Endoscopic Gastrointestinal Placement of Capsule Endoscopy to Investigate the Small Bowel: a Multicentric European Retrospective Series of 630 Procedures in Adult Patients.

BACKGROUND AND AIMS: Small bowel (SB) capsule endoscopy (CE) is a first line procedure for exploring the SB. Endoscopic GastroIntestinal PlacemenT (EGIPT) of SB CE is sometimes necessary. While the experience of EGIPT is large in pediatric populations, we aimed to describe the safety, efficacy and outcomes of EGIPT of SB CE in adult patients. METHODS: The international CApsule endoscopy REsearch (iCARE) group set up a retrospective multicenter study. Patients over 18 year-old who underwent EGIPT of SB CE before May 2022 were included. Data were collected from medical records and capsule recordings. The primary endpoint was the technical success rate of the EGIPT procedures. RESULTS: 630 patients were included (mean age 62.5 years old, 55.9% female) from 39,565 patients (1.6%) issued from 29 centers. EGIPT technical success was achieved in 610 procedures (96.8%). Anesthesia (moderate/deep sedation or general anesthesia) and centers with intermediate or high procedure loads were independent factors of technical success. Severe adverse events occurred in three (0.5%) patients. When technically successful, EGIPT was associated with a high SB CE completion rate (84.4%) and with a substantial diagnostic yield (61.1%). Completion rate was significantly higher when the capsule was delivered in the SB compared to when delivered in the stomach. CONCLUSION: EGIPT of SB CE is highly feasible, safe and comes with high completion rate and diagnostic yield. When indicated, it should rather be performed under anesthesia and the capsule should be delivered in the duodenum rather than in the stomach, for better SB examination outcomes.

Endoscopic ultrasound-guided colo-colostomy for the treatment of benign complete occlusion of colonic anastomosis: a case series and description of technique.

AIM: The incidence of benign colonic anastomotic stricture is approximately 2% in patients undergoing left hemicolectomy or anterior resection and as high as 16% in patients undergoing low anterior or intersphincteric resection. In the majority, rather than complete occlusion, a stenosis forms, which can be managed with endoscopic balloon dilatation, a self-expanding metallic stent or endoscopic electroincision. In the less common scenario of a completely occluded colonic anastomosis, surgery is often required. In this study, we aim to describe the technique we used to treat this condition non-operatively METHOD: We describe a case series of three patients with benign complete occlusion of their colorectal anastomosis and how we managed them nonoperatively with a colonic/rectal endoscopic ultrasound (EUS) anastomosis technique and a Hot lumen-apposing metallic stent. RESULTS: We demonstrate that the technical and clinical success for this technique is 100%. CONCLUSIONS: We believe that the technique we describe is effective and safe. It should be widely reproducible in centres with expertise in interventional EUS, given the similarity to well-established procedures such as EUS-guided gastroenterostomy. Patient selection and timing of reversal of ileostomy need careful consideration, especially in patients with a history of keloid formation. Given the shorter hospital stay and reduced invasiveness of this technique, we believe it should be considered for all patients who have complete benign occlusion of a colonic anastomosis. However, given the small number of cases and short period of follow-up, the long-term outcome of this technique is not known. More studies with higher power and a longer period of follow-up should be conducted to further ascertain the effectiveness of this technique.

Corrigendum: The Conversion of Planned Colonoscopy to Sigmoidoscopy and the Effect of this Practice on the Measurement of Quality Indicators.

This corrects the article DOI: 10.1038/ajg.2017.138.

The Conversion of Planned Colonoscopy to Sigmoidoscopy and the Effect of this Practice on the Measurement of Quality Indicators.

