Training Experience and Outcomes of the First Cohort of the ASGE Diagnostic EUS Training Program

Introduction: Despite the expanding role and need for endoscopic ultrasound, training opportunities for established endoscopists in the USA are limited. ASGE launched a novel competency-based program to address this training need in 2019. It includes an online learning modules, live webinars, a hands-on weekend course, a summative knowledge exam, followed by a customizable preceptorship with an EUS expert. Aim(s): To describe the training experience of a sample from the first cohort of the ASGE Diagnostic EUS training program. Method(s): A total of 26 applicants were chosen for the first cohort of the training program in 2019. We describe the experience of 3 endoscopists (ST at the Swedish Digestive Health Institute, Seattle, WA;BM at the Borland Groover Clinic, Jacksonville, FL and JH at Guthrie, Sayre, PA) who completed their hands-on training. Their case volumes were 160 (4 mentors), 185 (2 mentors) and 185 (3 mentors) respectively over a total of 12 weeks each. While 1 trainee (JH) was able to get trained at the same institute where he was employed, the other 2 (ST, JH) had to seek training in another state due to lack of preceptorship sites within their states of employment. One center tracked TEESAT scores (The EUS and ERCP Skills Assessment Tool) for every 5 procedures for their trainee (ST), and he was noted achieved a global score of 4 by the 150 th procedure. Result(s): All 3 trainees have been credentialed for EUS privileges at their respective institutes, and are performing EUS independently. Conclusion(s): The ASGE EUS diagnostic training program was able to fulfil the training needs of motivated established clinicians in full time practice. The main challenges encountered were identifying willing institutes and expert EUS preceptors, and institutional administrative barriers. COVID restrictions were a unique hurdle to the timely completion of preceptorship. This program's success in the future depends on buy in from EUS experts in the community and their respective institutions.

Cholelithiasis Causing Asymptomatic Cholecystoenteric Fistula

Introduction: Biliary fistulas are a rare complication of gallstones. Fistula formation can occur in a number of adjacent sites;even more rare complication is the formation of a cholecystocolonic fistula. Case Description/Methods: A 74-year-old man who had recently undergone an extensive hospitalization secondary to inflammatory demyelinating polyneuropathy (IDP) and COVID-19 infection. During his hospitalization, he required ICU admission and mechanical ventilation with subsequent PEG tube placement. He was discharged to an inpatient rehabilitation facility when he developed worsening respiratory distress. Laboratory examinations were pertinent for ALT of 252, AST of 140 and ALP of 401 without hyperbilirubinemia. Blood cultures revealed Escherichia coli bacteremia. Given transaminitis and bacteremia, an MRCP was performed which demonstrated evidence absent space between gallbladder and hepatic flexure of the colon suggesting a CCF (Figure A). An ERCP with sphincterotomy was performed which showed extravasation of contrast from the gallbladder into the colon at the hepatic flexure (Figure B). He underwent cholecystectomy and fistula repair without any complications and gradual improvement in liver function test. He was discharged to a rehabilitation facility. Discussion(s): Complications of gallstones are well established, which include the common bile duct obstruction, but also include the rare occurrences of acute cholangitis, malignancy, and fistula formation. CCF is a rare complication of gallstones which can occur in the stomach, duodenum, or colon with a variable clinical presentation. Complications from an undiagnosed fistula can be life threatening including colon perforation and fecal peritonitis. This case highlights the diagnostic challenge and the high degree of clinical suspicion involved in establishing the diagnosis of CCF in patient without abdominal symptoms suggestive of gallbladder disease. We hypothesize that stone formation resulting in the development of the fistula may be secondary to the underlying history of IDP and subsequent immobility. Although rare, CCF should be considered in patients presenting with unexplained pneumobilia and bacteremia. A timely diagnosis should be made to proceed with immediate treatment including cholecystectomy and fistula closure to prevent fatal complications.

What the Eye Cannot See: A Case of Persistent Altered Mental Status in a Patient With Cholestatic Liver Disease?

Introduction: Altered mental status (AMS) is a common symptom in patients with liver disease with a wide list of differential diagnoses. Knowledge of etiologies of AMS unique to patients with hepatic dysfunction is vital in order to help recognize, diagnose, and treat the underlying cause in a timely manner. Case Description/Methods: A 46-year-old man with a history of recent COVID infection was transferred to our hospital for further evaluation of acute liver injury and AMS. On arrival, his labs were notable for AST of 408 U/L, ALT of 620 U/L, ALP of 5942 U/L, TB of 11.0 mg/dL, and an INR of 1.1. His work-up included an MRCP that showed segmental biliary ductal dilation with associated restricted diffusion and peribiliary enhancement concerning for sclerosing cholangitis. ERCP revealed a 3cm biliary cast that was removed and noted diffuse rarefaction of ducts throughout the entire biliary tree. A liver biopsy revealed centrizonal cholestasis with portal-based bile ductular reaction and mild bile duct injury. Despite adequate treatment of suspected infection and hepatic encephalopathy, his AMS persisted. His basic metabolic panel (BMP) was notable for Na of 143 mEq/L. A send-out lipid panel that was obtained to work-up his dyslipidemia revealed a total cholesterol of 1018 mg/dL, triglycerides of 420mg/dL, and the presence of lipoprotein X. A venous blood gas (VBG) was obtained showing a Na of 157 mEq/L and serum osmolality was 322 mmol/kg, confirming true hypernatremia. He was slowly treated with hypotonic solutions with significant improvement in his mentation. On follow-up one year later, he has persistent cholestasis and is currently being considered for liver transplant. Discussion(s): The final diagnosis was COVID-related ischemic cholangitis and disappearing bile ducts with persistent cholangiopathy, presenting with severe cholestasis, accumulation of lipoprotein X, and pseudonormonatremia. When faced with severe cholestatic liver disease, clinicians should keep in mind the possibility of accumulation of lipoprotein X and its association with hyperviscosity and spurious electrolyte abnormalities. Clinicians should rely on obtaining blood gas analyses for accurate electrolyte measurement in such cholestatic patients as blood gas analyses utilize direct ion-sensitive electrodes (ISE) to measure electrolytes, whereas routine basic metabolic panels utilize indirect ISE that are liable to spurious results in the presence of hyperlipoproteinemia/lipoprotein X.

