (95%CI 55.7-90.0), respectively. The pooled incidence of adverse events and stent migration with LAMS for benign GI strictures was 13.5% (95%CI 8.6-18.5) and 10.6% (95%CI 6.0-15.2), respectively. The pooled event rate for reintervention with LAMS for GI strictures was 23.0% (95%CI 15.7-30.3). In a subgroup analysis focusing only on anastomotic strictures there was no significant difference in the pooled event rates for various outcomes. Conclusions: LAMS have a high technical and short-term clinical success rate, with an acceptable safety profile for the management of benign GI strictures. Further studies are needed to determine the appropriate duration of stent therapy and long-term outcomes. [ABSTRACT FROM AUTHOR]

The current standard of treatment for nonvariceal upper gastrointestinal bleeding (NVUGIB) includes endoscopic hemostasis with either through-the-scope clips or thermal therapy. However, they may be associated with rebleeding, especially in high-risk ulcers. Over-the-scope clips (OTSC) have been demonstrated in multiple recent studies to be an effective measure for NVUGIB. We aimed to analyze the current literature on standard therapy with OTSC to manage NVUGIB. A meta-analysis was performed by pooling the data from randomized studies obtained from a comprehensive search of Medline, Embase, and Scopus from inception to February 2023. The outcomes analyzed included rates of persistent bleeding, rebleeding, mortality, and duration of hospitalization. A total of five studies were included in the final analysis. There was no significant difference in the risk of persistent bleeding between the groups, with a risk ratio (RR) of 0.29 (95% confidence interval [CI]: 0.07–1.27). The use of OTSC was associated with a significantly lower risk of 7-day and 30-day rebleeding compared with standard therapy with RR of 0.30 (95% CI: 0.16–0.59) and 0.42 (95% CI: 0.24–0.72), respectively. There was no difference in the risk of 30-day mortality or the duration of hospitalization. There was no change in the effect on subgroup analysis of studies using OTSC as first-line therapy. The use of OTSC can reduce the rebleeding rates after endoscopic hemostasis. However, they may not reduce the risk of persistent bleeding or mortality. Future studies are required on the cost-efficacy of this modality. [ABSTRACT FROM AUTHOR]

Aim of the study: Studies comparing atezolizumab plus bevacizumab (ATE/BEV) vs. lenvatinib (LEN) for advanced hepatocellular carcinoma (aHCC) have shown conflicting results. With this background, we aimed to collate the available evidence comparing ATE/BEV and LEN in aHCC. Material and methods: A comprehensive search of three databases was conducted from inception to November 2022 for studies comparing ATE/BEV with LEN for managing aHCC. Results were presented with their 95% confidence intervals (95% CI) as the hazard ratio (HR) for time-to-event outcomes or odds ratios (OR) for dichotomous outcomes. Results: A total of 8 studies were included. On analysis of matched cohorts, there was no difference in the objective response rate (ORR) (adjusted odds ratio [aOR] = 1.15, 95% CI: 0.83-1.61) or disease control rate (DCR) (aOR = 0.83, 95% CI: 0.49-1.38) between groups. Three studies reported a significantly longer progression-free survival (PFS) with ATE/LEN, while one reported a longer PFS with LEN. The adjusted hazard ratio (aHR) for PFS available from three studies was comparable (HR = 1.06, 95% CI: 0.75-1.50). Data were insufficient to carry out a formal analysis for overall survival (OS), but none of the studies reported any difference in OS. On comparison of overall adverse events (AE) and = grade 3 AE, there was no difference in the overall analysis, but higher risk of AE with LEN on sensitivity analysis. Conclusions: Based on the currently available literature, LEN was found to be non-inferior to ATE/BEV in terms of ORR, DCR, and PFS. However, LEN may be associated with a higher incidence of AEs. Further head-to-head trials are required to demonstrate the superiority of ATE/BEV over LEN. [ABSTRACT FROM AUTHOR]