OBJECTIVES: A cecal intubation rate (CIR) of >90% is a well-accepted quality indicator of colonoscopy and is consequently monitored within endoscopy units. Endoscopists' desire to meet this target may mean that incomplete colonoscopies are recorded as flexible sigmoidoscopies. The aim of this study was to examine whether the conversion of requested colonoscopies is a clinically significant phenomenon and whether this impacts upon the measurement of quality indicators. METHODS: A retrospective review of all flexible sigmoidoscopies performed between 1 January 2015 and 31 December 2015 at Nottingham University Hospitals, Sheffield Teaching Hospitals, and Cambridge University Hospitals was performed. Where a colonoscopy was requested but a flexible sigmoidoscopy performed, the patient's records and endoscopy reports were reviewed to determine whether this conversion was decided before the start of the procedure and documented. RESULTS: During the 12-month period, 6,839 flexible sigmoidoscopies were performed by 125 endoscopists. The original requests of 149 sigmoidoscopies could not be retrieved and were therefore excluded from this analysis. Of the 6,690 sigmoidoscopy requests reviewed, 2.8% (n=190) procedures were originally requested as a colonoscopy. On review of patient records, 85 conversions were appropriate according to pre-defined criteria. However, 105 conversions were deemed inappropriate, occurring in patients who had a valid documented indication for colonoscopy and had undergone full bowel preparation. The most common reasons cited included poor bowel preparation (n=37), technically challenging procedure (n=24), at the endoscopist's discretion based on clinical factors (n=21), and obstructing patology (n=8). A clear reason for conversion was not apparent in 11 cases. During the study period, 21,271 colonoscopies were performed and so conversions represent 0.45% of the total requests. When inappropriate conversions were included in individuals' performance data, 15 endoscopists fell to ≤90% target cecal intubation target. CONCLUSIONS: A small, but significant number of colonoscopies are converted to flexible sigmoidoscopies at the time of the procedure. This study demonstrates the conversion of colonoscopy to sigmoidoscopy as being a potential limitation of relying on CIR alone. Endoscopy units should consider monitoring the rate of inappropriate conversions to ensure quality.

'Pre-endoscopy point of care test (Simtomax- IgA/IgG-Deamidated Gliadin Peptide) for coeliac disease in iron deficiency anaemia: diagnostic accuracy and a cost saving economic model'.

BACKGROUND: International guidelines recommend coeliac serology in iron deficiency anaemia, and duodenal biopsy for those tested positive to detect coeliac disease. However, pre-endoscopy serology is often unavailable, thus committing endoscopists to take routine duodenal biopsies. Some endoscopists consider duodenal biopsy mandatory in anaemia to exclude other pathologies. We hypothesise that using a point of care test at endoscopy could fill this gap, by providing rapid results to target anaemic patients who require biopsies, and save costs by biopsy avoidance. We therefore assessed three key aspects to this hypothesis: 1) the availability of pre-endoscopy serology in anaemia; 2) the sensitivities and cost effectiveness of pre-endoscopy coeliac screening with Simtomax in anaemia; 3) whether other anaemia-related pathologies could be missed by this targeted-biopsy approach. METHODS: Group 1: pre-endoscopy serology availability was retrospectively analysed in a multicentre cohort of 934 anaemic patients at 4 UK hospitals. Group 2: the sensitivities of Simtomax, endomysial and tissue-transglutaminase antibodies were compared in 133 prospectively recruited patients with iron deficiency anaemia attending for a gastroscopy. The sensitivities were measured against duodenal histology as the reference standard in all patients. The cost effectiveness of Simtomax was calculated based on the number of biopsies that could have been avoided compared to an all-biopsy approach. Group 3: the duodenal histology of 153 patients presenting to a separate iron deficiency anaemia clinic were retrospectively reviewed. RESULTS: In group 1, serology was available in 361 (33.8 %) patients. In group 2, the sensitivity and negative predictive value (NPV) were 100 % and 100 % for Simtomax, 96.2 % and 98.9 % for IgA-TTG, and 84.6 % and 96.4 % for EMA respectively. In group 3, the duodenal histology found no causes for anaemia other than coeliac disease. CONCLUSION: Simtomax had excellent diagnostic accuracy in iron deficiency anaemia and was comparable to conventional serology. Duodenal biopsy did not identify any causes other than coeliac disease for iron deficiency anaemia, suggesting that biopsy avoidance in Simtomax negative anaemic patients is unlikely to miss other anaemia-related pathologies. Due to its 100 % NPV, Simtomax could reduce unnecessary biopsies by 66 % if only those with a positive Simtomax were biopsied, potentially saving £3690/100 gastroscopies. TRIAL REGISTRATION: The group 2 study was retrospectively registered with clinicaltrials.gov. Trial registration date: 13(th) July 2016; TRIAL REGISTRATION NUMBER: NCT02834429 .