Barking up the Wrong Hepatobiliary Tree: A Case of Elevated CA19-9

Introduction: Incidental elevations in Carbohydrate Antigen 19-9 (CA19-9) can trigger extensive medical evaluations for malignancy. Though classically associated with pancreatic cancer, CA19-9 is a nonspecific manifestation of multiple benign and malignant disease processes. Case Description/Methods: An asymptomatic, healthy 50-year-old female presented to primary care for an elevated CA19-9 level obtained for pancreatic cancer screening in Asia in 2019. Her evaluation in 2019 included abdominopelvic CT and magnetic retrograde cholangiopancreatography, which were normal. She was offered endoscopic ultrasonography to further evaluate pancreaticobiliary etiologies but was lost to follow-up amid the COVID-19 pandemic. She returned to the US in 2021, and basic laboratory testing and routine cervical cancer screening were performed. She was referred to Gastroenterology (GI) for further evaluation. Cervical cytology revealed atypical endometrial cells, and endometrial biopsy by gynecology was concerning for gastric-type endocervical adenocarcinoma. Transvaginal ultrasound revealed a thickened endometrial stripe, and pan CT revealed duodenal thickening, for which GI performed bidirectional endoscopy without significant abnormalities and no pancreatic or metastatic disease. Repeat CA19- 9 increased. She was referred to gynecologic oncology, where cervical biopsy and pelvic MRI confirmed an endocervical mass. She was diagnosed with Stage IIB gastric-type endocervical adenocarcinoma and underwent hysterectomy and left salpingectomy with adjuvant chemoradiation. Discussion(s): CA19-9 is synthesized in multiple organ systems. Elevations in asymptomatic patients are rarely predictive of pancreatic cancer but may expose patients to unnecessary testing and inadvertent harms without identifying malignancy. Thus, CA19-9 is not recommended for pancreatic cancer screening. Incidental elevations do warrant repeat testing. Benign processes will yield stable or decreasing levels, while rising levels suggest progressive or malignant processes. If concern for pancreatic malignancy is low, a reasonable investigation includes chest X-ray or CT, metabolic studies, hemoglobin A1c, liver and thyroid function panels, abdominopelvic CT or gynecologic cancer evaluation, and any other age-indicated cancer screening. In this case, prior imaging studies suggested low concern for pancreatic cancer. Her subsequent evaluation aligned with this suggested work-up and revealed gynecologic cancer as the ultimate etiology for her elevated CA19-9.

Respiratory support with nasal high flow without supplemental oxygen in patients undergoing endoscopic retrograde cholangiopancreatography under moderate sedation: a prospective, randomized, single-center clinical trial.

BACKGROUND: Nasal high flow (NHF) may reduce hypoxia and hypercapnia during an endoscopic retrograde cholangiopancreatography (ERCP) procedure under sedation. The authors tested a hypothesis that NHF with room air during ERCP may prevent intraoperative hypercapnia and hypoxemia. METHODS: In the prospective, open-label, single-center, clinical trial, 75 patients undergoing ERCP performed with moderate sedation were randomized to receive NHF with room air (40 to 60 L/min, n = 37) or low-flow O2 via a nasal cannula (1 to 2 L/min, n = 38) during the procedure. Transcutaneous CO2, peripheral arterial O2 saturation, a dose of administered sedative and analgesics were measured. RESULTS: The primary outcome was the incidence of marked hypercapnia during an ERCP procedure under sedation observed in 1 patient (2.7%) in the NHF group and in 7 patients (18.4%) in the LFO group; statistical significance was found in the risk difference (-15.7%, 95% CI -29.1 - -2.4, p = 0.021) but not in the risk ratio (0.15, 95% CI 0.02 - 1.13, p = 0.066). In secondary outcome analysis, the mean time-weighted total PtcCO2 was 47.2 mmHg in the NHF group and 48.2 mmHg in the LFO group, with no significant difference (-0.97, 95% CI -3.35 - 1.41, p = 0.421). The duration of hypercapnia did not differ markedly between the two groups either [median (range) in the NHF group: 7 (0 - 99); median (range) in the LFO group: 14.5 (0 - 206); p = 0.313] and the occurrence of hypoxemia during an ERCP procedure under sedation was observed in 3 patients (8.1%) in the NHF group and 2 patients (5.3%) in the LFO group, with no significant difference (p = 0.674). CONCLUSIONS: Respiratory support by NHF with room air did not reduce marked hypercapnia during ERCP under sedation relative to LFO. There was no significant difference in the occurrence of hypoxemia between the groups that may indicate an improvement of gas exchanges by NHF. TRIAL REGISTRATION: jRCTs072190021 . The full date of first registration on jRCT: August 26, 2019.

