Background and Aims Conventional endoscopic mucosal resection (EMR) using hot snare is the standard of care for resection of large (≥20 mm) nonmalignant sessile colonic polyps. Serious adverse events are predominantly due to electrocautery. This could potentially be avoided by cold snare piecemeal EMR (CSP-EMR). The study aimed to evaluate the safety and efficacy of CSP-EMR of sessile colonic polyps sized ≥20 mm. Methods All cases of CSP-EMR at 5 Australian academic hospitals for sessile polyps ≥20 mm over a 2-year period, from January 2016 to December 2017 were identified retrospectively. Efficacy was defined as the absence of residual or recurrent polyp tissue during the first surveillance colonoscopy (SC1) and second surveillance colonoscopy (SC2). Clinically significant intraprocedural or delayed adverse events and surveillance colonoscopy findings were assessed by reviewing medical records. Results CSP-EMR was performed on 204 polyps sized ≥20 mm in 186 patients (men 33.8%; median age 68 years). SC1 for 164 (80.4%) polyps at a median interval of 150 days showed residual or recurrent polyp in 9 cases (5.5%; 95% CI, 3%-11%). SC2 for 113 (72.9%) polyps at a median interval of 18 months showed late residual or recurrent polyp in 4 cases (3.5%; 95% CI, 0.9%-8.5%) after a normal SC1. Intra-procedural bleeding was successfully treated in 4 (2.2%) patients, 7 (3.8%) patients experienced self-limiting clinically significant post-EMR bleeding (CSPEB) and 1 patient (0.5%) required overnight observation for nonspecific abdominal pain that resolved spontaneously. None experienced other adverse events. Conclusion CSP-EMR of sessile colonic polyps ≥20 mm is technically feasible, effective, and safe. The adverse event rate and polyp recurrence rate were low. Randomized or large prospective trials are required to confirm the noninferiority and improved safety of CSP-EMR compared with conventional EMR, and to further determine the polyp morphologies that are best suited for CSP-EMR.

Background and Aims Previous meta-analysis showed marginal benefit of high-definition white-light endoscopy (HD-WLE) over standard-definition (SDC) colonoscopy for adenoma detection, but with residual uncertainty due to inclusion of nonrandomized studies. We aimed to further assess the effect of HD-WLE on adenoma detection by including only randomized controlled trials (RCTs). Methods A literature search was performed for RCTs evaluating HD-WLE versus SDC in terms of adenoma, advanced adenoma, and serrated sessile adenoma detection rates as well as mean number of adenomas (MAC), advanced adenomas (MAAC), and sessile serrated adenomas per colonoscopy (MSSAC). The effect size on study outcomes is presented as risk ratio (RR; 95% CI) or mean difference (MD; 95% CI). We assessed the strength of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results Six RCTs involving 4594 individuals (HD-WLE 2323; SDC 2271) were included. Clinical indications were screening (1 study), positive FOBT and personal/family history of colorectal cancer (1 study), and mixed indications (4 studies). Withdrawal time was similar between the 2 arms (MD, -0.06; 95% CI, -0.25 to 0.12; p=0.50). Adenoma detection rate was significantly higher in the HD-WLE compared with SDC arm (40% vs 35%; RR, 1.13; 95% CI, 1.05-1.22; p=0.001; I2=0%; GRADE: low). This effect was consistent for advanced and sessile serrated adenoma detection rates (RR, 1.33; 95% CI, 1.03-1.72; p=0.03; I2=0%; GRADE: low and RR, 1.55; 95% CI, 1.05-2.28; p=0.03; I2=0%; GRADE: low, respectively). On the contrary, the difference was not significant for MAC, MAAC, and MSSAC. Conclusions Meta-analysis of RCT data support the use of HD-WLE in clinical practice, although the additional benefit is limited.

Background and aims The efficacy of celiac plexus neurolysis (CPN) with EUS guidance has not been confirmed in the era of developed opioids. The aim of this study was to evaluate the efficacy of EUS-guided CPN (EUS-CPN) for patients with pancreatic cancer-associated pain to compare medication using oxycodone and/or fentanyl with and without EUS-CPN. Methods In this randomized control study involving patients who underwent EUS-CPN and those who did not, pain, quality of life (QOL), and opioid consumption were compared. Standard medicinal treatment using oxycodone and/or fentanyl was performed for both groups. The primary endpoint was defined as the pain evaluated by using a 0 to10 visual analogue scale (VAS) 4 weeks after the baseline. Results For 48 registered patients, the outcomes of 24 patients in the EUS-CPN group and 22 patients in the control group were analyzed. EUS-CPN was successfully performed and did not induce severe procedure-related adverse events for all patients in the EUS-CPN group. Although the average pain VAS scores for both groups significantly decreased in comparison with the baseline, they were not statistically different between the groups at week 4 (1.3 ± 1.3 for the EUS-CPN group vs 2.3 ± 2.3 for the control group, P = 0.10). There was no statistical difference nor tendency in favor of EUS-CPN at evaluation points of weeks 1, 2, 8, and 12. Moreover, the average VAS scores for QOL and the average opioid consumption between the groups were not different at all evaluation points. Conclusions EUS-CPN for patients with pancreatic cancer-associated pain did not appear to improve pain, QOL, nor opioid consumption in comparison to those who did not undergo EUS-CPN being medicated with oxycodone/fentanyl. Although EUS-CPN can be an option, it was not found to have a large enough impact to be routinely performed for all patients with pain.

Background and Aims The treatment of submucosal (T1b) esophageal adenocarcinoma (EAC) remains in evolution with some evidence supporting endoscopic management of low-risk lesions. Using a multicenter cohort, we evaluated outcomes of patients with T1b EAC and predictors of survival. Methods Patients diagnosed between 2001 and 2016 with T1b EAC were identified from 3 academic medical centers in the United States. Demographic, clinical and outcome data were collected. Outcomes studied included overall and cancer-free survival. Cox proportional hazards models were constructed to assess independent predictors of survival. Results One hundred forty-one patients were included, of whom 68 (48%) underwent esophagectomy and 73 (52%) were treated endoscopically. Most (85.8%) patients had high-risk histological features. Thirty-day operative mortality was 2.9%. Median follow-up in the esophagectomy and endoscopic cohorts was 49.4 and 43.4 months, respectively. Patients treated endoscopically were older with higher comorbidity scores. 46 (63%) patients treated endoscopically achieved histologic remission. Nineteen (26.0%) patients also received chemoradiation. Five-year overall survival rates in the surgical and endoscopic cohorts were 89% and 59% respectively whereas 5-year cancer free survival rates were 92 and 69%. Presence of high-risk histological features was associated with reduced overall survival. Conclusions In this large multicenter study of patients with T1b EAC, esophagectomy was associated with improved overall but not cancer-free survival. High-risk histological features were associated with poorer survival.

Background and Aims Outbreaks of infections transmitted by duodenoscopes have prompted changes to duodenoscope cleaning protocols. However, little is known about effectiveness of clinical cleaning practices. We present culture data after duodenoscope manufacturer-recommended high-level disinfection (HLD) and quarantine. Methods Our institution adopted a combination of manufacturer-recommended cleaning with the CDC-recommended culture and quarantine in 2015. Duodenoscopes (Olympus models TJF-Q180V, TJF-160, PJF-160) underwent HLD according to the manufacturer’s reprocessing manual protocols after use. Two culture specimens were then obtained using a sterile brush from the distal tip, including elevator mechanism, and by flushing sterile water through the working channel. Duodenoscopes were quarantined until cultures resulted. Positive cultures were defined as >10 colony-forming units (CFUs) of low-concern organisms, or any CFUs of high-concern organisms according to CDC recommendations. If either culture specimen was positive, the process was repeated until cultures were negative. Data were collected from December 2015 to July 2018. Results There were 140 instances of duodenoscope cleaning with 280 specimens. Twenty-eight of 234 (12%) initial culture specimens (18% of cultured duodenoscopes) were positive. Five of 36 (14%) second cultures were positive. Two of 8 (25%) third cultures were positive. Ninety-eight percent of organisms cultured were gram positive. There were 8 instances when both culture methods (brushing and flush) were positive; otherwise only one method was positive. There were 11 instances (8%) of duodenoscope removals from quarantine before final culture results. No patients had infections related to ERCP. Conclusions 18% of duodenoscopes had a positive culture after initial HLD. Only 3% were gram negative bacteria. Repeated HLD was 86% and 75% effective at eliminating initial and repeat positive cultures respectively. Initial HLD per manufacturer recommendations is not always effective at eliminating bacterial contamination. Additional steps are necessary to decrease risks of duodenoscope-transmitted infections.

