Clinical predictors of significant findings on EUS for the evaluation of incidental common bile duct dilation.

BACKGROUND AND AIMS: While endoscopic ultrasound(EUS) is highly accurate for the evaluation of common bile duct (CBD) dilation, the yield of EUS in patients with incidental CBD dilation is unclear. METHODS: Serial patients undergoing EUS for incidental, dilated CBD (per radiologist, minimum >6mm objectively) from two academic medical centers, without active pancreaticobiliary disease or significantly elevated LFTs were evaluated. Multivariable logistic regression identified predictors of EUS with significant findings and a novel prediction model was derived from one center, internally validated with bootstrapping, and externally validated at the second center. RESULTS: Of 375 patients evaluated, 31 (8.3%) had significant findings including 26 choledocholithiasis, 1 ampullary adenoma, and 1 pancreatic mass. Predictors of significant findings with EUS included: age ≥70(OR 3.7, 95CI 1.5-10.0), non-biliary-type abdominal pain without chronic pain(OR 6.1, 95CI 2.3-17.3), CBD diameter ≥15 mm or ≥17mm with cholecystectomy(OR 6.9, 95CI 2.7-18.7), and prior ERCP(OR 6.8, 95CI 2.1-22.5). A point-based novel clinical prediction model was created: age ≥70=1, non-biliary-type abdominal pain without chronic pain=2, prior ERCP=2, CBD dilation=2. A score <1 had 93% (development) and 100% (validation) sensitivity and predicted a <2% chance of having a significant finding in both cohorts while excluding the need for EUS in ∼30% of both cohorts. Conversely, a score >4 was >90% specific for the presence of significant pathology. CONCLUSION: Less than 10% of patients undergoing EUS for incidental CBD dilation had pathologic findings. This novel, externally validated, clinical prediction model may reduce low-yield, invasive evaluation in nearly a third of patients.

Identification of patients with malignant biliary strictures using a cholangioscopy-based deep learning artificial intelligence (with video).

BACKGROUND AND AIMS: Accurately diagnosing malignant biliary strictures (MBSs) as benign or malignant remains challenging. It has been suggested that direct visualization and interpretation of cholangioscopy images provide greater accuracy for stricture classification than current sampling techniques (ie, brush cytology and forceps biopsy sampling) using ERCP. We aimed to develop a convolutional neural network (CNN) model capable of accurate stricture classification and real-time evaluation based solely on cholangioscopy image analysis. METHODS: Consecutive patients with cholangioscopy examinations from 2012 to 2021 were reviewed. A CNN was developed and tested using cholangioscopy images with direct expert annotations. The CNN was then applied to a multicenter, reserved test set of cholangioscopy videos. CNN performance was then directly compared with that of ERCP sampling techniques. Occlusion block heatmap analyses were used to evaluate and rank cholangioscopy features associated with MBSs. RESULTS: One hundred fifty-four patients with available cholangioscopy examinations were included in the study. The final image database comprised 2,388,439 still images. The CNN demonstrated good performance when tasked with mimicking expert annotations of high-quality malignant images (area under the receiver-operating characteristic curve, .941). Overall accuracy of CNN-based video analysis (.906) was significantly greater than that of brush cytology (.625, P = .04) or forceps biopsy sampling (.609, P = .03). Occlusion block heatmap analysis demonstrated that the most frequent image feature for an MBS was the presence of frond-like mucosa/papillary projections. CONCLUSIONS: This study demonstrates that a CNN developed using cholangioscopy data alone has greater accuracy for biliary stricture classification than traditional ERCP-based sampling techniques.

Post-bariatric Surgery Changes in Secondary Esophageal Motility and Distensibility Parameters.

INTRODUCTION: Despite the increasing number of bariatric procedures over the recent years, the physiological changes in secondary esophageal motility and distensibility parameters after surgery remain unknown. METHODS: This is a retrospective, single-center cohort study comparing esophageal planimetry and gastroesophageal junction (GEJ) distensibility in post-bariatric surgery patients (Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and conversion/revisional patients (DH)) and native-anatomy patients with obesity (NAC). Distensibility refers to the area achieved with a certain amount of pressure, and secondary peristalsis represents the esophageal response to an intended obstruction. Patients with pre-surgical dysmotility symptoms were excluded from the study. RESULTS: From November 2018 to January 2023, 167 patients were evaluated and eligible for this study (RYGB = 87, SG = 33, NAC = 22, DH = 25). In NAC cohort, 17/22 (77%) patients presented normal motility patterns compared to 35/87 (40%) RYGB, 12/33 (36%) SG, and 5/25 (20%) DH (p < 0.05 for all comparisons). The most common abnormal motility pattern for all three bariatric cohorts was absent contractions. DH patients generally had the highest mean maximum distensibility index averages, followed by SG, RYGB, and NAC. CONCLUSION: Bariatric surgery affects esophageal and GEJ physiology, and it is associated with higher rates of secondary dysmotility. DH patients have even higher rates of dysmotility. Further studies assessing clinical data and their correlation with manometric and pH-metric findings are needed.