Indications and results in cholestatic liver disease - PSC, SSC, PBC.

Primary sclerosing cholangitis (PSC), secondary sclerosing cholangitis (SSC), and primary biliary cholangitis (PBC) are impor-tant indications for liver transplantation. An emerging indication for liver transplantation in selected cases is SSC after severe COVID-19 infection. The clinical presenta-tion of these cholestatic diseases is highly heterogeneous - from asymptomatic and mild elevations of liver enzymes to severe disease-specific complications like recurrent cholangitis or severe bone disorder to de-compensated liver cirrhosis. Such disease-specific clinical complications, disease-spe-cific scores, as well as the MELD score, need to be considered when selecting patients for liver transplantation.Copyright © 2023 Dustri-Verlag Dr. K. Feistle.

Simulator-based training method in gastrointestinal endoscopy training and currently available simulators.

The apprenticeship-based training method (ABTM) is highly effective for gastrointestinal (GI) endoscopic training. However, the conventional ABTM has significant issues. Although many supplementary training methods (TMs) have been developed and utilized, they cannot entirely replace the ABTM, which remains the major TM strategy. Currently, new TM construction is crucial and necessary due to financial constraints, difficulty of obtaining sufficient training time due to patient safety-related regulations, and catastrophic damage caused by disasters such as the coronavirus disease 2019 pandemic. The simulator-based TM (SBTM) is widely accepted as an alternative to the ABTM, owing to the SBTM's advantages. Since the 1960s, many GI endoscopy training simulators have been developed and numerous studies have been published on their effectiveness. While previous studies have focused on the simulator's validity, this review focused on the accessibility of simulators that were introduced by the end of 2021. Although the current SBTM is effective in GI endoscopic education, extensive improvements are needed to replace the ABTM. Incorporating simulator-incorporated TMs into an improved ABTM is an attempt to overcome the incompleteness of the current SBTM. Until a new simulator is developed to replace the ABTM, it is desirable to operate a simulator-integrated and well-coordinated TM that is suitable for each country and institution.

Secondary sclerosing cholangitis in patients with COVID-19 ARDS-a specific entity associated with high mortality?

Introduction SSC-CIP (secondary sclerosing cholangitis in critically ill patients) is characterized by biliary tract destruction after long intensive care treatment. Hypotension and vasopressor therapy are main risk factors. Increased prevalence of SSC-CIP occurred in patients with COVID-19 ARDS that were treated by endoscopic retrograde cholangiography (ERC). Aims The aim of the study was to analyze clinical, laboratory, microbiological and endoscopic fndings of patients with SSC-CIP with COVID-19 ARDS. Methods Data of 17 patients with SSC-CIP with COVID-19 ARDS between February 2020 and August 2022 were analyzed retrospectively. The focus was on endoscopic fndings, laboratory and microbiological values and on clinical parameters and potential risk factors during COVID-19 ARDS. Results 14 male and 3 female patients were included. The mean age was 60 years (range 40-76). All patients were mechanically ventilated, 11 patients were treated with ECMO. All patients required catecholamine therapy but only low dosed when compared with other septic conditions. On average 2.6 ERCs were performed. Biliary casts were found in 94 % of the patients and rarefcation of the intrahepatic bile ducts in 50 %. Bile duct stenosis was detected in 3 patients. Casts were extracted and stenoses were dilated. 13 patients died, 4 patients are in follow-up with repeated endoscopic intervention and re-evaluation in regard to liver transplantation. Discussion Mortality rate in patients with SSC-CIP with COVID-19 ARDS is high. Vasopressor therapy and hypotension was not prominent in this cohort. Endo-scopic treatment may improve liver function, however these patients must be evaluated for liver transplantation.

COVID-19 and liver diseases.