Background/Aims: The data on the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in patients with inflammatory bowel disease (IBD) are conflicting. The present systematic review was thus conducted to study the prevalence of HBV and HCV markers in patients with IBD. Methods: A comprehensive literature search of 3 databases was conducted from 2000 to April 2022 for studies evaluating the prevalence of HBV or HCV in patients with IBD. Pooled prevalence rates across studies were expressed with summative statistics. Results: A total of 34 studies were included in the final analysis. The pooled prevalence of hepatitis B surface antigen (HBsAg) and hepatitis B core antibodies were 3.3% and 14.2%, respectively. In HBsAg positive IBD patients, hepatitis B e antigen positivity and detectable HBV DNA were seen in 15.3% and 61.0% of patients, respectively. Only 35.6% of the IBD patients had effective HBV vaccination. The pooled prevalence of anti-HCV and detectable HCV RNA were 1.8% and 0.8%, respectively. The pooled prevalence of markers of HBV infection was higher in Asian studies, while the prevalence of markers of HCV infection was higher in European studies. The prevalence of viral hepatitis markers was similar between IBD patients and the general population and that between ulcerative colitis and Crohn’s disease. Conclusions: The prevalence of markers of viral hepatitis remains same as the general population with significant regional variations, although the quality of evidence remains low due to publication bias. Only a small proportion of IBD patients had an effective HBV vaccination, requiring improvement in screening and vaccination practices. [ABSTRACT FROM AUTHOR]

Background: The present guidelines stratify endoscopic ultrasound-guided tissue acquisition (EUS-TA) as a high-bleeding risk procedure in patients on antithrombotics. However, the data regarding the same are conflicting. Therefore, this meta-analysis aimed to analyze the bleeding event rates associated with EUS-TA in patients receiving antithrombotic therapy. Methods: A literature search from January 2000 to August 2022 was done for studies on EUS-guided TA in patients receiving antithrombotics. The primary outcome was incidence of overall and major bleeding. Pooled event rates across studies were expressed with summative statistics. Results: A total of 12 studies were included in the meta-analysis. The pooled risk of overall bleeding and major bleeding in patients on antithrombotics was 2.0% (0.6–3.4) and 0.8% (0.0–1.6), respectively. In patients taking thienopyridine or anticoagulants, the pooled risk of overall bleeding and major bleeding was 2.4% (0.9–3.9) and 1.7% (0.4–3.1), respectively. Patients on antithrombotics had a higher odd of overall bleeding (OR 2.12, 1.20–3.83) and major bleeding (OR 3.58, 1.11–11.52) compared to controls. The odds of overall bleeding (OR 0.95, 95%CI 0.38–2.42) and major bleeding (OR 1.57, 95%CI 0.45–5.54) were comparable between patients on antithrombotics who continued and those who discontinued it preprocedural. Conclusion: Despite an increase risk of bleeding with EUS-TA in patients on antithrombotics, the pooled incidence remains low. Compared to the previous guidelines stating thienopyridine use as high risk for bleeding, the present analysis showed a bleeding rate of less than 1%. Discontinuing antithrombotics prior to EUS-TA does not reduce the bleeding risk significantly, requiring strict monitoring. [ABSTRACT FROM AUTHOR]

Aim of the study: Studies comparing atezolizumab plus bevacizumab (ATE/BEV) vs. lenvatinib (LEN) for advanced hepatocellular carcinoma (aHCC) have shown conflicting results. With this background, we aimed to collate the available evidence comparing ATE/BEV and LEN in aHCC. Material and methods: A comprehensive search of three databases was conducted from inception to November 2022 for studies comparing ATE/BEV with LEN for managing aHCC. Results were presented with their 95% confidence intervals (95% CI) as the hazard ratio (HR) for time-to-event outcomes or odds ratios (OR) for dichotomous outcomes. Results: A total of 8 studies were included. On analysis of matched cohorts, there was no difference in the objective response rate (ORR) (adjusted odds ratio [aOR] = 1.15, 95% CI: 0.83-1.61) or disease control rate (DCR) (aOR = 0.83, 95% CI: 0.49-1.38) between groups. Three studies reported a significantly longer progression-free survival (PFS) with ATE/LEN, while one reported a longer PFS with LEN. The adjusted hazard ratio (aHR) for PFS available from three studies was comparable (HR = 1.06, 95% CI: 0.75-1.50). Data were insufficient to carry out a formal analysis for overall survival (OS), but none of the studies reported any difference in OS. On comparison of overall adverse events (AE) and = grade 3 AE, there was no difference in the overall analysis, but higher risk of AE with LEN on sensitivity analysis. Conclusions: Based on the currently available literature, LEN was found to be non-inferior to ATE/BEV in terms of ORR, DCR, and PFS. However, LEN may be associated with a higher incidence of AEs. Further head-to-head trials are required to demonstrate the superiority of ATE/BEV over LEN. [ABSTRACT FROM AUTHOR]