Herpes Gastritis: A Rare Cause of Gastric Outlet Obstruction

Introduction: Gastrointestinal tract involvement from herpes simplex virus is commonly associated with esophagitis. However, herpes simplex infection of the stomach is very rare with only a handful of cases being reported in immunocompromised patients. We present a case of herpes gastritis causing gastric outlet obstruction in an otherwise healthy, immunocompetent individual. Case Description/Methods: A 37-year-old male with a recent past medical history of COVID-19 infection, presented to the hospital with intractable nausea, vomiting, bloating, and early satiety for two days. Upon evaluation, CBC and CMP were remarkable for a WBC of 12.5 k/mm3 and ALT and AST of 124 U/L and 129 U/L, respectively. Lipase was 373 U/L. A CT abdomen/pelvis w/contrast showed circumferential wall thickening with edematous changes in the antrum consistent with localized inflammatory response. There was suspicion for gastric lymphoma and patient was admitted for further workup. An EGD was performed which showed exudative esophagitis and antral wall edema with luminal narrowing of gastric antrum. Endoscopic ultrasound (EUS) showed a 2.5 x 3 cm antral wall lesion worrisome for linitis plastica. Esophageal biopsies showed focal cytologic changes consistent with herpes esophagitis. The FNA of the gastric antral wall showed multinucleation of the basal cell layer with classic ground glass nuclei, consistent with herpes infection. No dysplasia or malignancy was seen. Both HSV1 and HSV2 IgG were elevated. HSV IgM was normal. A HSV PCR was ordered but never resulted. Patient was started on Valacyclovir 1 g PO BID for 10 days. He underwent a follow-up EGD 3 months later which showed complete resolution of the gastric antral changes (Figure). Discussion(s): Herpes gastritis is extremely rare. Literature review has revealed only 3 case reports of herpes gastritis;and all involved immunocompromised patients. To the best of our knowledge, this is the first case of herpes gastritis in an immunocompetent patient. Our patient presented with symptoms of gastric outlet obstruction which was caused by local inflammation from herpes simplex. It is unclear if having a COVID 19 infection altered patient's immunity and lead to herpes gastritis. This may need further investigation. No established guideline exists for treatment duration. Our patient received 10-day course of Valacyclovir, and his symptoms improved. Furthermore, patient had complete resolution of the herpes infection on follow-up EGD, indicating adequate treatment response.

A Diagnostically Challenging Case of Primary Pancreatic Lymphoma

Introduction: Primary Pancreatic Lymphoma (PPL) is the exceedingly rare instance of extranodal Non-Hodgkin's Lymphoma developing mainly in the pancreas.We report a diagnostically challenging case of a patient presenting with a rapidly growing pancreatic mass, found to have PPL. Case Description/Methods: A 48-year-old female with past history of tobacco use presented with several months of cramping abdominal pain following COVID-19 infection. She denied weight loss, fevers, or night sweats. Her physical exam, CBC, CMP, lipase, LDH, and CA 19-9 were unremarkable. An abdominal ultrasound revealed a 2.8 x 1.9 x 3 cm cystic mass of the pancreatic head, most congruent with a pseudocyst. Worsening abdominal pain prompted repeat ultrasound one month later, which showed a doubling in size. Endoscopic ultrasound (EUS) with fine needle aspiration of the cystic mass and surrounding lymph nodes yielded cystic contents and reactive lymphadenopathy. Two months later, her abdominal pain worsened and repeat imaging showed further doubling in size with encasement of the celiac plexus. A second FNA performed via EUS redemonstrated cystic contents. An ultrasound-guided core needle biopsy of the mass revealed necrotic CD301 diffuse large B cell lymphoma (DLBCL). PET scan was suggestive of stage IV PPL (Figure). Imaging also identified an inguinal lymph node that returned as CD101 BCL61 high grade follicular lymphoma, which was thought to be a distinct lesion. She was started on R-CHOP. Her clinical course was complicated by the formation and subsequent rupture of a splenic artery pseudoaneurysm, gastrointestinal bleeding, anuric kidney injury, and intestinal ischemia. She ultimately transitioned to comfort care. Discussion(s): Primary pancreatic lymphoma comprises 0.6% of extranodal lymphomas and 0.2% of primary pancreatic tumors. The clinical presentation is often vague and includes abdominal pain, B symptoms, jaundice, or bowel obstruction. The diagnostic criteria according to the WHO requires that the (1) majority of tumor burden be localized to the pancreas and (2) existing nearby and distant lymph node involvement should be secondary to pancreatic presentation. A biopsy is required to diagnose PPL, which is histologically most often DLBCL. Our case highlights the challenges associated with diagnosing PPL despite two EUS with FNA. Although rare, one should proceed with a high index of suspicion for PPL in any patient presenting with a rapidly enlarging pancreatic mass.