In patients with coronavirus disease 2019 (COVID-19), hepatic involvement occurs in up to 53% of all cases. Via the primary target for severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2), the angiotensin-converting enzyme 2 (ACE2) receptor, expressed on cholangiocytes, sinusoidal endothelial cells, and hepatocytes, direct damage to the liver may occur. Furthermore, indirect (= not receptor-mediated) damage to the liver plays a crucial role in the context of COVID-19 due to severe systemic inflammation with cytokine storm, hepatic thrombosis, and systemic hypoxia. In COVID-19, liver enzymes are considered significant predictors of outcome. Thus, it is essential to rule out other causes of liver enzyme elevation, such as other viral infections, drug-induced liver injury, and metabolic, autoimmune and other liver diseases. Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is highly relevant in treating critically ill patients in the intensive care unit (ICU). Risk factors for SSC-CIP include high doses of catecholamines, high positive end-expiratory pressure (PEEP), and extracorporeal membrane oxygenation (ECMO) therapy. Early recognition of this disease and treatment by endoscopic retrograde cholangiography (ERC) is crucial. Furthermore, liver transplantation should be evaluated. Some patients with COVID-19 are diagnosed with SSC, which is termed COVID-19-associated SSC. COVID-19-associated SSC and SSC-CIP are comparable with regard to clinical phenotype, risk factors, prognosis, and graft-free survival. Patients with pre-existing liver disease are not at increased risk for infection with SARS-CoV-2 but show more severe clinical courses of COVID-19 than patients without pre-existing liver disease. Patients with pre-existing liver cirrhosis may develop acute-on-chronic liver failure (ACLF) upon infection with SARS-CoV-2. ACLF has a high mortality rate, which must be treated in the ICU.Copyright © 2023, The Author(s).

Pancreaticopleural fistula presenting as respiratory distress in previously healthy adolescent

Case Report: Respiratory distress is one of the most common complaints evaluated by pediatric providers in the office and emergency department setting. While primary cardiopulmonary processes represent the majority of cases of respiratory distress, pleural effusions of extravascular origin remain a rare but important differential. In this case, we present a previously healthy adolescent female who presented to our institution with respiratory distress and was subsequently found to have a pancreatic pleural effusion in the setting of a pancreaticopleural fistula. A 13 year old female with no chronic past medical history presented to the emergency department for three weeks of progressively worsening shortness of breath. History was notable for SARS-CoV-2 infection 6 months prior and intermittent night sweats and fevers for previous 4 weeks. She denied trauma, abdominal pain, nausea, vomiting, diarrhea, or anorexia. Her exam was notable for tachycardia, tachypnea, tripod positioning and absent breath sounds on her left. Chest computed tomography (CT) revealed left pleural effusion of entire left hemithorax with midline shift in addition to right sided pulmonary thromboembolism, small right sided pleural effusion and venous thromboses of the left internal jugular, subclavian, and proximal innominate veins. A left thoracentesis was performed, and patient was admitted to the PICU on a heparin infusion with subsequent left chest tube placement. Follow-up CT imaging revealed bilateral renal infarcts, iliac vein thrombosis, and a pancreatic fluid collection extending into the mediastinum with pancreatic ductal dilation. Magnetic resonance cholangiopancreatography further characterized the pancreatic lesion as a cystic tract traversing from the inferior mediastinum into the retroperitoneum and replacing the majority of the pancreatic gland suggesting a pancreaticopleural fistula as the source of a pancreatic pleural effusion. Serum amylase was 256 U/L and serum lipase was 575 U/L. Pleural fluid amylase was 1702 U/L and pleural fluid lipase was >2400 U/L, exceeding detection limit of this institution's lab. An extensive diagnostic work-up included infectious, hematologic, oncologic, autoimmune and rheumatologic etiologies and was largely unremarkable. Given concern for pancreaticopleural fistula, patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) which was diagnostic for pancreatic divisum. A pancreatic duct stent was placed with normalization of serumpancreatic enzymes prior to discharge and resolution of pleural effusion at one month post ERCP Although an initial episode of acute pancreatitis usually resolves with supportive care, this case is a reminder that pancreatitis can present with local and systemic complications including pulmonary effusion or venous thromboses and keeping a high index of suspicionfor it is crucial toavoid delaying diagnosis and care. Copyright © 2023 Southern Society for Clinical Investigation.

Hafnia, a case of translocated septicemia

Case Report: Hafnia alvei, a member of the Enterococcus family, is a gram-negative anaerobe native to the gastrointestinal tract. While very rarely pathogenic, it has historically been associated with gastroenteritis, meningitis, bacteremia, pneumonia, and nosocomial wound infections. Here we report a non-fatal case of Hafnia-septicemia following recent ERCP for Choledocholithiasis. Case Report: 73-year-old Caucasian male with Chronic obstructive pulmonary disease, chronic kidney disease Stage 5, diabetes mellitus and hypertension who presented to the Emergency Department (ED) with a chief complaint of chills and fevers as well as worsening dry hacking cough and intermittent shortness of breath. Of note, patient had presented to the ED the previous day with abdominal pain and nausea after undergoing ERCP for Choledocholithiasis from day prior. Computed tomography (CT) imaging from 1st ED visit showed no acute signs of pancreatitis, however patient was noted to have bibasilar opacities. Lipase was normal at 39. Other lab work was significant for leukocytosis to 11 000. Patient's abdominal pain and nausea resolved while in the ED, he also denied shortness of breath and was breathing comfortably on room air. He was discharged from the ED with 7-day course of Azithromycin for community acquired pneumonia. On return visit next day, patient reported new onset shortness of breath and fevers. Physical exam was remarkable for hypoxia requiring 2 liters nasal cannula, and tachycardia to 104. Patient tested negative for Covid -19. Patient admitted for acute hypoxic respiratory failure and sepsis secondary to presumed bacterial pneumonia. Patient was started on IV Vancomycin and Cefepime and required oxygen support for hypoxia. He showed marked improvement by day two of hospitalization and was weaned off oxygen. Admission Blood cultures were positive for gram negative rods after 24 hours and subsequently grew Hafnia that was pan sensitive except to Ampicillin + Sulbactam. Repeat blood cultureswere negative 24 hours later. Patient was deemed medically stable on day 3 of admission and discharged on PO Levofloxacin for 10-day course for Hafnia septicemia and pneumonia. Discussion(s): When considering the etiology of septicemia especially in the context of a recent gastrointestinal procedure, translocation of anaerobic bacteria should be on the differential. Hafnia alvei is a rare pathologic cause of septicemia with only a handful of reported cases upon literature review. Copyright © 2023 Southern Society for Clinical Investigation.