Background and Aims The visual detection of early esophageal neoplasia (high-grade dysplasia and T1 cancer) in Barrett’s esophagus (BE) with white-light and virtual chromoendoscopy still remains challenging. The aim of this study was to assess whether a convolutional neural artificial intelligence network can aid in the recognition of early esophageal neoplasia in BE. Methods Nine hundred sixteen images from 65 patients were collected of histology-proven early esophageal neoplasia in BE containing high-grade dysplasia or T1 cancer. The area of neoplasia was masked using image annotation software. Nine hundred nineteen control images were collected of BE without high-grade dysplasia. A convolutional neural network (CNN) algorithm was pretrained on ImageNet and then fine-tuned with the goal to provide the correct binary classification of “dysplastic” or “nondysplastic.” We developed an object detection algorithm that drew localization boxes around regions classified as dysplasia. Results The CNN analyzed 458 test images (225 dysplasia/233 nondysplasia) and correctly detected early neoplasia with sensitivity of 96.4%, specificity of 94.2% and accuracy of 95.4%. With regard to the object detection algorithm for all images in the validation set, the system was able to achieve a mean-average-precision (mAP) of 0.7533 at an intersection over union (IOU) of 0.3 Conclusion In this pilot study, our AI model was able to detect early esophageal neoplasia in Barrett’s esophagus images with high accuracy. In addition, the object detection algorithm was able to draw a localization box around the areas of dysplasia with high precision and at a speed that allows for real-time implementation.

Background and Aims Propofol is increasingly being used for sedation in colonoscopy; however, its benefits over midazolam (+/- short-acting opioids) are not well quantified. The objective of this study was to compare safety, satisfaction, and efficiency outcomes of propofol versus midazolam (+/- short-acting opioids) in patients undergoing colonoscopy. Methods We systematically searched MEDLINE, Embase, and the Cochrane library (to July 30, 2018) for randomized controlled trials of colonoscopies performed with propofol versus midazolam (+/- short-acting opioids). We pooled odds ratios for cardiorespiratory outcomes using mixed-effects conditional logistic models. We pooled standardized mean differences (SMD) for patient and endoscopist satisfaction and efficiency outcomes using random-effects models. Results Nine studies of 1,427 patients met inclusion criteria. There were no significant differences in cardiorespiratory outcomes (hypotension, hypoxia, bradycardia) between sedative groups. Patient satisfaction was high in both groups, with most patients reporting willingness to undergo a future colonoscopy with the same sedative regimen. In meta-analysis, patients sedated with propofol had greater satisfaction than those sedated with midazolam (+/- short-acting opioids) (SMD, 0.54; 95% CI, 0.30-0.79); however, there was considerable heterogeneity. Procedure time was similar between groups (SMD, 0.15; 95% CI, 0.04-0.27). Recovery time was shorter in the propofol group (SMD, 0.41; 95% CI, 0.08-0.74). The median difference in recovery time was 3 minutes 6 seconds shorter in patients sedated with propofol. Conclusions Both propofol and midazolam (+/- short-acting opioids) result in high patient satisfaction and appear safe for use in colonoscopy. There are marginal benefits to propofol, including improvements in satisfaction and recovery time.

Background & Aims We assessed the preliminary diagnostic accuracy of a recently developed computer aided detection (CAD) system for detection of Barrett’s neoplasia during live endoscopic procedures. Methods The CAD system was tested during endoscopic procedures of 10 patients with nondysplastic Barrett’s esophagus (NDBE), and 10 patients with confirmed Barrett’s neoplasia. White-light endoscopy images were obtained at every 2-centimeter level of the Barrett’s segment, and immediately analyzed by the CAD system, providing instant feedback to the endoscopist. At every level, 3 images were evaluated by the CAD system. Outcome measures were as follows: (1) diagnostic performance of the CAD system per-level and per-patient, defined as accuracy, sensitivity, and specificity. Ground truth was established by expert assessment and corresponding histopathology; and (2) concordance of 3 sequential CAD predictions per-level. Results Accuracy, sensitivity, and specificity of the CAD system in a per-level analyses were 90%, 91%, and 89%, respectively. In total, 9 out of 10 neoplastic patients were correctly diagnosed. The single lesion not detected by CAD, showed NDBE in the endoscopic resection specimen. In only 1 NDBE patient, the CAD system produced false positive predictions. In 75% of all levels, the CAD system produced 3 concordant predictions. Conclusion This is one of the first studies to evaluate a CAD system for Barrett’s neoplasia during live endoscopic procedures. The system detected neoplasia with high accuracy, with only a small number of false-positive predictions, and with a high concordance rate between separate predictions. The CAD system is thereby ready for testing in larger, multicenter trials.

Background and Aims Metastasis to the gastrostomy site in patients with upper aerodigestive tract (UADT) malignancies is a rare but devastating adverse event that has been poorly described. Our aim was to determine the overall incidence and clinicopathological characteristics observed with development of gastrostomy site metastasis in patients with UADT cancers. Methods Systematic review and meta-analysis of 6,138 studies retrieved from MEDLINE, EMBASE, CINAHL, and the Cochrane Register after being queried for studies including gastrostomy site metastasis in patients with UADT malignancies. Results The final analysis included 121 studies. Pooled analysis showed overall event rate gastrostomy site metastasis to be 0.5% (95% CI, 0.4%-0.7%). Subgroup analysis showed an event rate of 0.56% (95% CI, 0.40%-0.79%) with the pull technique and 0.29% (95% CI, 0.15%-0.55%) with the push technique. Clinicopathological characteristics observed with gastrostomy site metastasis included: late stage disease (T3/T4) (57.8%), positive lymph node status (51.2%), and no evidence of systemic disease (M0) (62.8%) at initial presentation. Average time from gastrostomy placement to diagnosis of metastasis was 7.78 ± 4.9 months, average tumor size on detection was 4.65 (SD, 2.02) cm, and average length of survival was 7.26 (SD, 6.23) months. Conclusions Gastrostomy site metastasis is a rare, but serious adverse event that occurs at an overall rate of 0.5%, particularly in patients with advanced stage disease, and is observed with a very poor prognosis. These findings emphasize a need for clinical practice guidelines to include a regular assessment of the PEG site and highlight the importance of detection and management of gastrostomy site metastasis by the multidisciplinary care oncology team.

Background and Aims Endoscopic hand-suturing (EHS) provides secure intraluminal mucosal closure and should decrease the risk of adverse events after gastric endoscopic submucosal dissection (ESD). We prospectively investigated the feasibility and safety of EHS after gastric ESD, particularly for preventing post-ESD bleeding. Methods Patients scheduled for gastric ESD at 3 institutions were prospectively recruited. Just after ESD, the mucosal defect was closed by EHS. The primary outcome was endoscopic assessment of adequately sustained closure of the defect on postoperative day (POD) 3. Endoscopy was performed to assess maintenance of the closure for the primary outcome. During postoperative week 3 to 4, the patients were interviewed as outpatients about any occurrence of delayed bleeding. Results Data from 30 patients (15 each who did or did not take antithrombotic agents [ATAs]) were analyzed. Mucosal closure by EHS was completed in 29 of 30 cases (97%) and was well maintained on POD 3 in 25 cases (84%). Emergency endoscopy was required for major postoperative bleeding in 3 cases (10%), including the one in which suturing had been incomplete. Excluding one patient with a remnant stomach, the other 24 with sustained closure had no bleeding, regardless of whether they did or did not take ATAs (0/11 and 0/13, respectively). No serious adverse events occurred during EHS. Conclusions The results show that EHS is feasible and safe with favorable outcomes. Provided that mucosal suturing is successfully completed and sustained, post-ESD bleeding can be decreased even in patients undergoing antithrombotic therapy.

Background and aims Seronegative villous atrophy (SNVA), raised intraepithelial lymphocytes (IELs) and crypt hyperplasia on duodenal histology can be secondary to celiac disease (CD) or other causes such as medications or infections. Our aims were to assess the role of small-bowel capsule endoscopy (SBCE) in these patients and to ascertain whether findings on SBCE at diagnosis can predict disease outcome. Methods Patients (177) with SNVA, IELs +/-crypt hyperplasia on duodenal histology were studied. These patients all had an equivocal diagnosis of CD. Results Overall, 56 (31.6%) patients had a positive SBCE. Most patients had disease affecting the proximal third of the small bowel (SB) (33, 58.9%). The diagnostic yield of SBCE was 40.0% (22 patients), 51.4% (18 patients), 27.0% (10 patients), and 14.0% (7 patients) in patients with an unknown cause for SNVA (SNVA-UO), patients with SNVA who responded to a gluten-free diet (SNVA-CD), SNVA-KNOWN CAUSE, patients with railed intraepithelial lymphocytes +/- crypt hyperplasia respectively. In SNVA-UO, SBCE at diagnosis was more likely to be positive in patients with persistent SNVA (10, 90.9%) and persistent SNVA with lymphoproliferative features (4, 80.4%) than patients with spontaneous resolution of SNVA (8, 20.5%) (p=0.0001). All patients in the SNVA-CD group who eventually developed adverse events had a positive SBCE (p=0.022). They also had more extensive SB disease than those without adverse events (50% vs 1% p=0.002). More-extensive SB disease on SBCE correlated with a higher SNVA-related mortality in patients with SNVA-UO and SNVA-CD (p=0.019). Severity of histology did not correlate with mortality (p=0.793). Conclusions A positive SBCE at diagnosis predicts a worse outcome. More importantly, more extensive disease in these patients is associated with poor survival. Targeting patients with extensive disease at diagnosis with more aggressive therapy can help to improve prognosis.

