A simple clinical score can stratify the risk of procedure-related adverse events in ERCP procedures with trainee involvement

Background and aims: Optimal training strategies in endoscopic retrograde cholangiopancreatography (ERCP) remain controversial despite the shift towards competence-based training models, with limited data available on patient safety during training. We aimed to assess whether pre-procedural clinical predictors could identify patients at low-risk of developing procedure-related adverse-events(AE) in a training environment. Methods: We performed a prospective, multicenter,cohort study including 5 training centers. A data collection system documenting indication, clinical data, trainee performance as assessed using a validated competence assessment tool (TEESAT), technical outcomes and AEs over a 30-day follow-up was utilized. We compared the rate of AE in a training environment between low-risk and high-risk patients as stratified using a previously derived clinical risk score (Trainee involvement in ERCP Risk Score-TIERS). The association between the trainee performance as assessed using TEESAT scores and the occurrence of AEs was also evaluated. Results: A total of 1283 ERCPs (409 (31.9% 95%CI 29.3%-34.4%) with trainee involvement) performed by 11 trainers and 10 trainees were analyzed. AE were more frequent in the high risk compared to the low risk group 27% (CI95% 20.5%-34.7%) vs 17.1% (CI95% 12.8%-22.2%). The TIERS risk score demonstrated a high negative predictive value for AE (82.86%, 95% CI 79.40% - 85.84%) and was the only predictor of AE (OR 1.38 (1.09-1.75)) on multivariate analysis. Suboptimal trainee performance was associated with an increase in AE rates. Conclusion: Simple, clinical-based predictive tools, could improve ERCP training through an individualized selection of cases for hands-on training, with the aim of increasing patient safety

The liver adventures of bariatric endoscopy

In the past few decades, endoscopy has overtaken many procedures that were routinely done surgically; the list is impressively long. With the advent of suturing devices, endoscopists are not only capable of closing defects, fixing stents, etc. but are also capable of suturing and remodeling organs such as the stomach. Bariatric endoscopy is a newborn that already runs by its own legs. The massive expansion of bariatric endoscopy is driven by need: today, one-third of the world’s population is overweight or obese and has associated nonalcoholic fatty liver disease (NAFLD) [1]. Bariatric surgery is very effective but invasive; thus, more and more patients and physicians are looking into less invasive treatments such as bariatric endoscopy, specialized diets, lifestyle coaching, and glucose-dependent insulinotropic polypeptide–glucagon-like peptide-1 (GLP-1) receptor agonists [2]. Bariatric endoscopy intended as gastric plication, or better, endoscopic sleeve gastroplasty (ESG), is becoming very attractive to patients; it is scarless, gives less pain, and is associated with fewer short- and long-term complications, and recovery is fast. However, procedures are less effective in patients with higher body mass index (BMI) and more effective in those with lower BMIs. ESG fits vast types of patients, for example, those in whom conservative medical interventions have failed but who are unfit for or decline bariatric surgery, and also pediatric and geriatric populations [3] [4] where surgery is unsuitable

Small intestine is a big player!

Background: Patients suffering from inflammatory bowel diseases (IBDs) express increased mucosal levels of transforming growth factor (TGF)-β compared with non-IBD controls. SMAD7 negatively regulates TGF-β signaling. An earlier study aiming to target Smad7 showed a lack of clinical benefit. It remains unknown whether inhibition of SMAD7 is beneficial in specific settings of IBD. We evaluated the effect of Smad7 deficiency on inflammation, fibrogenesis, and wound healing. Methods: For the initiation of fibrosis in Smad7-/- (Smad7Δex-I) CD-1 mice, the dextran sodium sulfate-induced chronic colitis model and the heterotopic transplantation model of fibrosis were used. Wound closure of fibroblasts from Smad7-/- mice was determined using culture inserts and electric cell-substrate impedance sensing in vitro. Results: In dextran sodium sulfate-induced chronic colitis, Smad7 deficiency was associated with ameliorated inflammation, as evidenced by decreased clinical score, histological score, and myeloperoxidase activity. Absence of SMAD7 decreased T-cell accumulation in colonic tissue and tumor necrosis factor (TNF) mRNA expression levels. Smad7-/- mice showed a significant increase in hydroxyproline and collagen content, as well as ColIVa1 mRNA expression. Wild type mice transplanted with terminal ileum from Smad7-/- mice in the heterotopic animal model for intestinal fibrosis showed a significant increase in collagen content and protein expression of α-smooth muscle actin. Conclusions: Smad7 deficiency is associated with a decrease in intestinal inflammation and an increase in fibrosis. Targeting SMAD7 constitutes a potential new treatment option for IBD; progression of disease-associated fibrosis should be considered. Keywords: fibrosis; inflammatory bowel disease; mongersen

Young Gi angle: Tips from improving your endoscopic technique

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Perioperative Interventions to Prevent Gastroesophageal Reflux Disease and Marginal Ulcers After Bariatric Surgery — an International Experts’ Survey

Objective: This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate perioperative interventions to prevent gastroesophageal reflux disease (GERD) and marginal ulcers (MU) after MBS. Background: Very important long-term complications after MBS include GERD, Barrett’s esophagus, and MU. Prevention might be fundamental to reduce the incidence, severe complications, and the increasing number of revisional bariatric surgeries. Methods: An international scientific team designed an online confidential questionnaire with 45 multiple-choice questions. The survey was sent to 110 invited experts and 96 of them (from 41 different countries) participated from 21 July 2022 to 4 September 2022. Results: Most experts (≥ 90%) prescribe postoperative acid suppression agents after MBS. Life-long proton pump inhibitors prophylaxis in smokers with avoidance of non-steroidal anti-inflammatory drugs are recommended by most of the experts (66%, 73%) after any type of gastric bypass. Two-thirds of experts (69%) perform Helicobacter pylori eradication prior to MBS. Two-thirds of experts (68%) routinely perform EGD and biopsy before MBS. Follow-up esophagogastroduodenoscopy (EGD) and timing threshold for revisional and conversional MBS were variable among experts. Conclusion: This expert survey underlines important perioperative interventions that reached a two-thirds consensus among MBS international experts. Variability in follow-up EGD, approach to complication management, and thresholds for revisional and conversional MBS emphasize the need for further researches and consensus guidelines. Graphical Abstract: [Figure not available: see fulltext.]