Real-life patency of plastic biliary stents in the pandemic era: is stent removal after 6 months safe and effective?

BACKGROUND: The SARS-CoV-2 pandemic conditioned the optimal timing of some endoscopic procedures. ESGE guidelines recommend replacement or removal of the plastic biliary stents within 3-6 months to reduce the risk of complications. Our aim was to analyse the outcomes of patients who had delayed plastic biliary stent removal following endoscopic retrograde cholangiopancreatography (ERCP) in the pandemic era. METHODS: Retrospective study including consecutive ERCPs with plastic biliary stent placement between January 2019 and December 2021. Delayed removal was defined as presence of biliary stent >6 months after ERCP. The evaluated outcomes were stent migration, stent dysfunction, obstructive jaundice, cholangitis, acute pancreatitis, hospitalization, and biliary pathology-related mortality. RESULTS: One-hundred and twenty ERCPs were included, 56.7% male patients, with a mean age of 69.4 ± 15.7 years. Indications for plastic biliary stent insertion were choledocholithiasis (72.5%), benign biliary stricture (20.0%), and post-cholecystectomy fistula (7.5%). Delayed stent removal occurred in 32.5% of the cases. The median time to stent removal was 3.5 ± 1.3 months for early removal and 8.6 ± 3.1 months for delayed removal. Patients who had delayed stent removal did not have a significantly higher frequency of stent migration (20.5 vs 11.1%, p = 0.17), stent dysfunction (17.9 vs 13.6%, p = 0.53), hospitalization (17.9 vs 14.8%, p = 0.66), obstructive jaundice (2.6 vs 0.0%, p = 0.33), cholangitis (10.3 vs 13.6%, p = 0.77), acute pancreatitis (0.0 vs 1.2%, p = 1.0), or biliary pathology-related mortality (2.6 vs 1.2%, p = 0.55). CONCLUSIONS: Delayed plastic biliary stent removal does not seem to have a negative impact on patients' outcomes. In the current pandemic situation, while scheduled endoscopic procedures may have to be postponed, elective removal of plastic biliary stents can be safely deferred.

ENDOSCOPY SITUATION AND GASTROENTEROLOGICAL MEDICAL CARE IN BHUTAN

Since October 2019, I worked for 2 years as an endoscopist at Jigme Dorji Wangchuck National Referral Hospital, located at Thimphu, Bhutan. Though this period overlapped the COVID-19 pandemic, I was involved in approximately 4, 000 cases of upper gastrointestinal (GI) endoscopy, 350 cases of colonoscopy, and 140 cases of ERCP. In Bhutan, the infection rate of Helicobacter pylori is higher than 70%, and even among young adults the rate is alarming. Gastric cancer is a malignant disease with the highest mortality and is mostly detected in advanced stages. Therefore, a national flagship project that takes aim at the eradication of H. pylori and early detection of gastric cancer has been recently created. Endoscopic health examinations named Endoscopy Camp are being conducted every weekend. In this article, we showed how upper GI endoscopy, colonoscopy, and ERCP is developing in Bhutan, which still lacks sufficient medical resources. We hope more Japanese endoscopists take an active interest in developing countries' medical care. Copyright © 2022 Japan Gastroenterological Endoscopy Society. All rights reserved.

Secondary sclerosing cholangitis in a young COVID-19 patient resulting in death: A case report.

BACKGROUND: With the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in late 2019 in Wuhan, China, liver injury in patients with coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 infection has been regularly reported in the literature. There are a growing number of publications describing the occurrence of secondary sclerosing cholangitis (SSC) after SARS-CoV-2 infection in various cases. We present a case of sudden onset SSC in a critically ill patient (SSC-CIP) following COVID-19 infection who was previously healthy. CASE SUMMARY: A 33-year old female patient was admitted to our University Hospital due to increasing shortness of breath. A prior rapid antigen test showed a positive result for SARS-CoV-2. The patient had no known preexisting conditions. With rapidly increasing severe hypoxemia she required endotracheal intubation and developed the need for veno-venous extracorporeal membrane oxygenation in a setting of acute respiratory distress syndrome. During the patient´s 154-d stay in the intensive care unit and other hospital wards she underwent hemodialysis and extended polypharmaceutical treatment. With increasing liver enzymes and the development of signs of cholangiopathy on magnetic resonance cholangiopancreatography (MRCP) as well as endoscopic retrograde cholangiopancreatography (ERCP), the clinical setting was suggestive of SSC. At an interdisciplinary meeting, the possibility of orthotopic liver transplantation and additional kidney transplantation was discussed due to the constant need for hemodialysis. Following a deterioration in her general health and impaired respiratory function with a reduced chance of successful surgery and rehabilitation, the plan for transplantation was discarded. The patient passed away due to multiorgan failure. CONCLUSION: SSC-CIP seems to be a rare but serious complication in patients with SARS-CoV-2 infection, of which treating physicians should be aware. Imaging with MRCP and/or ERCP seems to be indicated and a valid method for early diagnosis. Further studies on the effects of early and late SSC in (post-) COVID-19 patients needs to be performed.