Background And Aims Enteroscopy-assisted ERCP is challenging in patients with surgically altered upper gastrointestinal anatomy. This study evaluated a novel procedure, EUS-directed transenteric ERCP (EDEE), in de novo creation of enteroenteric (EE) anastomosis for the performance of ERCP in non-RYGB patients. Patients And Methods This was a multicenter retrospective study involving 7 centers between January 2014 and October 2018. Primary outcome was clinical success (completion of EDEE and ERCP with intended interventions). Secondary outcomes included technical success and rate/severity of adverse events (AEs). Results A total of 18 patients (mean age 63 years, 13 female) were included. The most common type of surgical anatomy was Whipple (10/18) and Roux-en-Y hepaticojejunostomy (RYHJ) (6/18). Technical success rate of EUS-guided lumen-apposing metal stent (LAMS) placement was 100%. Technical success rate of ERCP was 94.44% (17/18). A total of 14 patients underwent separate session EDEE with a median of 21 (IQR 11.5-36) days between the 2 procedures. Median total procedure time was 111 (IQR 81-192) minutes. Clinical success and AEs occurred in 17 (94.4%) and 1 (5.6%; abdominal pain) patients, respectively, during a median follow-up of 88 (IQR 54-142) days. Conclusion This study suggests that EDEE using LAMSs is feasible and safe in patients with non-RYGB surgical anatomy and complex pancreaticobiliary pathologies.

Background and Aims The impact of recurrent low-grade dysplasia (LGD) on the risk of advanced neoplasia (high-grade dysplasia and colorectal cancer) in inflammatory bowel disease (IBD) patients is unknown. In addition, it is unclear how a neoplasia-free period after index LGD impacts this risk. We aimed (1) to determine whether recurrent LGD is a risk factor for advanced neoplasia development and (2) to evaluate the impact of a neoplasia-free time period after initial LGD diagnosis on the advanced neoplasia risk. Methods This is a nationwide cohort study using data from the Dutch National Pathology Registry (PALGA) to identify all IBD patients with LGD and ≥1 follow-up colonoscopy between 1991 and 2010 in the Netherlands. Follow-up data were collected until January 2016. We compared the cumulative advanced neoplasia incidence between patients with and without recurrent LGD at first follow-up colonoscopy using log-rank analysis. We subsequently studied the impact of a neoplasia-free period after initial LGD on the advanced neoplasia incidence. Results We identified 4,284 IBD patients with colonic LGD with a median follow-up of 6.4 years. Recurrent low-grade dysplasia was a risk factor for advanced neoplasia (HR, 1.66; 95% CI, 1.22-2.25; p=0.001). A neoplasia-free period of >3 years after LGD protected against advanced neoplasia. Conclusions Recurrent LGD at follow-up colonoscopy after initial LGD was a risk factor for advanced neoplasia. A neoplasia-free period of >3 years after initial LGD was associated with a reduced subsequent risk of advanced neoplasia.

Background and Aims Endoscopic dilation (ED) is still the mainstay of therapeutic management of benign esophageal strictures (BES). This study aimed to establish risk factors for refractory BES and assess long-term clinical outcomes of ED. Methods We performed a retrospective study in 891 patients who underwent ED from 2003 to 2018 for BES. We searched electronic medical records in 6 tertiary care centers in the Netherlands for data on clinical outcome of ED. Median follow-up was 39 months. The primary endpoint was risk factors for refractory BES, defined as factors associated with an increased number of ED sessions during follow-up. Secondary endpoints included time from first to last ED session and adverse events. Results Dilation up to 13-15 mm was associated with a higher number of ED sessions than 16-18 mm (5.0 vs 4.1; hazard rate [HR]=1.4; p=0.001). Compared with peptic strictures, anastomotic (4.9 vs 3.6; HR=2.1; p<0.001), radiation (5.0 vs 3.6; HR=3.0; p<0.001), caustic (7.2 vs 3.6; HR=2.7; p<0.001) and postendotherapy (3.9 vs 3.6; HR=1.8; p=0.005) strictures were associated with a higher number of ED sessions. After 1 year of follow-up, the proportions of patients who remained free of ED was 75% in anastomotic, 71% in radiation, 70% in peptic, 83% in postendotherapy and 62% in caustic strictures. Esophageal perforation occurred in 23 (0.4%) ED sessions, in 22 (2.4%) patients. Conclusions More than 60% of patients with BES remain free of ED after 1 year of follow-up. Because dilation up to 16 to 18 mm diameter was associated with fewer ED sessions during follow-up, we suggest that clinicians should consider dilation up to at least 16 mm to reduce the number of ED sessions in these patients.

Background and Aims Argon plasma coagulation (APC) of the gastrojejunal anastomosis (GJA) is effective in treating weight regain after Roux-en-Y gastric bypass (RYGB). This study aims to compare efficacy of different APC settings at treating weight regain. Methods This was a single-center retrospective study of RYGB patients who underwent APC from 2014 to 2018 for weight regain. Patients receiving only low-dose APC (45-55 watts) or high-dose APC (70-80 watts) were compared. Primary outcome was the difference in percent total weight loss (%TWL) between groups at 6 and 12 months after the last treatment. Secondary outcomes were technical success, adverse events (AEs) and predictors of weight loss at 12 months. Results Two hundred seventeen patients met inclusion criteria and underwent 411 APC sessions. Of these, 116 (53.5%) patients underwent 267 low-dose APC (2.4±1.5 sessions/patient) and 101 (46.5%) patients underwent 144 high-dose APC (1.4±0.7 sessions/patient). Follow-up rates were 82.9% and 75.3% at 6 and 12 months. At 6 months, the low- and high-dose groups experienced 7.3±6.6% and 8.1±7.4% TWL, respectively (p=0.41). At 12 months, the low- and high-dose groups experienced 5.1±8.5% and 9.7±10.0% TWL, respectively (p=0.008). Technical success was 100%. The overall AE rate was 8.0%, with the most common one being GJA stenosis (4.6%). The GJA stenosis rate was similar between the low- and high-dose groups (3.0% vs 7.6%, p=0.06). High-dose APC remained a significant predictor of greater weight loss at 1 year after controlling for confounders. Conclusion APC is effective at treating weight regain after RYGB, with higher-watt APC being associated with greater weight loss.

Background and Aims Endoscopic recognition of early Barrett’s neoplasia is challenging. Blue-light imaging (BLI) and linked-color imaging (LCI) may assist endoscopists in appreciation of neoplasia. Our aim was to evaluate BLI and LCI for visualization of Barrett’s neoplasia in comparison with WLE alone, when assessed by nonexpert endoscopists. Methods In this web-based assessment, corresponding white-light endoscopy (WLE), BLI, and LCI images of 30 neoplastic Barrett’s lesions were delineated by 3 expert endoscopists to establish ground truth. These images were then scored and delineated by 76 nonexpert endoscopists from 3 countries and with different levels of expertise, in 4 separate assessment phases with a washout period of 2 weeks. Assessments were as follows: Assessment 1: WLE only; Assessment 2: WLE+BLI; Assessment 3: WLE+LCI; Assessment 4: WLE+BLI+LCI. The outcomes were (1) appreciation of macroscopic appearance and ability to delineate lesions (VAS-scores); (2) preferred technique (ordinal scores); and (3) assessors’ delineation performance in terms of overlap with expert ground truth. Results Median VAS scores for phases 2 to 4 were significantly higher than in phase 1 (P < 0.001). Assessors preferred BLI and LCI over WLE for appreciation of macroscopic appearance (P < 0.001) and delineation (P < 0.001). Linear mixed-effect models showed that delineation performance increased significantly in phase 4. Conclusions The use of BLI and LCI has significant additional value for the visualization of Barrett’s neoplasia, when used by nonexpert endoscopists. Assessors appreciated the addition of BLI and LCI better than the use of WLE alone. This addition furthermore led to improved delineation performance, thereby allowing for better targeted biopsy acquisition.

Background and Aims For rectal neuroendocrine tumors (NETs) with size ≤10 mm, endoscopic resection is the first choice of treatment. However, because rectal NETs usually invade the submucosal layer, achieving R0 resection is difficult. Endoscopic submucosal dissection (ESD) has a high R0 resection rate, and underwater endoscopic mucosal resection (UEMR) was recently introduced to secure a negative resection margin easily and safely. The aim of this study was to evaluate the efficacy and safety of UEMR versus ESD for rectal NETs ≤10 mm in size. Methods This retrospective observational study enrolled 115 patients with rectal NETs sized ≤10 mm who underwent ESD or UEMR between January 2015 and July 2019 at the National Cancer Center, Korea. The differences in R0 resection rate, adverse event rate, and procedure time between the ESD and UEMR groups were evaluated. Results Of the included 115 patients, 36 underwent UEMR and 79 underwent ESD. R0 resection rate was not different between the UEMR and ESD groups (UEMR vs ESD, 86.1% vs 86.1%, p=0.996). Procedure time was significantly shorter with UEMR (UEMR vs ESD, 5.8 ± 2.9 vs 26.6 ±13.4 minutes, p< 0.001). Two patients (2.5%, 2/79) and none experienced adverse events in the ESD and UEMR groups, respectively; however, this difference was not statistically significant. Conclusion UEMR is a safe and effective technique that should be considered when removing small rectal NETs. Further studies are warranted to define its role when compared with ESD.