Curriculum for bariatric endoscopy and endoscopic treatment of the complications of bariatric surgery: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

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

Peroral Cholangioscopy: How Technology and Imaging Have Changed ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is the minimally invasive standard of care for the treatment of several biliary and pancreatic pathologies. One of the limitations of this technique is the lack of endoluminal vision within the biliary tree or Wirsung's duct. This limits the diagnostic accuracy of the procedure and reduces the effectiveness of many treatments. Technological progress and the use of increasingly ergonomic and high-definition imaging equipment have led to the dissemination of peroral cholangioscopy (POC). Thanks to the high quality of video image resolution, POC could well be a powerful tool used to characterize malignant biliary strictures. It could also allow targeted biopsies or local treatments, hence reducing the risk of complications and increasing outcomes. The technological improvement of the last generation of POC is opening new horizons in the treatment of biliopancreatic pathologies, thereby contributing to refine and enhance the ERCP management of several diseases in the near future

Endoscopic bariatric and metabolic therapies for non-alcoholic fatty liver disease: Evidence and perspectives

Non-alcoholic fatty liver disease (NAFLD) has become the most common liver disease in industrialized countries because of the worldwide epidemic of obesity. Beyond metabolic complications, a subset of patients with NAFLD develop non-alcoholic steatohepatitis (NASH) with fibrosis, which is emerging as a leading cause of liver transplantation due to progression to cirrhosis and cancer. For these reasons, NAFLD is considered a public health burden. In recent years endoscopic bariatric and metabolic therapies (EBMT) have emerged as safe and effective for the treatment of obesity and type 2 diabetes mellitus. EBMT include gastric and duodenal devices and techniques such as intragastric balloons, endoscopic sleeve gastroplasty, endoscopic small bowel by-pass and duodenal mucosal resurfacing. Observational studies and pilot trials have revealed beneficial effects of EBMT on NAFLD as assessed by non-invasive parameters or histology. In this review we summarise current evidence for the efficacy and safety of EBMT in obese patients with NAFLD and examine future clinical applications

Long-term treatment with infliximab in inflammatory bowel disease: Safety and tolerability issues

Crohn's disease and ulcerative colitis represent the most common forms of inflammatory bowel disease (IBD), clinical conditions affecting the small and/or large bowel. It is well known that IBD is an immune-mediated condition and that TNF-α plays a pivotal role in the pathogenesis of the disease. TNF-α has been scrupulously studied as a target for therapeutic intervention in this setting. A number of biologic compounds have been developed, including the European Medicine Agency (EMEA)-approved agents, infliximab and adalimumab. Although their efficacy in induction and maintenance of remission has been established by several clinical trials, many issues regarding safety remain to be elucidated. In fact, anti-TNF treatment may be associated with a number of rare, but serious, adverse events, including infusion reactions, infections, lymphomas and other malignancies. A black-box warning has to be taken into consideration when looking at potential serious infections such as tuberculosis. Active infections, demyelinating disorders and severe heart failure are contraindications for anti-TNF treatment. This review focuses on drug toxicity and adverse events related to infliximab treatment in IBD. © 2008 Informa UK Ltd

Maintenance treatment with infliximab for the management of Crohn's disease in adults

Crohn's disease (CD) is a chronic, relapsing disease, the continuous cycle of which deeply affects the long-term course which, eventually, leads to fi brosis and development of transmural complications. It is well known that CD is an immune-mediated clinical condition and that tumor necrosis factor-α (TNF-α) plays a fundamental role in the pathogenesis of the disease. Current clinical guidelines recommend that patients with mild to moderate active CD should be treated initially with corticosteroids. Although this approach is effective in inducing remission, some patients may become dependent on, or refractory to, these drugs in the long term, thus increasing the risk of developing steroid-related adverse effects. A recent Cochrane systematic review established that infl iximab (IFX) is effective in inducing remission in patients with CD. Although only a few published studies have assessed IFX for the maintenance of remission in the long term, there is evidence that IFX is superior to placebo in sustaining clinical remission and fi stula healing; moreover, corticosteroid-sparing effects have been demonstrated. IFX is associated with the formation of antibodies to IFX which can lead to infusion reactions and shorter duration of response, but when comparing episodic vs scheduled maintenance treatment, the latter appears to sensibly reduce immunogenicity, thus offering improved effi cacy and tolerance. The fi nal point to consider is the best time to introduce IFX in the therapeutic algorithm of CD. Early use of IFX has been suggested to be more effective than late, and may potentially change the natural history of the disease. Effective induction and maintenance therapy with IFX is the only means with which to maintain long-lasting clinical and mucosal remission which, in turn, may modify the long-term course of the disease. Furthermore, when treating inflammatory bowel disease patients with IFX, an appropriate risk-benefit balance has to be taken into consideration, because the precise risk of serious adverse events associated with anti-TNF treatment in CD remains to be fully elucidated. © 2009 Caviglia et al, publisher and licensee Dove Medical Press Ltd