Impact of the Second Wave of COVID 19 on Maternal and Fetal Outcome in Tertiary Care Centre and its Comparison with the First Wave - Observational Study

Introduction: The emergence of the COVID-19 pandemic in 2020, have similar effect on pregnant women as influenza or other coronavirus infections. The impact of the COVID-19 pandemic is likely to be context specific and differ depending on a variety of country-specific factors. A global pandemic is likely to only reveal its consequences after significant time passes, and literature published before or immediately after policies are implemented may not capture all relevant outcomes. Material(s) and Method(s): The study was conducted in the Department of Obstetrics and Gynaecology, Gandhi Medical College, Bhopal. It included all antenatal COVID 19 patients which reported to the hospital during April 2020 to May 2021, 1st wave from April 2020 to December 2020 and second wave from Jan 2021 to May 2021 after taking due informed consent. The detailed history and full clinical and general examination were performed using a predesigned proforma. The antenatal patients were categorized into mild, moderate and severe COVID. Data on clinical manifestations, laboratory tests, maternal and perinatal outcomes were extracted and analysed. The comparisons of 1st wave and second wave was done. Result(s): There were 210 confirmed pregnant women with coronavirus disease (COVID-19). 26 maternal deaths occurred from these confirmed cases. Compared to pregnant women without COVID-19, pregnant women with a confirmed COVID-19 diagnosis had an increased risk of maternal complications and caesarean section. In initial months (April 20 to December 20) there were 89 confirmed cases of covid 19 and 4 maternal mortality and from January 21 to May 21 there were 121 cases and 22 maternal deaths. The second wave has taken greater toll on life of pregnant women. Conclusion(s): In the second wave, pregnant women with severe or critical coronavirus disease were admitted to the ICU, intubated if they require mechanical ventilation, and were at increased risk of composite morbidity. Thus, the second wave affected the pregnant women in a much serious way and the maternal as well as fetal outcome were very poor. Copyright © 2022, Dr. Yashwant Research Labs Pvt. Ltd.. All rights reserved.

Pediatric Gastrointestinal Procedural Patterns during the Covid-19 Pandemic in New York City

The COVID-19 pandemic has led to significant disruptions in medical care and initially elective medical procedures were put on hold. Patients avoided medical facilities, deferring care for non-acute conditions. One study found an 86% decrease in colorectal cancer screening volumes after COVID, and research has shown that adult gastroenterology (GI) admissions for conditions such as bleeds and cholecystitis decreased during the pandemic. There is sparse literature documenting pediatric GI procedures and medical utilization during the pandemic. This study analyzes data from five New York City hospitals comprising the INSIGHT Clinical Research Network (CRN) to evaluate procedural patterns during the COVID-19 pandemic. We extracted demographic and clinical data on 18177 GI procedures for children <21 years from the INSIGHT CRN, available from 3/2019 to 11/2021 (27 months). GI procedures were categorized using the card sort method, in which clinicians independently sorted procedures into predefined categories that were then harmonized across clinician results. Daily procedure frequencies from March to July 2020 were plotted to assess early-pandemic trends. Changes in weekly procedure frequency from 2019 to 2021 were also analyzed by year, using 2019 as a baseline against which data from 2020 and 2021 were compared. Specifically, changes across years in weekly mean procedure frequency were assessed using a separate analysis of variance (ANOVA) model for each procedure category, and post-hoc Tukey tests were used for pairwise comparisons of year-specific means for ANOVA models with significant overall differences at a Type I error rate of 0.05. Percent changes in procedure frequency compared to 2019 were plotted by category and year, with post-hoc adjusted statistical significance noted. All races except Pacific Islander showed a decline in procedures during 2020 and a rise in 2021. Median age at procedure was stable. Though literature shows Hispanic and African American communities to be more affected by COVID, they did not have the greatest decline in procedure frequency relative to 2019 (25% and 20% respectively vs Asian decline 41%). During the pandemic period in 2020 (Figure 1), EGD/colonoscopies comprised the majority of procedures taking place. However, overall pediatric GI procedures declined precipitously during this period, from a mean daily procedure count of 23.5 from March to November of 2019 to 0.77 in April 2020 (Figure 1). We noted a >40% decline in more invasive procedures such as liver and rectal suction biopsies. Procedures used in more acute settings, such as foreign body removal and bleeding control, had a smaller percent change during the pandemic (11% for both, see Figure 2). Compared to 2019, we noted a significant increase in motility procedures in 2021, potentially indicating a rise in functional illness. Further, there was an increase in foreign body removal during the same period, possibly due to circumstances of less supervision, and ERCP and EUS also increased. The COVID-19 pandemic led to multiple changes in pediatric GI procedures, however EGD/colonoscopies continued in the pediatric population contrary to what has been seen in adult literature. More invasive procedures requiring procedural rooms and admission were delayed, while more urgent procedures continued as expected. Additionally, it is noted after the initial pandemic wave that motility procedures increased. This phenomenon follows research showing increases in functional and mental health illnesses post pandemic. More research is needed to assess the health ramifications of the significant decline in procedures during the pandemic.