Background and Aims Prediction models for esophageal squamous cell carcinoma are not common, and no model, which targets a clinical population, has previously been developed and validated. We aimed to develop a prediction model for estimating the risk of high-grade esophageal lesions for application in clinical settings, and to validate the performance of this model in an external population. Methods This model was developed based on results of endoscopic evaluation of 5,624 outpatients in one hospital in a high-risk region in northern China, and was validated using 5,765 outpatients who had undergone endoscopy in another hospital in a non-high-risk region in southern China. Predictors were selected with unconditional logistic regression analysis. The Akaike information criterion was used to determine the final model structure. Discrimination was estimated using the area under the receiver operating characteristic curve (AUC). Calibration was assessed using a calibration plot with an intercept and slope. Results The final prediction model contained 5 variables, including age, smoking, BMI, dysphagia, and retrosternal pain. This model generated an AUC of 0.871 (95%CI, 0.842-0.946) in the development set, with an AUC of 0.862 after bootstrapping. The 5-variable model was superior to a single age model. In the validation population, the AUC was 0.843 (95% CI, 0.793-0.894). This model successfully stratified the clinical population into 3 risk groups and showed high ability for identifying concentrated groups of cases. Conclusions Our model for esophageal high-grade lesions has a high predictive value. It has the potential for application in clinical opportunistic screening to aid decision-making for both healthcare professionals and individuals.

Background and Aims Residual or recurrent adenoma (RRA) is the major limitation of piecemeal endoscopic mucosal resection (p-EMR) for large colonic laterally spreading lesions (LSLs) ≥20 mm. En bloc EMR (e-EMR) has been shown to achieve low rates of RRA but specific procedural and long-term outcomes are unknown. Our aim was to compare long-term outcomes of size-matched LSLs stratified by whether they were resected e-EMR or p-EMR. Methods Data from a prospective tertiary referral multicenter cohort of large LSLs referred for EMR over a 10-year period were analyzed. Outcomes were compared between sized-matched LSLs (20-25 mm) resected by p-EMR or e-EMR. Results Five hundred seventy LSLs met the inclusion criteria of which 259 (45.4%) were resected by e-EMR. The risk of major deep mural injury (DMI) was significantly higher in the e-EMR group (3.5% vs 1.0%, p=0.05), whereas rates of other intraprocedural adverse events did not differ significantly. Five out of 9 (56%) LSLs, with endoscopic features of submucosal invasion (SMI), resected by e-EMR were saved from surgery. RRA at first surveillance was lower in the e-EMR group (2.0% vs 5.7%, p=0.04) but this difference was negated at subsequent surveillance. Rates of surgical referral were not significantly different between the groups at either surveillance interval. Conclusion In a large prospective multicentre cohort when comparing e-EMR against p-EMR for lesions ≤25 mm in size of similar morphology, e-EMR offered no additional advantage for predicted-benign LSLs. It was however associated with an increased risk of major DMI. Thus, en bloc resection techniques should be reserved for lesions suspicious for invasive disease.

Background and Aims Capsule endoscopy (CE) is an established, noninvasive modality for examining the small bowel. Minimum training requirements are primarily based on guidelines and expert opinion. A validated assessment tool of CE competence is lacking. In this prospective, multicenter study we determined the minimum number of CE procedures required to achieve competence during gastroenterology fellowship; validated a capsule competency test (CapCT); and evaluated any correlation between CE competence and endoscopy experience. Methods We included second- and third-year gastroenterology fellows from 3 institutions between 2013 and 2018 to participate in a structured CE training program with supervised CE interpretation. Fellows completed the CapCT with a maximal score of 100. For comparison, expert faculty completed the same CapCT. Trainee competence was defined as a score >90% compared with the mean expert score. Fellows were tested after 15, 25, and 35 supervised CE interpretations. CapCT was validated using expert consensus and item analysis. Data were collected on number of prior endoscopies. Results A total of 68 trainees completed 102 CapCTs. Fourteen CE experts completed the CapCT with a mean score of 94. Mean scores for fellows after 15, 25, and 35 cases were 83, 86, and 87, respectively. Fellows with at least 25 interpretations achieved a mean score >84 in all 3 institutions. CapCT item analysis showed high interobserver agreement among expert faculty (k=0.85). There was no correlation between scores and number of endoscopies performed. Conclusion After a structured CE training program, gastroenterology fellows should complete a minimum of 25 supervised CE interpretations before assessing competence using the validated CapCT, regardless of endoscopy experience.

Background and Aims EUS-guided microforceps biopsy (MFB) and needle-based confocal laser endomicroscopy (nCLE) are emerging diagnostic tools for pancreatic cystic lesions (PCLs). There is a paucity of data regarding their performance and impact. The aim of this study was to compare diagnostic outcomes and changes in clinical management resulting from MFB and nCLE use in PCLs. Methods Single-center retrospective study of patients with PCLs who underwent combined EUS-guided FNA, MFB, and nCLE. Primary outcomes included diagnostic yield (specific PCL type) and change in clinical management for each modality compared with the current "composite standard" (CS) obtained by combining clinical, morphologic, cyst fluid cytology, and chemical analysis. Results A total of 44 cysts were studied in 44 patients. Technical success: EUS-FNA 100%, MFB 88.6%, nCLE 97.7%. Adverse events: 1 out of 44 (2.3%, one infected pseudocyst). Diagnostic yield for each individual modality: CS 34.1%, MFB 75.0% (p<0.05 vs CS), nCLE, 84.1% (p<0.05 vs CS). Diagnostic yield for combined tests: CS/MFB 79.5%, CS/nCLE, 88.6%, CS/MFB/nCLE, 93.2% (p=NS). Compared with the CS, the use of MFB, nCLE, and their combination, led to overall change in clinical management in 38.6%, 43.2%, and 52.3% of cases. MFB and nCLE led to an overall increase in discontinuation of surveillance (MFB 34.1% p<0.05, nCLE 31.8%, p<0.05), led by a reduction in the indication for follow-up radiologic or endoscopic studies (MFB 34.1%, p<0.05, nCLE 38.6%, p<0.05). Based on MFB and nCLE, 2 out of 28 (7.1%) and 3 out of 28 (10.7%) patients who would have undergone further surveillance were referred for surgery. Conclusion In the evaluation of PCLs, the use of combined EUS-guided FNA, MFB and nCLE is safe. MFB and nCLE lead to significant improvements in specific PCL diagnosis, which in turn has major impact in clinical management.

Background and Aims The endoscopic management of malignant hilar biliary obstruction (MHBO) remains extremely challenging without a universal consensus. We compared, for the first time, 4 major modalities aiming to determine the optimal strategy. Methods We reviewed 1239 patients with advanced MHBO who underwent endoscopic stent placement as the primary treatment in 4 tertiary centers. Among them, 633 eligible patients were identified and classified into 4 groups: bilateral metal stent placement (BMS), unilateral metal stent placement (UMS), bilateral plastic stent placement (BPS), and unilateral plastic stent placement (UPS). The outcomes were compared before and after propensity score matching (PSM). Results After PSM, 87, 97, 91, and 81 patients in the BMS, UMS, BPS, and UPS groups, respectively, were matched. The clinical success rates were 98.9%, 83.5%, 71.4%, and 65.4% in the BMS, UMS, BPS, and UPS groups (p<0.001), respectively. The postprocedural cholangitis rates were 8.0%, 17.5%, 26.4%, and 29.6% (p=0.002), respectively. The median symptom-free stent patency was 9.6, 6.8, 4.6, and 4.2 months (p<0.001), respectively. The mean total interventions required was 1.2±0.5, 1.7±0.8, 2.0±1.4, and 1.9±1.3 (p<0.001), respectively. The median (95% confidence interval) overall survival (OS) was 7.1 (6.0-8.2), 4.4 (3.8-4.9), 4.1 (2.9-5.2), and 2.7 (1.8-3.7) months (p=0.001), respectively. Compared with plastic stent placement, metal stent placement achieved higher success in all outcome parameters (p≤0.001). Bilateral stent placement was superior to unilateral stent placement in terms of clinical success (p=0.024), stent patency (p=0.018), and OS (p=0.040). Conclusions If technically possible, dual metal stent placement could be a preferred palliation for inoperable MHBO, and unilateral metal stent placement be the second option.

Background and Aims Colorectal polyps are often detected during insertion phase of colonoscopy, but they are commonly removed during withdrawal phase. We aimed to investigate the clinical advantages of instant removal of colorectal polyps during insertion phase to determine the appropriate strategy for polyps detected upon insertion. Methods This prospective multicenter randomized trial targeted patients with at least one left-sided polyp <10 mm in size detected unintentionally upon endoscope insertion from April 2018 to March 2019. Patients were allocated to the following 2 groups: the Study group consisted of patients who had polyp removal instantly upon insertion, and the Control group comprised patients who had the endoscope inserted to the cecum first and the polyps were removed subsequently upon withdrawal. Carbon dioxide gas insufflation and cold polypectomy were applied to minimize the influences of polypectomy on endoscope insertion. Twenty advanced endoscopists from 7 community-based institutions participated in this trial. Results Out of 1451 patients enrolled, 220 patients were eligible for full assessment. Mean total procedure time was significantly shorter in the study group (18.9 vs 22.3 min, p<0.001). Mean pure cecal intubation time and number of polyps per patient were similar between the 2 groups. In the control group, among 107 polyps found during insertion, 48 polyps (45.8%) required reinspection, and 7 (6.5%) polyps were completely missed with an average reinspection time of approximately 3 minutes. Conclusion Polypectomy during the insertion phase in the colon and rectum significantly shortens the total procedure time and eliminates all missed polyps without experiencing any disadvantages.