Successful endoscopic removal of foreign body lacerating into the duodenum.

Video 1The endoscope was advanced under direct visualization to the third part of the duodenum. A foreign body consistent with a ballpoint pen was identified in the duodenum. The sharp end of the pen formed a deep laceration through the second portion of the duodenum. The blunt end of the pen was ulcerated into the third portion of the duodenum with 2 additional pressure ulcers located in close proximity. Removal of the pen was first attempted using a snare without success. The foreign body was then successfully removed with a rat tooth. The second portion of the duodenum showed minimal oozing with contained deep laceration. The third portion of the duodenum showed 2 pressure ulcers.

Efficacy and safety of endoscopic ultrasound-guided gastrojejunostomy in patients with malignant gastric outlet obstruction and ascites.

Background and study aims Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is an endoscopic procedure for treating gastric outlet obstruction (GOO). Limited data exist regarding the safety and efficacy of EUS-GJ in patients with malignant GOO with ascites. Thus, we aimed to study the outcomes and safety of EUS-GJ in GOO patients with vs. without ascites. Patients and methods This is a retrospective cohort study of patients with malignant GOO who underwent successful EUS-GJ at a tertiary care academic center. Primary outcomes included the efficacy and safety of EUS-GJ. Secondary outcomes included 30-day readmission, reintervention, and survival utilizing Kaplan-Meier analysis. Results A total of 55 patients (mean age of 67.0 ±â€Š11.3 years, 40.0 % female) who underwent EUS-GJ, of whom 24 had ascites (small in 22, large in 2) were included. Clinical success was achieved in 91.7 % and 93.5 % ( P =  1.00) of patients with and without ascites, respectively. A higher rate of adverse events (AEs) was noted in patients with ascites but this was not statistically significant (37.5 % vs. 19.4 %, P =  0.13). Four patients in the ascites group (16.6 %) developed clinical evidence of peritonitis or sepsis post-EUS-GJ. Eight patients with ascites developed worsening ascites within a month of EUS-GJ. In contrast, only one patient without ascites developed evidence of new ascites. The median survival of patients was not significantly different between the two groups (patients with ascites: 129 days vs. patients without ascites: 180 days, ( P =  0.12). Conclusions The efficacy EUS-GJ in the presence of ascites is promising; however, the safety profile remains concerning given the high rate of AEs, specifically peritonitis and sepsis.

Histological assessment of new cholangioscopy-guided forceps in ERCP biliary stricture sampling: a blinded comparative study.

Background and study aims Obtaining quality tissue during ERCP biliary stricture sampling is of paramount importance for a timely diagnosis. While single-operator cholangioscopy (SOC)-guided biopsies have been suggested to be the superior biliary tissue acquisition modality given direct tissue visualization, less is known about the specimen histological quality. We aimed to analyze the specimen quality of SOC biopsies and compare the new generation forceps with prior "legacy" forceps. Patients and methods Patients who underwent SOC from January 2017-August 2021 for biliary sampling were reviewed. In February 2020, the SOC-guided biopsy forceps were changed from legacy SpyBite to the SpyBite Max forceps (max). Specimens were assessed by blinded pathologists for crush artifact (none, mild, or severe) and gross size (greatest dimension in mm). Crush artifact and gross size were compared between the two groups. The diagnostic performance characteristics for cholangiocarcinoma (CCA), were assessed in an exploratory fashion. Results Eighty-one patients (max = 27, legacy = 54) with similar baseline characteristics were included in this study. On blinded pathological assessment, 58 % had crush artifact, without significant differences between the two groups (Max 63 % vs. Legacy 56 %; P  = 0.64). A similar mean specimen size was found (max 3 mm vs. legacy 3.2 mm; P  = 0.24). The overall prevalence of CCA was 40 %. The sensitivity, specificity, positive predictive value, and negative predictive value of the entire cohort using a combination of cytology, fluorescence in situ hybridization, and SOC-guided biopsies were 78.1 %, 91.8 %, 86.2 %, and 86.5 %, respectively. No difference between legacy or max groups was found. Conclusions A high rate of crush artifact was found in SOC-guided biopsy specimens. Further investigation regarding proper biopsy technique and handling is necessary to increase the diagnostic yield with SOC-guided biopsies.