Quality of death in cancer patients managed by gastroenterologists

Background: Care in hospitals is generally focused on prolonging life and may not adequately address the needs of dying patients. The incidence of oncologic diseases is rising, and efforts should be made to guarantee a better quality of death and dying. Aim: to evaluate the end-of-life care in patients with cancer under gastroenterologist care. Methods: Cross-sectional study including all in-patients with cancer who deceased in a Gastroenterology department in Portugal between 2012-2021. Demographic characteristics, clinical attitudes, therapeutic interventions and symptom control up to 6 months prior to the patient’s death were assessed. Results: We included 120 patients, 73% male, mean age 71±12.5 years. The most common cancers were hepatocellular carcinoma (35%), gastric cancer (16%), pancreatic cancer (15%) and cholangiocarcinoma (14%). One third of the patients had ECOG of 0-1 at admission and 77% (n=92) had advanced disease (stage IV or Barcelona Clinic Liver Cancer C/D). The median number of emergency consultations and hospitalizations in the 6 months before death was 2 (IQR 1-4). In their last month of life, the median time of hospitalization was 21.5 (IQR 12-25) days. It was documented the presence of an available caregiver in 56%(n=68) and spiritual support in only 2% (n=2) of the cases. One quarter of the patients experienced not adequately controlled pain and 72% received opioids. Palliative care consultation occurred in 60% (n=72) with a median time between that and death of 12 (IQR 3-18) days. Invasive procedures (diagnostic and therapeutic endoscopy, ERCP and EUS) were performed in half of the patients, achieving technical and clinical success in 62% (n=38) and 32% (n=19) of the cases, respectively. The mean time between those interventions and death was 12±10 days. The prognosis was discussed with the patient and family in 35% and 68% of the cases, respectively. At least 73% of the patients had visits at the end of life, which was negatively affected by the COVID-19 pandemic (p=0.022). Conclusions: In our cohort, we found a high hospitalization length of stay in the last month of life and high percentage of invasive treatments until shortly before dying. Thus, it is urgent to define and implement metrics of quality of death to prevent futile/potentially inappropriate treatment. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.

LIKELIHOOD OF ENDOSCOPY CANCELLATION BASED ON VANCOMYCINRESISTANT ENTEROCOCCI (VRE) COLONIZATION STATUS AND INFECTION CONTROL PRACTICES

Background: “Terminal cleaning” is a practice of rigorous cleaning of endoscopy suite following endoscopies for patients colonized with vancomycin-resistant enterocci (VRE) with the intention of reducing VRE transmission. Such practice entails double-wiping all surfaces including the floor with disinfectants before a non-VRE patient can use the endoscopy room. While intuitive, such time-consuming practice is not supported by evidence and may have unintended negative impact on patient access to timely endoscopic evaluation. Aims: To determine whether terminal cleaning of endoscopy suite for VRE-colonized patients has any negative impact on inpatient access to timely endoscopic evaluation. Methods: As part of a quality improvement study, inpatient endoscopy data was gathered over a 3-month period between February 2021 and April 2021 at a tertiary centre. EUS, ERCP, and travel cases outside of the endoscopy suite were excluded. The cancellation rates were compared between VRE-colonized patients and non-VRE patients using the Fisher's exact test. P value of <0.05 was considered statistically significant. Results: A total of 262 inpatient endoscopic procedures were scheduled and included in the study. Sixty-six (25.2%) of inpatient procedures were cancelled during this period (Table 1). A total of 24 procedures were scheduled for VRE patients, 9 of which were cancelled because of insufficient operating time and two due to concurrent carbapenamase-producing organism carriage and poor bowel preparation. In the non-VRE group, 55 (23.3%) procedures were cancelled for various reasons (Table 1). In subgroup analysis where cancellations related to COVID-19 (n=14) were omitted, VRE patients had a significantly higher rate of procedure cancellations compared to non-VRE patients (42.3% vs. 18.5%;p<0.01). Conclusions: The overall endoscopy cancellation rate for VRE-colonized patients was higher than those who were non-VRE-colonized. We propose that this is likely secondary to the delays from unnecessary terminal cleans imposed for VRE-colonized patients and await for postintervention data. (Table Presented).