Background and Aims Food impactions are a common reason for emergent upper endoscopy. Current guidelines call for urgent upper endoscopy (within 24 hours) for food impactions without complete esophageal obstruction and emergent endoscopy (within 6 hours) for those with complete esophageal obstruction. Multiple adverse events can arise from esophageal foreign bodies. Cases with longer delays from symptom onset to presentation have been associated with higher rates of surgical intervention. However, data on esophageal soft food impactions are scant. We set out to determine differences in outcomes for food impactions intervened on within 12 hours versus over 12 hours of symptom onset. Methods A retrospective review of medical records was conducted to identify patients who presented to our hospital with an esophageal soft food impaction and underwent an esophagogastroduodenoscopy (EGD) between January 2010 and January 2018. Patients were divided into 2 groups based on the timing from symptom onset to EGD. An EGD within 12 hours was considered an early intervention and over 12 hours was considered a delayed intervention. Patients who had ingested bones or hard objects were not included. Primary outcomes studied were rates of aspiration, admission, local esophageal adverse events, and 30-day all-cause mortality. Results We identified 110 patients with a soft food impaction who underwent an EGD. Forty- two patients had an early intervention and 68 a delayed intervention. There were no differences in basic demographics and comorbidities. Additionally, it was found that there were no differences in rates of local esophageal adverse events, aspiration, admission, or 30-day mortality. Multivariate analysis revealed endoscopic accessory use was associated with increased odds of local esophageal adverse events (OR = 6.37; p=0.01). Conclusion The overall rates of serious adverse events in esophageal soft food impactions is low. Delayed intervention is not associated with increased adverse events or 30-day mortality compared with early intervention. However, accessory use is associated with higher adverse event rates.

Background and Aims Treatment of large esophageal neoplasia is gradually evolving from piecemeal to en bloc resections. Endoscopic submucosal dissection (ESD) is known to achieve more complete resections than piecemeal endoscopic mucosal resection (EMR) for large lesions, yet it remains underused in the West due to technical and safety concerns with traditional electrosurgical knives. We aimed to evaluate a novel endoscopic articulating knife (ESD-AR) to determine its safety and efficacy for large esophageal neoplasms in comparison with EMR. Method We retrospectively studied clinically indicated cases of ESD-AR and EMR for esophageal lesions that were 15 mm or greater. All EMR cases had at least 3 simultaneous EMRs to adequately compare resection area. Rates of perforation, gastrointestinal bleeding, technical performance, and pre- and postendoscopic resection diagnoses were evaluated. Results A total of 72 ESD-AR and 72 widespread EMR cases were evaluated for the following indications: Barrett’s esophagus (56%), adenocarcinoma (36%), squamous nodularity (2%), and squamous cell carcinoma (6%). There were no statistical differences in age, sex, Barrett’s esophagus length, and lesion or resection size between the 2 groups. No perforations occurred. Two adverse events were recorded with ESD-AR and none occurred with EMR (3% vs 0%, P=0.50); these were associated with anticoagulation use (P=0.04) and greater resection area (P=0.02). There were more upgraded diagnoses post-ESD versus EMR (27% vs 12%, P=0.05). Conclusion ESD performed with an articulating knife by an experienced endoscopist has a comparable safety profile to widespread EMR for large esophageal neoplasia and may have advantages for diagnostic staging.

Background and Aims Linked color imaging (LCI) is a newly available image-enhanced endoscopy (IEE) system that emphasizes the red mucosal color. No study has yet compared LCI with other available IEE systems. Our aim was to investigate polyp detection rates using LCI compared with narrow-band imaging (NBI). Methods This is a prospective randomized tandem colonoscopy study. Eligible patients who underwent colonoscopy for symptoms or screening/surveillance were randomized in a 1:1 ratio to receive tandem colonoscopy with both colonoscope withdrawals using LCI or NBI. The primary outcome was the polyp detection rate. Results Two hundred seventy-two patients were randomized (mean age, 62 years; 48.2% male; colonoscopy for symptoms, 72.8%) with 136 in each arm. During the first colonoscopy, the polyp detection rate (71.3% vs 55.9%; P = .008), serrated lesion detection rate (34.6% vs 22.1%; P = .02), and mean number of polyps detected (2.04 vs 1.35; P = .02) were significantly higher in the NBI group than in the LCI group. There was also a trend of higher adenoma detection rate in the NBI group compared with the LCI group (51.5% vs 39.7%, respectively; P = .05). Multivariable analysis confirmed that use of NBI (adjusted odds ratio, 1.99; 95% confidence interval, 1.09-3.68) and withdrawal time >8 minutes (adjusted odds ratio, 5.11; 95% confidence interval, 2.79-9.67) were associated with polyp detection. Overall, 20.5% of polyps and 18.1% of adenomas were missed by the first colonoscopy, but there was no significant difference in the miss rates between the 2 groups. Conclusion NBI was significantly better than LCI for colorectal polyp detection. However, both LCI and NBI missed 20.5% of polyps. (Clinical trial registration number: NCT03336359.)

Background and Aims Devices for flattening colon folds can improve polyp detection at colonoscopy. However, there are few data on the endoscopic ring-fitted cap (EndoRings; EndoAid, Caesarea, Israel). We sought to compare adenoma detection with EndoRings with that of standard high-definition colonoscopy. Methods This was a single-center, randomized controlled trial of 562 patients (284 randomized to EndoRings and 278 to standard colonoscopy) at 2 outpatient endoscopy units in the Indiana University Hospital system. Adenoma detection was the primary outcome measured as adenoma detection rate (ADR) and adenomas per colonoscopy (APC). We also compared sessile serrated polyp detection rate, insertion times, withdrawal times, and ease of passage through the sigmoid colon. Results EndoRings was superior to standard colonoscopy in terms of APC (1.46 vs 1.06, P = .025), but there were no statistically significant differences in ADR or sessile serrated polyp detection rate. Mean withdrawal time (in patients with no polyps) was shorter and insertion time (all patients) was longer in the EndoRings arm by 1.8 minutes and 0.75 minutes, respectively. One provider had significantly higher detection with Endo-Rings and contributed substantially to the overall results. Conclusions EndoRings can increase adenoma detection without a significant increase in procedure time, but the effect varies between operators. The use of EndoRings slows colonoscope insertion. (Clinical trial registration number: NCT03418662.)

Achalasia is a primary esophageal motor disorder of unknown etiology characterized by degeneration of the myenteric plexus, which results in impaired relaxation of the esophagogastric junction (EGJ), along with the loss of organized peristalsis in the esophageal body. The criterion standard for diagnosing achalasia is high-resolution esophageal manometry showing incomplete relaxation of the EGJ coupled with the absence of organized peristalsis. Three achalasia subtypes have been defined based on high-resolution manometry findings in the esophageal body. Treatment of patients with achalasia has evolved in recent years with the introduction of peroral endoscopic myotomy. Other treatment options include botulinum toxin injection, pneumatic dilation, and Heller myotomy. This American Society for Gastrointestinal Endoscopy Standards of Practice Guideline provides evidence-based recommendations for the treatment of achalasia, based on an updated assessment of the individual and comparative effectiveness, adverse effects, and cost of the 4 aforementioned achalasia therapies.

Background and Aims Adenoma miss rate during colonoscopy is directly linked to risk of postcolonoscopy colorectal cancer. One of the reasons for missed adenomas is poor visualization of proximal folds during standard colonoscopy withdrawal. Disposable distal attachments such as the plastic cap and Endocuff that hold back folds appear to improve adenoma detection. Primary aim of this study was to compare adenoma detection rates between Endocuff-assisted colonoscopy (EAC) and cap-assisted colonoscopy (CAC). Methods This is a randomized, single-center, tandem colonoscopy trial performed by the same endoscopists, on the same day, first with Endocuff Vision followed by cap or vice-versa. All procedures were performed by 3 experienced gastroenterology fellows. Results A total of 154 patients were recruited. Seventy-eight (50.6%) had CAC as their first procedure. Mean patient age was 61 years (male: female 1:1). Polyp miss rate was significantly lower in EAC (8.4%) compared with CAC (26.1%, p<0.001) as was adenoma miss rate (EAC vs CAC, 6%, vs 19%, p=0.002) and diminutive adenoma (<5 mm) miss rate EAC group (1.8% vs 19.6%, p<0.001). However, there was no significant differences in the miss rates for small (5-9 mm) (3.7% vs 2.9%, p=0.69) or adenomas 10 mm or larger (1.6% vs 2.6%, p=0.98 ). The mean number of adenomas per procedure was significantly higher in the EAC compared with CAC (1.5 vs 0.8, p<0.001). Cecal intubation time was significantly shorter in EAC than CAC (median 6 vs 7 mins, p=0.01) Conversely, withdrawal time (median 10 vs 8 mins, p=0.01) was significantly longer in EAC. Conclusions This randomized, tandem study demonstrates that EAC has a significantly higher adenoma detection rate and lower adenoma miss rate than CAC. Although insertion times were shorter with EAC, procedures were slightly more uncomfortable, and the cuff had to be removed in a small number of cases.