Safety of the colonoscope magnetic imaging device (ScopeGuide) in patients with implantable cardiac devices.

BACKGROUND AND STUDY AIMS: Use of the colonoscope magnetic imaging device (ScopeGuide, Olympus Medical Systems, Tokyo, Japan) is currently contraindicated by the manufacturer for patients with implantable cardiac devices, a group of patients that is increasing annually along with the number of colonoscopies performed in the era of colorectal cancer screening. This is the first study to examine the safety of ScopeGuide in patients with permanent pacemakers, implantable cardioverter defibrillators, and cardiac resynchronization therapy. PATIENTS AND METHODS: Nonimplanted cardiac devices were exposed to the electromagnetic field of ScopeGuide ex vivo and assessed for evidence of interference or change in device settings. Following this, consecutive patients attending device check clinics were prospectively recruited and exposed to the ScopeGuide electromagnetic field. After an initial device check, patients underwent continuous external cardiac monitoring and device interrogation while a colonoscope was placed on the abdomen over clothing and connected to ScopeGuide to simulate colonoscopy. Patients were monitored for 2 minutes to assess for any interference. ScopeGuide was then disconnected and devices were checked for any change in settings. RESULTS: A total of 230 patients were invited to participate and 100 were recruited to the study. There was no evidence of interference on device leads or change in programming following exposure to the electromagnetic field generated by ScopeGuide. CONCLUSION: ScopeGuide does not appear to cause interference or change in settings and is therefore likely to be safe for use in patients with implantable cardiac devices.

Service Evaluation of the Impact of Capnography on the Safety of Procedural Sedation.

Background: Capnography has been associated with a reduced incidence of events related to respiratory compromise during procedural sedation. Methods: A prospective service evaluation was conducted at a large United Kingdom (UK) teaching hospital to assess the impact of capnography on patient safety within four speciality services: bronchoscopy, endoscopy, interventional cardiology, and interventional radiology. Events were defined as provided by the World Society of Intravenous Anaesthesia. One thousand four hundred one patients were enrolled in the evaluation, with 666 patients before and 735 after implementation of capnography. Data was entered as a convenience sample on site in an offline data-collection tool. Results were assessed for the relative reduction in the incidence and resulting adjusted odds ratio for the combined incidence of oxygen desaturation (75-90% for <60s), severe oxygen desaturation (<75% at any time) or prolonged oxygen desaturation (<90% for >60s), bradycardia (>25% from baseline) and tachycardia (>25% from baseline). The adjusted odds ratio was controlled for both procedure and patient characteristics. Results: After implementation of capnography, a significant reduction (43.2%, p ≤ 0.05) in adverse events was observed: 147 adverse events occurred during 666 procedures without capnography compared with 93 adverse events that occurred during 735 procedures with capnography. The adjusted odds ratio for the occurrence of the target adverse events was 0.57 (95% CI: 0.42-0.77). Multivariable linear regression indicated that capnography was a significant predictor (p 0.001) of reduced adverse events. Conclusion: These results suggest improved patient safety following capnography implementation.

Corrigendum: Service evaluation of the impact of capnography on the safety of procedural sedation.

[This corrects the article DOI: 10.3389/fmed.2022.867536.].

Survey on the perceptions of UK gastroenterologists and endoscopists to artificial intelligence.