Congenital nephrotic syndrome.

Congenital nephrotic syndrome (CNS), a challenging form of nephrotic syndrome, is characterized by massive proteinuria, hypoalbuminemia, and edema. Extensive leakage of plasma proteins is the main feature of CNS. Patients can be diagnosed in utero or during the first few weeks of life, usually before three months. The etiology of CNS can be related to either genetic or nongenetic etiologies. Pathogenic variants in NPHS1, NPHS2, LAMB2, WT1, and PLCE1 genes have been implicated in this disease. The clinical course is complicated by significant edema, infections, thrombosis, hypothyroidism, failure to thrive, and others. Obtaining vascular access, frequent intravenous albumin infusions, diuretic use, infection prevention, and nutritional support are the mainstay management during their first month of life. The best therapy for these patients is kidney transplantation. CNS diagnosis and treatment continue to be a challenge for clinicians. This review increases the awareness about the pathogenesis, diagnosis, and management of CNS patients.

Complete endoscopic removal of an eroded magnetic sphincter augmentation device.

Video 1Technique for complete endoscopic removal of the eroded and migrated LINX device using the Ovesco DC current retrieval system.

Indications and Outcomes of Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass: a Systematic Review and a Meta-analysis.

PURPOSE: Sleeve gastrectomy (SG) is the most performed bariatric procedure. Conversion to Roux-en-Y gastric bypass (RYGB) for SG-related complications such as gastroesophageal reflux disease (GERD), insufficient weight loss (ISWL), and weight regain (WR) is increasing. Our aim was to investigate the safety, efficacy, and outcomes of conversion from SG to RYGB. METHODS: A literature search was performed from database inception to May 2020. Eligible studies must report indications for conversion, %total body weight loss (%TWL), and/or complications. The pooled mean or proportion were analyzed using a random-effects model. RESULTS: Seventeen unique studies (n = 556, 68.7% female, average age at time of conversion 42.6 ± 10.29 years) were included. The pooled conversion rate due to GERD was 30.4% (95% CI 23.5, 38.3%; I2 = 63.9%), compared to 52.0% (95% CI 37.0, 66.6%; I2 = 85.89%) due to ISWL/WR. The pooled baseline BMI at conversion was 38.5 kg/m2 (95% CI 36.49, 40.6 kg/m2; I2 = 92.1%) and after 1 year was 32.1 kg/m2 (95% CI 25.50, 38.7 kg/m2; I2 = 94.53%). The pooled %TWL after 1 year was 22.8% (95% CI 13.5, 32.1%; I2 = 98.05%). Complication rate within 30 days was 16.4% (95% CI 11.1, 23.6%; I2 = 57.17%), and after 30 days was 11.4% (95% CI 7.7, 16.7%; I2 = 0%). CONCLUSION: This meta-analysis showed that conversion from SG to RYGB is an option for conversion at a bariatric care center that produces sufficient weight loss outcomes, and potential resolution of symptoms of GERD. Further indication-based studies are required to obtain a clearer consensus on the surgical management of patients seeking RYGB following SG.

The Efficacy of Therapeutic Selective Nerve Block in Treating Lumbar Radiculopathy and Avoiding Surgery.

BACKGROUND: Selective nerve root block (SNRB) is a procedure that can be used as a diagnostic or a therapeutic method. SNRB can be used in multiple sites, including cervical and lumbar . Our study aims to investigate the clinical effectiveness of the use of fluoroscopically guided therapeutic selective nerve root block as a non-surgical symptom management of lumbar radiculopathy. PATIENTS AND METHODS: This is a prospective study of therapeutic nerve root block in 76 patients with low back pain and/or sciatica at Jordan University Hospital. Data was collected by independent clinical interviewers, and visual analogue score (VAS) was used to measure pain severity. RESULTS: A total of 76 patients, 25 (32.8%) males and 51 (67.2%) females, underwent SNRB. 69 (90.7%) patients improved immediately after the procedure. Out of the total, 22 (28.9%) patients showed a long-term relief of symptoms and did not experience any recurrence during the three months of follow-up, while 47 (61.8%) experienced a recurrence of pain. In patients experiencing recurrence of symptoms, 35 needed surgery. CONCLUSION: Therapeutic SNRB is an important procedure in the pain management of patients with lumbar radiculopathy caused by lumbar disc prolapse and foraminal stenosis. Our study showed that avoidance of surgery was achieved in up to 54% of patients; pain relief for at least 6 months was achieved in up to 29% of patients after a single SNRB. This makes it a very good second line of management after conservative treatment and a possible method to delay, and sometimes cease, the need for surgery.