Background and Aims Transoral outlet reduction (TORe) is a common endoscopic treatment for patients with weight regain after Roux-en-Y gastric bypass (RYGB) with a dilated gastrojejunal anastomosis (GJA). This study aims to assess long-term efficacy of TORe. Methods This was a retrospective review of prospectively collected data on RYGB patients who underwent TORe for weight regain or inadequate weight loss. The primary outcome was efficacy of TORe at 1, 3, and 5 years. Secondary outcomes were procedure details, safety profile, and predictors of long-term weight loss after TORe. Results A total of 331 RYGB patients underwent 342 TORe procedures and met inclusion criteria. Of these, 331, 258, and 123 patients were eligible for 1-, 3- and 5-year follow-ups, respectively. Mean body mass index (BMI) was 40 ± 9 kg/m2. Pre-TORe GJA size was 23.4 ± 6.0 mm, which decreased to 8.4 ± 1.6 mm after TORe. Patients experienced 8.5 ± 8.5%, 6.9 ± 10.1%, and 8.8 ± 12.5% total weight loss (TWL) at 1, 3, and 5 years with follow-up rates of 83.3%, 81.8%, and 82.9%, respectively. Of 342 TORe procedures, 76%, 17.5%, 4.4%, and 2.1% were performed using single pursestring, interrupted, double-pursestring, and running suture patterns, respectively, with an average of 9 ± 4 stitches per GJA. Pouch reinforcement suturing was performed in 57.3%, with an average of 3 ± 2 stitches per pouch. There were no severe adverse events. A total of 39.3% had additional weight loss therapy (pharmacotherapy or procedure), with 3.6% getting repeat TORe. Amount of weight loss at 1 year (β=0.43, p=0.01) and an additional endoscopic weight loss procedure (β=8.52, p=0.01) were predictors of %TWL at 5 years. Conclusions TORe appears to be safe, effective, and durable at treating weight regain after RYGB.

Background and Aims Gastroparesis (GP) is a chronic debilitating condition. Prior pyloric-targeted procedures are either invasive or have questionable efficacy. Gastric peroral pyloromyotomy(G-POEM) has been proposed as a minimally invasive approach. We performed a pooled-analysis to evaluate the efficacy and safety of G-POEM for GP. Methods Electronic databases(Medline, Scopus, EMBASE) were searched up to January 2019. Studies including patients who underwent G-POEM for GP were eligible. Procedural, clinical and safety outcomes were assessed pooling data by means of a random- or fixed-effect model according to the degree of heterogeneity to obtain a proportion with a 95% confidence interval(CI). Results Ten studies were eligible for inclusion (292 patients), 2/10 being prospective. Seven studies were performed in the United States, 2 in France and 1 in China. The endoscopic pyloromyotomy was feasible in all the patients. Significant symptomatic improvement was achieved after 83.9% of the procedures (mean follow-up period:7.8±5.5 months). When comparing the mean values of pre- and postprocedural scintigraphic evolution, there was a significant decreasing of the residual percentage at 2 and 4 hours. The overall adverse events rate was 6.8%. Discussion G-POEM appears as a promising approach for GP in terms of safety and efficacy outcomes in the short term.

Colonic volvulus and acute colonic pseudo-obstruction (ACPO) are 2 causes of benign large-bowel obstruction. Colonic volvulus occurs most commonly in the sigmoid colon as a result of bowel twisting along its mesenteric axis. In contrast, the exact pathophysiology of ACPO is poorly understood, with the prevailing hypothesis being altered regulation of colonic function by the autonomic nervous system resulting in colonic distention in the absence of mechanical blockage. Prompt diagnosis and intervention leads to improved outcomes for both diagnoses. Endoscopy may play a role in the evaluation and management of both entities. The purpose of this document from the American Society for Gastrointestinal Endoscopy’s Standards of Practice Committee is to provide an update on the evaluation and endoscopic management of sigmoid volvulus and ACPO.

Endoscopic assessment is currently the criterion standard for the diagnosis and assessment of mucosal disease activity, prognosis and monitoring for dysplasia and the assessment of response to therapy. Wider appreciation of the potential disconnect between symptoms and objective measures of disease activity and evidence that uncontrolled inflammation may lead to progressive intestinal injury and irreversible bowel damage with adverse events, has led to the concept of “treating to target.” ”Treating to target” is defined as treating patients with high risk for disease progression early to prevent or limit intestinal injury or disability. Endoscopic remission (mucosal healing) has emerged as a key goal of therapy. Although there are no currently validated definitions of endoscopic mucosal remission, the use of endoscopic scoring systems add uniformity, objectivity and aid standardization with reporting of mucosal appearances, augmenting clinical decision-making. A plethora of scoring systems exist to define activity, response and remission in both Crohn’s disease and ulcerative colitis. In this review, we discuss the most commonly used endoscopic scoring systems, proposed definitions of response and remission and discuss how they can be integrated into a treat-to target approach to optimize patient outcomes.

Background and Aims In children with eosinophilic oesophagitis (EoE), the relationship among Endoscopic Reference Score (EREFS), Histology Scoring System (EoEHSS), and peak eosinophil count (PEC) is incompletely described. Our aim was to determine the relationship among EREFS, EoEHSS, and PEC, and develop a predictive model using components of EREFS and EoEHSS for EoE activity. Methods We analyzed 189 paired EREFS, EoEHSS, and PEC. Active EoE (aEoE; n=98) was defined as ≥15 eos/hpf, and inactive EoE (iEoE; n=91) as <15 eos/hpf. Spearman correlation (r) with Bonferroni correction was used to assess the relationship between EREFS, EoEHSS and PEC, and a back-transformed average Fisher test to determine the statistical significance of the differences. Reciever operating characteristic analysis was used to develop the predictive model. Results The relationship between total EREFS and EoEHSS was modest (r= 0.61) but significantly stronger than the correlation between total EREFS and PEC (r=0.55; P=0.04). The relationship between total EREFS and EoEHSS tended to be stronger in aEoE compared with iEoE (r: 0.41 vs 0.24; P=0.09). Compared with EREFS, EoEHSS had a significantly higher area under the curve (AUC, 0.78 vs 0.92; P=0.04) to predict aEoE. A combination of furrows, eosinophilic inflammation, basal cell hyperplasia, eosinophilic abscess, and dilated intercellular spaces had an AUC of 0.97, accuracy of 98%, sensitivity of 97% and specificity of 98% to predict aEoE. Conclusions Endoscopy score modestly correlates with histologic scoring system. As such, endoscopy score is not a reliable marker of tissue involvement in EoE. A panel of individual endoscopic and histologic signs hold promise to accurately predict EoE activity.

Background and Aims Gastric stenosis is a rare but potentially serious adverse event after sleeve gastrectomy. Despite current suboptimal treatments, endoscopic balloon dilatation (EBD) has emerged as a safe and efficacious approach. The purpose of this study is to assess the overall success of EBD for sleeve gastrectomy stenosis (SGS) as first-line therapy. Methods MEDLINE, Embase, Web of Science, Google Scholar, and Cochrane Database were searched from inception to July 2018, whereas OPUS, LILACS, BVS, CINAHL were not searched. The primary outcome was defined as overall success rate of clinical resolution of SGS obstructive symptoms with EBD, expressed as pooled event rate and 95% confidence interval (95% CI). The secondary predefined outcomes include EBD success rates for SGS in proximal (cardia) location or mid-distal location (antrum/incisura), in early SGS (up to 3 months after LSG) and late SGS (3 months or longer after LSG), and success rate of cases requiring stents or salvage surgery. Results Eighteen studies encompassing 426 patients were analyzed. The average age and BMI were 41.7 and 40.1, respectively, and average number of dilations for all cases was 1.8 per person. Overall EBD success rate was 76% (95% CI, 0.67-0.86). EBD success rates were as follows: proximal SGS was 90% (95% CI, 63%-98%); distal SGS was 70% (95% CI, 47%-86%); early SGS within 3 months was 59% (95% CI, 34%-79%); and late SGS after 3 months was 61% (95% CI, 41%-78%). Seventeen percent of patients underwent secondary salvage surgery, with a success rate of 91% (95% CI, 80%-96%). Conclusion EBS appears to be a safe and effective minimally invasive alternative to surgical revision and should be used as first-line therapy for SGS

Background and Aims Post-ESD coagulation syndrome (PECS) occasionally occurs after colorectal endoscopic submucosal dissection (ESD), presenting with localized abdominal pain and inflammation. We conducted a randomized controlled trial (RCT) to assess the usefulness of endoscopic clipping closure to prevent PECS and delayed perforation (PECS/DP). Methods This is a multicenter, single-blind RCT. Prospectively enrolled patients undergoing colorectal ESD were randomly allocated to endoscopic clipping closure and nonclosure after ESD, stratifying by institution and tumor size. All participants received computed tomography scan after ESD. PECS was defined as visual analogue scale (VAS) ≥30 mm, a raise of VAS ≥20 mm from baseline, body temperature ≥37.5ºC or white blood cells ≥10,000/μL after colorectal ESD. DP was defined as PECS accompanied by extraluminal air. The pre-planned sample size was 320 patients, and the primary endpoint was the rate of PECS/DP. Results At the planned interim analysis, this trial was terminated by recommendation of the independent data and safety monitoring committee because conditional power with superiority was lower than the preplanned futility limit. Finally, 155 patients were analyzed. PECS/DP’s rate was 16 (95 % confidence interval [CI], 8%-23%) in the nonclosure and 24 (95% CI, 14%-34%) in the closure groups, respectively (P = 0.184). All DP cases were within minor criteria, and all PECS/DP patients were conservatively managed without surgical treatment. Simple periluminal air without PECS was observed in 16 (95 % CI, 8%-23%) of the nonclosure and 10 (95% CI, 3%-17%) of the closure groups. Conclusion Endoscopic clipping closure could not reduce the high incidence of PECS/DP after colorectal ESD.