Background and aims: With the potential integration of artificial intelligence (AI) into clinical practice, it is essential to understand end users' perception of this novel technology. The aim of this study, which was endorsed by the British Society of Gastroenterology (BSG), was to evaluate the UK gastroenterology and endoscopy communities' views on AI. Methods: An online survey was developed and disseminated to gastroenterologists and endoscopists across the UK. Results: One hundred four participants completed the survey. Quality improvement in endoscopy (97%) and better endoscopic diagnosis (92%) were perceived as the most beneficial applications of AI to clinical practice. The most significant challenges were accountability for incorrect diagnoses (85%) and potential bias of algorithms (82%). A lack of guidelines (92%) was identified as the greatest barrier to adopting AI in routine clinical practice. Participants identified real-time endoscopic image diagnosis (95%) as a research priority for AI, while the most perceived significant barriers to AI research were funding (82%) and the availability of annotated data (76%). Participants consider the priorities for the BSG AI Task Force to be identifying research priorities (96%), guidelines for adopting AI devices in clinical practice (93%) and supporting the delivery of multicentre clinical trials (91%). Conclusion: This survey has identified views from the UK gastroenterology and endoscopy community regarding AI in clinical practice and research, and identified priorities for the newly formed BSG AI Task Force.

Intraductal fully covered self-expanding metal stents in the management of post-liver transplant anastomotic strictures: a UK wide experience.

Background: Fully covered intraductal self-expanding metal stents (IDSEMS) have been well described in the management of post-liver transplant (LT) anastomotic strictures (ASs). Their antimigration waists and intraductal nature make them suited for deployment across the biliary anastomosis. Objectives: We conducted a multicentre study to analyse their use and efficacy in the management of AS. Design: This was a retrospective, multicentre observational study across nine tertiary centres in the United Kingdom. Methods: Consecutive patients who underwent endoscopic retrograde cholangiopancreatography with IDSEMS insertion were analysed retrospectively. Recorded variables included patient demographics, procedural characteristics, response to therapy and follow-up data. Results: In all, 162 patients (100 males, 62%) underwent 176 episodes of IDSEMS insertion for AS. Aetiology of liver disease in this cohort included hepatocellular carcinoma (n = 35, 22%), followed by alcohol-related liver disease (n = 29, 18%), non-alcoholic steatohepatitis (n = 20, 12%), primary biliary cholangitis (n = 15, 9%), acute liver failure (n = 13, 8%), viral hepatitis (n = 13, 8%) and autoimmune hepatitis (n = 12, 7%). Early AS occurred in 25 (15%) cases, delayed in 32 (20%) cases and late in 95 (59%) cases. Age at transplant was 54 years (range, 12-74), and stent duration was 15 weeks (range, 3 days-78 weeks). In total, 131 (81%) had complete resolution of stricture at endoscopic re-evaluation. Stricture recurrence was observed in 13 (10%) cases, with a median of 19 weeks (range, 4-88 weeks) after stent removal. At removal, there were 21 (12%) adverse events, 5 (3%) episodes of cholangitis and 2 (1%) of pancreatitis. In 11 (6%) cases, the removal wires unravelled, and 3 (2%) stents migrated. All were removed endoscopically. Conclusion: IDSEMS appears to be safe and highly efficacious in the management of post-LT AS, with low rates of AS recurrence.

Cholangiocyte organoids can repair bile ducts after transplantation in the human liver.

Organoid technology holds great promise for regenerative medicine but has not yet been applied to humans. We address this challenge using cholangiocyte organoids in the context of cholangiopathies, which represent a key reason for liver transplantation. Using single-cell RNA sequencing, we show that primary human cholangiocytes display transcriptional diversity that is lost in organoid culture. However, cholangiocyte organoids remain plastic and resume their in vivo signatures when transplanted back in the biliary tree. We then utilize a model of cell engraftment in human livers undergoing ex vivo normothermic perfusion to demonstrate that this property allows extrahepatic organoids to repair human intrahepatic ducts after transplantation. Our results provide proof of principle that cholangiocyte organoids can be used to repair human biliary epithelium.

