Role of artificial intelligence-guided esophagogastroduodenoscopy in assessing the procedural completeness and quality.

BACKGROUND AND AIMS: The quality of esophagogastroduodenoscopy (EGD) can have great impact on the detection of esophageal and gastric lesions, including malignancies. The aim of the study is to investigate the use of artificial intelligence (AI) during EGD by the  endoscopists-in-training so that a real-time feedback can be provided, ensuring compliance to a pre-decided protocol for examination. METHODS: This is an observational pilot study. The videos of the EGD procedure performed between August 1, 2021, and September 30, 2021, were prospectively analyzed using AI system. The assessment of completeness of the procedure was done based on the visualizsation of pre-defined 29 locations. Endoscopists were divided into two categories - whether they are in the training period (category A) or have competed their endoscopy training (category B). RESULTS: A total of 277 procedures, which included 114 category-A and 163 category-B endoscopists, respectively, were included. Most commonly covered areas by the endoscopists were greater curvature of antrum (97.47%), second part of duodenum (96.75%), other parts of antrum such as the anterior, lesser curvature and the posterior aspect (96.75%, 94.95%, and 94.22%, respectively). Commonly missed or inadequately seen areas were vocal cords (99.28%), epiglottis (93.14%) and posterior, anterior, and lateral aspect of incisura (78.70%, 73.65%, and 73.53%, respectively). The good quality procedures were done predominantly by categoryB endoscopists (88.68% vs. 11.32%, p < 0.00001). CONCLUSION: AI can play an important role in assessing the quality and completeness of EGD and can be a part of training of endoscopy in future.

A prospective study of fully covered self-expandable metal stents for refractory benign pancreatic duct strictures.

BACKGROUND/AIMS: Fully covered self-expanding metal stents (FCSEMSs) are a relatively novel option for treating painful main pancreatic duct refractory strictures in patients with chronic pancreatitis. Herein, we aimed to assess the efficacy, feasibility, and safety of FCSEMSs in this patient group. METHODS: This prospective single-center study included patients who underwent endoscopic retrograde pancreatography with FCSEMS placement. The primary endpoints were the technical and clinical success rates. A reduction in visual analog scale pain score of >50% compared with that before stent placement was defined as clinical success. Secondary endpoints were resolution of pancreatic strictures on fluoroscopy during endoscopic retrograde pancreatography and the development of stent-related adverse events. RESULTS: Thirty-six patients were included in the analysis. The technical success rate was 100% (n=36) and the clinical success rate was 86.1% (n=31). There was a significant increase in stricture diameter from 1.7 mm to 3.5 mm (p<0.001) after stent removal. The mean visual analog scale pain score showed statistically significant improvement. At 19 months of follow-up, 55.6% of the patients were asymptomatic. Stent migration (16.7%), intolerable abdominal pain (8.3%), development of de novo strictures (8.3%), and mild pancreatitis (2.8%) were the most common adverse events. CONCLUSION: FCSEMS placement showed good technical and clinical success rates for achieving pain relief in patients with refractory main pancreatic duct strictures.

Endoscopic ultrasonography-guided rendezvous technique for removal of a long biliary ascariasis: a challenging case.

Video 1Video demonstrating the EUS-rendezvous technique for biliary access and removal of a long biliary ascariasis.

Difficult Biliary Cannulation for Intradiverticular Papilla: Forceps Technique Revisited.

Periampullary diverticula (PAD) have been encountered in 5.9 to 18.5% of patients during all the endoscopic retrograde cholangiopancreatography (ERCP). Cannulation in the presence of PAD can sometimes be difficult, time consuming, and often requires a higher level of endoscopic skills. Several techniques have been reported to facilitate and increase the chances of successful bile duct cannulation in the presence of PAD. The two-devices in one-channel method has been sparingly used. It involves the simultaneous use of a biopsy forceps and another instrument, either a cannula or sphincterotome through the same working channel. We successfully performed ERCP in three cases, where bile duct cannulation was performed in the setting of intradiverticular papilla using two-devices in one-channel method. We feel that the two-devices in one-channel method can be very useful and positioned higher up in the algorithm for successful cannulation in patients with PAD.

Efficacy and safety of cholangioscopy guided laser lithotripsy for difficult bile duct stones - A prospective study from a tertiary care centre in Eastern India.