Background and Aims The quality of bowel preparation is an important factor that can affect the effectiveness of a colonoscopy. Several tools, such as the Boston Bowel Preparation Scale (BBPS) and Ottawa Bowel Preparation Scale, have been developed to evaluate bowel preparation. However, understanding the differences between evaluation methods and consistently applying them can be challenging for endoscopists. There are also subjective biases and differences among endoscopists. Therefore, this study aimed to develop a novel, objective, and stable method for the assessment of bowel preparation through artificial intelligence. Methods We used a deep convolutional neural network to develop this novel system. First, we retrospectively collected colonoscopy images to train the system and then compared its performance with endoscopists via a human-machine contest. Then, we applied this model to colonoscopy videos and developed a system named ENDOANGEL to provide bowel preparation scores every 30 seconds and to show the cumulative ratio of frames for each score during the withdrawal phase of the colonoscopy. Results ENDOANGEL achieved 93.33% accuracy in the human-machine contest with 120 images, which was better than that of all endoscopists. Moreover, ENDOANGEL achieved 80.00% accuracy among 100 images with bubbles. In 20 colonoscopy videos, the accuracy was 89.04%, and ENDOANGEL continuously showed the accumulated percentage of the images for different BBPS scores during the withdrawal phase and prompted us for bowel preparation scores every 30 seconds. Conclusions We provided a novel and more accurate evaluation method for bowel preparation and developed an objective and stable system—ENDOANGEL—that could be applied reliably and steadily in clinical settings.

Background and Aims Lugol chromoendoscopy facilitates the endoscopic visualization of esophageal dysplasia and carcinoma. Vitamin C solution (VCS) can theoretically neutralize free iodine, which causes mucosal irritation. The aim was to assess the safety and efficacy of VCS for relieving adverse symptoms caused by Lugol iodine staining. Methods Two hundred forty eligible subjects were randomized to receive 20 mL of normal saline solution (NS), 5% sodium thiosulfate solution (STS), or 2% VCS after spraying 10 mL of 2% Lugol iodine solution on the mid-distal esophagus. The primary endpoints were statistically significant reductions in the acute and late adverse symptom severity scores. The secondary endpoint was the discoloration effect on esophageal brown iodine-stained mucosa. Results Spraying both VCS and STS similarly decreased the severity scores of the acute (NS vs VCS = 2.58 vs 1.61, P = 0.040; VCS vs STS = 1.61 vs 1.89, P > 0.999) and late (NS vs VCS = 1.70 vs 0.91, P = 0.002; VCS vs STS = 0.91 vs 1.38; P = 0.212) adverse symptoms after Lugol chromoendoscopy compared with spraying NS. Compared with STS spray, VCS spray remarkably alleviated acute acid regurgitation or heartburn (33% vs 15%, P = 0.017) and late retrosternal discomfort or pain (21% vs 9%, P = 0.027). Moreover, compared with spraying NS, spraying VCS quickly discolored the iodine-stained mucosa, with a better decolorization score (2.26 vs 3.56, P = 0.000), and the effects of fading iodine dye were similar between VCS and STS (3.56 vs 3.59, P = 0.908). Conclusions VCS can reduce the mucosal irritation symptoms induced by Lugol chromoendoscopy and can be routinely recommended.

Background and Aims Accurate diagnosis of indeterminate biliary strictures is challenging but important for patient prognostication and further management. Biopsy under direct cholangioscopic vision might be superior to standard ERCP techniques such as brushing or biopsy. Our aim was to investigate whether digital single-operator cholangioscopy (DSOC) compared with standard ERCP work-up improves the diagnostic yield in patients with indeterminate biliary strictures. Methods Patients with an indeterminate biliary stricture on the basis of MRCP were randomized to standard ERCP visualization with tissue brushing (Control Arm [CA]) or DSOC visualization and DSOC-guided biopsy (Study Arm [SA]). This was a prospective international multicenter trial with a procedure-blinded pathologist. Results First sample sensitivity of DSOC-guided biopsies was significantly higher than ERCP-guided brushing (SA 68.2% vs CA 21.4%, P<0.01). The sensitivity of visualization (SA 95.5% vs CA 66.7%; P=0.02) and overall accuracy (SA 87.1% vs CA 65.5%, P=0.05) were significantly higher in the SA compared with the CA whereas specificity, positive predictive value, and negative predictive value showed no significant difference. Adverse events were equally low in both arms. Conclusions DSOC-guided biopsies were shown to be safe and effective with a higher sensitivity compared with standard ERCP techniques in the visual and histopathological diagnosis of indeterminate biliary strictures.

Background and Aims Recent increases in colorectal cancer (CRC) incidence in adults less than 50 years of age have led to more colonoscopies in this age group. As a result, there may be an increasing number of adults <50 with polyps detected. There is concern that younger adults may require closer follow-up. Our goal was to use data from the New Hampshire Colonoscopy Registry (NHCR) to examine the risk for metachronous advanced adenomas and large (>1cm) serrated polyps in younger versus older adults who return for a follow-up colonoscopy. Methods Our cohort consisted of NHCR participants with at least one polyp on index examination and a follow-up colonoscopy at least 1 year after the index examination. Outcomes were the risks for metachronous advanced adenomas (AA: adenomas >1cm, with villous elements or high-grade dysplasia, or CRC) and large (>1 cm) serrated polyps (SP). We present absolute risk and adjusted risks from a logistic regression model stratified by age at index colonoscopy (<40, 40-49, 50-59, and 60+ [ref]). Covariates included index findings, endoscopist adenoma detection rates, sex, smoking, body mass index (BMI), follow-up time (months), bowel preparation quality, and family history of CRC Results In our sample of 12,380 adults, absolute risk for metachronous AA was lower for younger patients than for patients >age 60. After adjusting for covariates, when comparing to the 60+ group (reference), the lowest risk was observed in those < 40 (OR, 0.19; 95% CI, 0.05-0.80). Of note, similar risks were observed in the 40 to 49 (OR, 0.61; 95% CI, 0.41-0.92) and 50 to 59 (OR, 0.71; 95% CI, 0.58-0.86) groups. The risk for large metachronous SPs was not associated with age. Conclusions Younger adults <40 with index adenomas had a lower risk for metachronous AAs than those >60. The 40- to 49-year age group was found to have metachronous risk similar to the 50- to 59-year age group, with both less than the >60 age group. These data suggest that current surveillance interval guidelines for patients >50 may appropriately be used with younger adults.

Background and Aims Peroral endoscopic myotomy (POEM) is one of the available treatment modalities for achalasia. The reported efficacy of POEM in the only prospective multicenter study was 82%, reported by Von Renteln et al; however, a retrospective multicenter study in Japan reported a higher efficacy rate of 95%. The aim of this study was to prospectively verify treatment outcomes after POEM at multiple facilities in Japan. Methods This was a prospective single-arm trial of POEM for achalasia at eight facilities in Japan between April 2016 and March 2018 to evaluate its safety and efficacy. Patients were re-evaluated at 3 months and up to 1 year after POEM. Results Among the 233 patients with achalasia who underwent POEM, procedure-related adverse events occurred in 24 (10.3%) patients, none of whom required surgical intervention. In the 207 patients satisfying the inclusion criteria after the study by Von Renteln et al, the efficacy rate of POEM, defined by an Eckardt score ≤3 at 1 year, was 97.4% (95.3%–99.7%). The Eckardt score decreased significantly from 6.6 ± 2.0 preoperatively to 1.1 ± 1.1, 1 year after POEM. Postoperative reflux esophagitis, severe reflux esophagitis, and symptomatic gastroesophageal reflux disease were reported in 54.2%, 5.6%, and 14.7%, respectively, and proton pump inhibitors were administered in 21.1%. Conclusions Our prospective multicenter study in Japan showed greater efficacy of POEM for achalasia compared with the results of a previous prospective multicenter study. POEM is safe and highly effective for at least 1 year.