A retrospective study assessing fully covered metal stents as first-line management for malignant biliary strictures.

OBJECTIVES: Fully covered self-expanding metal stents (FCSEMS) constitute the first type of metal stent that can easily be removed endoscopically and/or intraoperatively, which may be advantageous in the management of distal malignant biliary strictures (DMBS). To assess the efficacy of FCSEMS as first-line treatment for DMBS, we compared patency, survival and complication rates between FCSEMS, uncovered self-expanding metal stents (USEMS) and plastic stents (PS). METHODS: This was a multicentre retrospective study of 315 consecutive patients with DMBS, who underwent endoscopic retrograde cholangiopancreatography and stenting (FCSEMS, USEMS or PS) at two hospitals between 1 January 2007 and 31 December 2013. Stent patency and patient survival were compared using the Kaplan-Meier method; complication rates were compared using Fisher's exact test; and Cox regression analysis was used to screen for confounding factors. RESULTS: FCSEMS were associated with prolonged stent patency (median=145 days) compared with USEMS (median=110 days, P<0.003) and PS (median=34 days, P<0.001). Biliary sepsis rates were lower for FCSEMS compared with PS (4.7 vs. 17.8%, P=0.02), whereas pancreatitis rates were higher for FCSEMS compared with USEMS (7.8 vs. 1.0%, P=0.04), but not PS (2.6%, P=NS). CONCLUSION: The use of FCSEMS as first-line management for DMBS is associated with longer patency and reduced complication rates compared with the use of PS. However, the higher rate of pancreatitis compared with USEMS requires further evaluation in a large randomized controlled trial.

Comparison of Pentax HiLine and Olympus Lucera systems at screening colonoscopy.

AIM: To compare the performance characteristics of Pentax HiLine (PHL) (with i-scan) and Olympus Lucera (OL) systems in a screening population. METHODS: Screening colonoscopies in asymptomatic guaiac faecal occult blood test-positive patients with PHL (n = 58) and OL (n = 425) colonoscopes were analysed. All procedures were performed by a single colonoscopist. PHL used white-light endoscopy (WLE) on scope insertion and contrast/surface enhancement (i-scan 1) on withdrawal, and OL utilised WLE both on insertion and withdrawal. Patient age, sex, instrument insertion and withdrawal times, nurse assessed patient comfort scores, midazolam and fentanyl doses, procedure completion and rates of lesion detection were recorded separately for each group. Comparisons between the groups were made using either Fisher's exact test (for dichotomous variables) or Mann-Whitney U test (for ordinal and continuous variables). RESULTS: Colonoscopy completion rates were similar in both groups: 413/425 (97.2%) for OL and 55/58 (94.9%) for PHL (P = 0.24). For complete colonoscopies, the two groups were well matched for age, sex, colonoscope insertion times (mean 11.1 min in OL vs 11.6 min in PHL, P = 0.93) and normal colonoscopy withdrawal times (mean 15.6 min in OL vs 14.7 min in PHL, P = 0.2). Patients in the PHL group experienced a small increase in discomfort (mean patient comfort scores were 0.49 in the OL and 0.95 in the PHL group, P < 0.0001). While Fentanyl doses required were similar between groups (mean 57.5 µg in OL vs 61.4 µg in PHL, P = 0.13), slightly more Midazolam was required in the PHL group (mean 2.1 mg in OL vs 2.4 mg in PHL, P = 0.035). There was no difference in polyp (58% in OL vs 67% in PHL) or adenoma (49% in OL vs 56% in PHL) detection rates between the groups. Neither the total number of polyps and adenomas, nor the characteristics of these (including size, location or presence of advanced features) were different between the two systems. CONCLUSION: This study suggests that there is no advantage of either colonoscope system in lesion detection.