BACKGROUND AND STUDY AIMS: Endoscopic sphincterotomy combined with endoscopic papillary balloon dilatation, mechanical lithotripsy or both, are effective modalities for the ex- traction of difficult common bile duct (CBD) stones. However, approximately 5-15% of cases are still difficult to treat. In the present study, we have evaluated the safety and efficacy of single- operator cholangioscopy guided laser lithotripsy (LL) for difficult to treat CBD stones. PATIENTS AND METHODS: Consecutive patients undergoing LL for the extraction of difficult CBD stones were enrolled in the study. The primary outcomes were related to the efficacy of the procedure in terms of ductal clearance and safety in terms of complications. RESULTS: During the 36 months, 764 patients presented for biliary stone extraction. Most of the patients, 683 (89.4%), had a successful stone extraction with standard techniques. Thirteen patients (1.7%) were not suitable for endoscopic therapy or did not consent for endoscopic therapy, and were referred directly for surgical treatment. Sixty-seven patients (8.8%) were included in the study. Cholangioscope was able to reach the stone in all the cases but one. Complete ductal clearance was achieved in 61 (91%) patients. Complications were encountered in 8 (11.9%) patients. All patients were asymptomatic at one-month of follow-up. CONCLUSION: LL is a highly effective and safe procedure with minimal and transient complications.

Single-balloon enteroscopy in management of small-bowel disorders.

BACKGROUND: Device-assisted enteroscopy including single-balloon enteroscopy (SBE) allows direct visualization of the small bowel and has good safety and efficacy in experienced hands. Our study is aimed to share our single-centre experience of SBE in diagnosing and treating small-bowel disorders. METHODS: We reviewed the prospectively collected data (from December 2016 to December 2019) of 180 consecutive anterograde and/or retrograde procedures. Analysis of baseline characteristics, endoscopic findings, and diagnostic and therapeutic rates was done. RESULTS: SBE was done in 158 patients with a median age of 55 years (range, 13-94 years) for suspected small-bowel lesions. Dual enteroscopy (anterograde plus retrograde) was done in 22 patients (13.92%). The indication for the procedure was obscure gastrointestinal bleeding in 129 (71.66%), chronic unexplained abdominal pain in 20 (11.11%), suspected small-bowel abnormality in the form of narrowing and/or mass on imaging in 10 (5.5%), chronic diarrhea in 9 (5%), unexplained iron deficiency anemia in 9 (5%), and retained capsule in 2 (1.11%). The most common finding was ulcer, which was noted in 45 (25%) patients followed by stricture in 8 (4.44%) and both ulcers and strictures in 6 (3.33%) patients. SBE was normal in 61 (33.88%) patients. SBE gave a diagnosis in 66.11% while in 28.43% cases, therapeutic intervention was done. Minor complications like bleeding were noted in 3 patients and mild acute pancreatitis in 2 patients. Jejunal perforation requiring surgical intervention was noted in 1 patient. CONCLUSION: SBE is a safe and effective procedure in diagnosing and treating small-bowel diseases.

Endoscopic Management with a Novel Over-The-Scope Padlock Clip System.

BACKGROUND/AIMS: The Padlock clip is a recently introduced over-the-scope clip (OTSC) that requires the use of an alternate technique and has a different design from previous OTSCs. However, data regarding its clinical use are limited. The aim of this study is to present our clinical experience using this novel Padlock clip system. METHODS: Between September 2018 and June 2019, 7 consecutive patients underwent Padlock clip application at our center by an experienced endoscopist. A Padlock clip was used for achieving hemostasis in 4 patients presenting with gastrointestinal (GI) bleeding, as well as for endoscopic full-thickness resection in the remaining 3 patients. RESULTS: All 7 patients achieved technical as well as clinical success, with absence of complications or rebleeding, during a follow-up of a minimum of 3 weeks. All patients were hospitalized post procedure for a minimum of 48 hours, and an absence of adverse events was noted in our patient population throughout the procedure and post-procedure period. Antiplatelet therapy was reinstated shortly after the application of the Padlock clip, with no GI bleeding observed. CONCLUSION: The Padlock clip is a novel OTSC, with benefits that include safe, simple, and rapid deployment. Antiplatelet therapy may be reinstated for patients, when necessary, shortly after applying the Padlock clip due to full-thickness closure of the tissue.