Background and Aims High rates of technical and clinical success were reported of lumen-apposing metal stent (LAMS) placement for peripancreatic fluid collection (PFC) drainage. However, data on the adverse event (AE) rates are heterogeneous. The aim of this study was to evaluate the incidence, severity, management, and risk factors of AEs related to the use of LAMSs for drainage of PFCs in a large cohort of patients. Methods This is a multicenter, international, retrospective review from 15 centers of all patients who underwent placement of LAMSs for the management of PFCs. A nested case-control study was conducted in patients with (case) or without (control) AEs. Results A total of 333 procedures in 328 patients were performed (5 patients treated with 2 LAMS). Technical success was achieved in 321 (97.9%) patients. Three hundred four patients were finally included in the study (7 excluded for lost to follow-up information; 10 excluded for deaths unrelated to LAMSs). The rate of clinical success was 89.5%. Seventy-nine LAMS-related AEs occurred in 74 out of 304 patients (24.3%), after a mean time of 25.3 days (median, 18 days, IQR, 6-30 days) classified as 20 (25.3%) mild, 54 (68.4%) moderate, or 5 (6.3%) severe. On multivariable analysis, compared with controls, cases were more likely to have walled-off necrosis (WON) versus pancreatic pseudocysts (PP) (ORs, 2.18; 95% CI, 1.09-4.46; P=0.028), whereas cases were less likely to have undergone tract (balloon) dilation (yes vs no, OR, 0.47; 95% CI, 0.22-0.93; P=0.034). Conclusions Data from this large international retrospective study confirm that the use of LAMSs for management of PFC has excellent technical and good clinical success rates. The rate of AEs, however, is not negligible and should be carefully considered before using these stents for drainage of PFCs, and in particular for WON. Further prospective studies are needed to confirm these findings.

Background and Aims Variable diagnostic performance of sampling techniques during EUS-guided tissue acquisition of solid pancreatic masses based on needle type (FNA versus fine-needle biopsy [FNB]) and gauge (19-gauge vs 22-gauge vs 25-gauge) has been reported. We performed a systematic review with network meta-analysis to compare the diagnostic accuracy of EUS-guided techniques for sampling solid pancreatic masses. Methods Through a systematic literature review to November 2018, we identified 27 randomized controlled trials (2711 patients) involving adults undergoing EUS-guided sampling of solid pancreatic masses that evaluated the diagnostic performance of FNA and FNB needles based on needle gauge. The primary outcome was diagnostic accuracy. Secondary outcomes were sample adequacy, histologic core procurement rate, and number of needle passes. We performed pairwise and network meta-analyses and appraised the quality of evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. Results In the network meta-analysis, no specific EUS-guided tissue sampling technique was superior, based on needle type (FNA vs FNB) or gauge (19-gauge vs 22-gauge vs 25-gauge) (low-quality evidence). Specifically, there was no difference between 25-gauge FNA versus 22-gauge FNA (relative risk [RR], 1.03; 95% confidence interval [CI], 0.91-1.17) and 22-gauge FNB versus 22-gauge FNA (RR, 1.03; 95% CI, 0.89-1.18) needles for diagnostic accuracy, sample adequacy, and histologic core procurement. Findings were confirmed in sensitivity analysis restricted to studies with no rapid on-site cytologic evaluation and no use of the fanning technique. Conclusion In a network meta-analysis, no specific EUS-guided tissue sampling technique was superior with regard to diagnostic accuracy, sample adequacy, or histologic procurement rate for solid pancreatic masses, with low confidence in estimates.

Background and Aims Antithrombotic therapy among patients undergoing GI procedures is frequently encountered and can impact the procedure and patient outcomes. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines help to manage these medications before endoscopy depending on the patient’s clinical status and the type of GI procedure. However, currently there is no readily available electronic tool that can assist in decision-making regarding preprocedural management of these agents. Our aim was to develop an electronic application, endoscopy + aid (ENDOAID), to help manage antithrombotic agents before endoscopy and to perform a validation study to test its accuracy. Methods ENDOAID, a web-based application, was developed using JavaScript software (Oracle Corporation, Redwood Shores, Calif, USA) based on an algorithm to categorize patients and procedures into low and high risk as outlined in the updated ASGE guidelines published in 2016. Once pertinent information regarding a patient’s clinical status and the procedure are entered, the application generates recommendations for the management of antithrombotic agents based on their cardiovascular risk and published ASGE guidelines. We performed a validation study with 52 patients who were referred to endoscopy and were taking antithrombotic agents. The patients were divided into groups of 5, and in the simulation each patient had 4 procedures. Different GI procedures were used in the simulation for each group of patients to ensure the entire spectrum of procedures were covered for analysis. Every simulation was then run through ENDOAID. The results from ENDOAID were compared with recommendations based on ASGE guidelines. The latter was derived by consensus between 2 endoscopists (the criterion standard). The personnel using the ENDOAID and those using the ASGE guidelines were different to avoid bias. Any clinical scenario that was unclear or not clearly outlined in ASGE guidelines was discussed with expert endoscopists for a final decision. We evaluated ASGE recommendations and calculated concordance rates between guidelines and ENDOAID results. The Pearson correlation coefficient (r) was calculated to assess the correlation between ENDOAID results to guidelines. Results There was a total of 208 simulated encounters, including 26 procedures. Initial concordance between ENDOAID recommendations and the criterion standard was seen in 206 encounters (99.03%). The 2 encounters that needed further review occurred among patients with Factor V Leiden mutation and deep vein thrombosis from antiphospholipid antibody syndrome and who were undergoing high-risk procedures that had ambiguous guidelines. ENDOAID suggested consultations with an expert before the elective procedure. This suggestion was agreed on by expert endoscopist consensus. Thus, ENDOAID showed a 100% concordance with the ASGE guideline for managing antithrombotics. There was a high degree of correlation (r = .996, P < .01) between ENDOAID results with ASGE. Conclusions We have developed and validated an easy-to-use web-based application that can help in periprocedural management of antithrombotics. Such an application has the potential to simplify the management of these agents and potentially prevent procedural delays, cancellations, or unnecessary consults.

Background and Aims A novel device that provides real-time depiction of functional luminal image probe (FLIP) panometry (ie, esophagogastric junction [EGJ] distensibility and distension-induced contractility) was evaluated. We aimed to compare real-time FLIP panometry interpretation at the time of sedated endoscopy with high-resolution manometry (HRM) in evaluating esophageal motility. Methods Forty consecutive patients (aged 24-81 years; 60% women) referred for endoscopy with a plan for future HRM from 2 centers were prospectively evaluated with real-time FLIP panometry during sedated upper endoscopy. The EGJ distensibility index and contractility profile were applied to derive a FLIP panometry classification at the time of endoscopy and again (post-hoc) using a customized program. HRM was classified according to the Chicago classification. Results Real-time FLIP panometry motility classification was abnormal in 29 patients (73%), 19 (66%) of whom had a subsequent major motility disorder on HRM. All 9 patients with an HRM diagnosis of achalasia had abnormal real-time FLIP panometry classifications. Eleven patients (33%) had normal motility on real-time FLIP panometry and 8 (73%) had a subsequent HRM without a major motility disorder. There was excellent agreement (κ = .939) between real-time and post-hoc FLIP panometry interpretation of abnormal motility. Conclusions This prospective, multicentered study demonstrated that real-time FLIP panometry could detect abnormal esophageal motility, including achalasia, at the endoscopic encounter. Additionally, normal motility on FLIP panometry was predictive of a benign HRM. Thus, real-time FLIP panometry incorporated with endoscopy appears to provide a suitable and well-tolerated point-of-care esophageal motility assessment.

Background and Aims To further optimize endoscopic stent placement, an esophageal fully covered self-expandable metal stent with a through-the-scope (TTS) delivery system was designed, providing direct endoscopic control during stent placement. The aim of the study was to assess the feasibility and safety of a TTS stent approach for palliation of malignant dysphagia. Methods This multicenter prospective feasibility study included patients with malignant dysphagia undergoing stent placement. The primary outcome was technical success of TTS stent placement. Secondary outcomes included functional outcome, adverse events, and survival. Patients were prospectively evaluated at days 14 and 28, and monthly thereafter, until death or stent removal. Results In total, 33 stents were placed in 32 patients. TTS stent placement was feasible in 30 (91%) procedures. In the other 3 procedures (9%), no large-channel endoscope could be introduced because of patient discomfort. In 10 (33%) TTS procedures, technical success was achieved because no fluoroscopy and/or guidewire was used, whereas in 20 (67%) TTS procedures, placement was supported by a guidewire (n = 9), or fluoroscopy and a guidewire (n = 11). After 2 weeks, dysphagia scores had improved in 24 (86%) patients. Median dysphagia-free time was 32 days (interquartile range [IQR], 17–76 days). In 20 (63%) patients, 29 serious adverse events (SAEs) occurred. Recurrent dysphagia occurred in 13 (41%) patients due to migration (n = 5), tissue overgrowth (n = 4), and stent deformation (n = 4). Other SAEs included significant retrosternal pain (n = 4), hemorrhage (n = 2), and esophageal perforation (n = 1). No patient died from a stent-related cause. Median survival was 42 days (IQR, 28–91 days). Conclusion Placement of an esophageal TTS stent was feasible in most of the patients with malignant dysphagia. However, stent placement was associated with a relatively high adverse event rate, and in more than one-third of patients, stent placement still required fluoroscopy, which limited optimal benefit of the TTS approach. (Clinical trial registration number: NCT03269903.)