THE IMPACT OF CENTRAL COORDINATION ON ENDOSCOPY EFFICIENCY

Background: The impacts of the COVID-19 pandemic have been far reaching and have necessitated many changes to healthcare delivery. At the QEII Health Sciences Center physical space limitations for patient check-in and recovery have restricted outpatient endoscopy to 3 of 4 available endoscopy suites. On June 1, 2020 a new system of central endoscopy triage and coordination for the Division of Digestive Care and Endoscopy (DC&E) was implemented in an effort to increase efficiency and maintain patient access to endoscopy. The components of the RESET (Re-introduce Endoscopy Safely and EfficienTly) Plan included a) a new endoscopy coordinator role to manage a common endoscopy waitlist, endoscopist schedules, and booking clerks, b) a modified triage system to improve waitlist consistency, c) a common endoscopy waitlist with patients booked in the next available appointment regardless of endoscopist, d) discontinuation of fixed endoscopy slots for endoscopists, and e) appointment scheduling no sooner than 4-weeks in advance to minimize no-shows and last-minute cancellations. Aims: The aim of this study is to evaluate the impact of the RESET Plan on the efficiency of DC&E endoscopy. Methods: A retrospective pre- and post-implementation study evaluating the volume and efficiency of outpatient endoscopy before and after implementation of the RESET Plan. The Pre-RESET period included all procedures performed from June 1, 2019 to October 31, 2019. The Post-RESET period included all procedures performed from June 1, 2020 to October 31, 2020. A separate endoscopy suite and triage system is used for endoscopic retrograde cholangiopancreatography (ERCP) and these cases were excluded. Early effectiveness outcomes were reported including a comparison of the number of endoscopic procedures per week and per list, pre- and post- implementation. Data analysis was primarily descriptive with data expressed as frequencies, means (SD), and proportions (%). Exploratory group comparisons were performed using independent-samples T-Test. Results: During the 5-month Pre-RESET period, 2203 endoscopic procedures were performed. During the Post-RESET period a total of 1920 procedures were performed. Due to pandemic restrictions, there was a 29% decrease in available endoscopy lists from 2019 to 2020. There was a 24% increase in the number procedures performed per endoscopy list, from 6.4 to 8.0 (p=0.004, 95% CI 0.52- 2.53), pre- and post-RESET. Conclusions: While the COVID-19 pandemic has disrupted healthcare delivery, it has also provided an opportunity to implement health system structure and process changes. The RESET Plan resulted in significant gains in efficiency which largely offset losses in endoscopy throughput imposed by COVID-19 pandemic restrictions. Future research will determine what patient and health system factors most significantly impact system efficiency as well as the cost-effectiveness of the RESET Plan.

THE CLINICAL IMPACT OF COVID-19 DELAYS ON PLASTIC BILIARY STENT REMOVAL IN NOVA SCOTIA

Background: The COVID-2019 pandemic continues to restrict access to endoscopy, resulting in delays or cancellation of non-urgent endoscopic procedures. A delay in the removal or exchange of plastic biliary stents may lead to stent occlusion with consensus recommendation of stent removal or exchange at three-month intervals [1-4]. We postulated that delayed plastic biliary stent removal (DPBSR) would increase complication rates. Aims: We aim to report our single-centre experience with complications arising from DPBSR. Methods: This was a retrospective, single-center, observational cohort study. All subjects who had ERCP-guided plastic biliary stent placement in Halifax, Nova Scotia between Dec 2019 and June 2020 were included in the study. DPBSR was defined as stent removal >=90 days from insertion. Four endpoints were assigned to patients: 1. Stent removed endoscopically, 2. Died with stent in-situ (measured from stent placement to documented date of death/last clinical encounter before death), 3. Pending removal (subjects clinically well, no liver enzyme elevation, not expired, endpoint 1 Nov 2020), and 4. Complication requiring urgent reintervention. Kaplan-Meier survival analysis was used to represent duration of stent patency (Fig.1). Results: 102 (47.2%) had plastic biliary stents placed between 2/12/2019 and 29/6/2020. 49 (48%) were female, and the median age was 68 (R 16-91). Median follow-up was 167.5 days, 60 (58.8%) subjects had stent removal, 12 (11.8%) died before replacement, 21 (20.6%) were awaiting stent removal with no complications (median 230d, R 30-332), 9 (8.8%) had complications requiring urgent ERCP. Based on death reports, no deaths were related to stent-related complications. 72(70.6%) of patients had stents in-situ for >= 90 days. In this population, median time to removal was 211.5d (R 91-441d). 3 (4.2%) subjects had stent-related complications requiring urgent ERCP, mean time to complication was 218.3d (R 94-441). Stent removal >=90 days was not associated with complications such as occlusion, cholangitis, and migration (p=1.0). Days of stent in-situ was not associated with occlusion, cholangitis, and migration (p=0.57). Sex (p=0.275), cholecystectomy (p=1.0), cholangiocarcinoma (p=1.0), cholangitis (p=0.68) or pancreatitis (p=1.0) six weeks prior to ERCP, benign vs. malignant etiology (p=1.0) were not significantly associated with stent-related complications. Conclusions: Plastic biliary stent longevity may have been previously underestimated. The findings of this study agree with CAG framework recommendations [5] that stent removal be prioritized as elective (P3). Limitations include small sample size that could affect Kaplan-Meier survival analysis. Despite prolonged indwelling stent time as a result of COVID-19, we did not observe an increased incidence of stent occlusion or other complications.