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.

Radiologic and Endoscopic Treatment for a Disconnected Pancreatic Duct Syndrome Associated to Percutaneous Pancreatic Fistula: Achieving the "Internalization of the Fistula"

Background and aim: A 40-year-old male was referred to our institute for the management of a percutaneous pancreatic fistula after acute pancreatitis due to SARS-COV2 infection. He developed a peripancreatic collection(PPC) which was percutaneously drained due to infection. After the resolution of PPC, a percutaneous leakage of the main pancreatic duct (MPD) was observed, so he underwent Endoscopic Retrograde ColangioPancreatography(ERCP) with biliary plus pancreatic sphincterotomy and placement of both pancreatic and biliary stent without resolution of the leak. Material(s) and Method(s): Then he was referred to our institution, where initial management included ERCP with placement of two trans-papillary pancreatic stents and the removal of percutaneous catheter, but the fistula kept to drain. Result(s): A multidisciplinary-board decided to perform a rendezvous with interventional radiology to facilitate an endoscopic ultrasound(EUS) trans-gastric drainage of the pancreatic area draining in the percutaneous fistula. Conclusion(s): The procedure included an initial ERCP with replacement of the two pancreatic stents while the radiologist places percutaneously a guidewire through the fistula to the pancreatic point of leakage into MPD. After that, EUS identified the point in which the percutaneous guidewire was getting into the MPD and a trans-gastric EUS-guided insertion of a guidewire achieved the MPD through a 19-Gauge needle. The latter guidewire crossed the percutaneous fistula and came out. At that point, a dilation up to 10 mm was performed to create a trans-gastric pancreatic fistula. The next step was to insert percutaneously a double pigtail(10 Fr) releasing the distal side into the stomach and the proximal side into the main pancreatic duct in order to stabilize the neo-fistula. Another trans-gastric plastic stent was endoscopically placed through the pancreato-gastric neo-fistula. At the end, injection of contrast dye through the percutaneous fistula showed a complete drainage into stomach. In conclusion, the procedure achieved the complete exclusion and resolution of the pancreatic-cutaneous fistula.Copyright © 2023. Editrice Gastroenterologica Italiana S.r.l.

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).

A SINGLE CENTER COHORT ANALYSIS COMPARING ENDOSCOPIC ULTRASOUND FINE NEEDLE ASPIRATION BIOPSY FOR SOLID PANCREATIC LESIONS USING RAPID ON-SITE EVALUATION (ROSE) WITH IN-ROOM PATHOLOGIST VS TELECYTOLOGY

Background: Rapid On-Site-Evaluation (ROSE) with an in-room pathologist (ROSE-P) has been shown to improve the diagnostic yield of specimens obtained from patients undergoing Endoscopic Ultrasound Fine Needle Aspiration Biopsy (EUS-FNAB) of pancreatic lesions. Recently, there has been an increased interest and utilization of telecytology (ROSE-T) to address social distancing during the COVID-19 pandemic and to optimize clinical workflows. With ROSE-T, a technician equipped with a video conferencing capable microscope unit prepares the EUS-FNAB cytology slides, which are then examined by Cytopathologists remotely. The purpose of this study is to compare diagnostic outcomes of ROSE-P prepandemic with ROSE-T during the COVID-19 pandemic. Methods: A single-center mixed retrospective-prospective cohort study of patients who underwent EUS-FNAB of solid pancreatic lesions with ROSE was conducted. All patients who underwent EUS-FNA were entered into a prospective database. The retrospective arm was patients who underwent ROSE-P pre-pandemic, whereas the prospective arm was patients who underwent ROSE-T during the pandemic. 165 patients in each group were needed to detect a 10% difference in diagnostic yield between the two groups, based on sample size calculation. An interim analysis was performed based on available data. Statistical analyses were performed using descriptive statistics and univariate analysis. Results: A total of 295 patients were enrolled in the study. 168 (57%) were in the ROSE-P group and 127 (43%) in the ROSE-T group. ROSE-T was associated with significantly more needle passes than ROSE-P (3.7 vs 3.0, p<0.0001). There was increased use of 22-gauge needle and decreased use of 25-gauge needles with ROSE-T during the pandemic (p = 0.012). There was no difference in age (63.4 vs 66.3, p=0.14), gender (43.5% vs 48.8 female gender, p=0.36), means mass size (27.2 vs 27.5 mm, p=0.14), mean procedure time (48.2 vs 46.2 minutes, p=0.92), adverse events (0.6% vs 0%, p=0.38), or diagnostic yield (97% vs 98.4%, p=0.38) between ROSEP and ROSE-T respectively. Conclusion: Rapid on-site evaluation using Telecytology was associated with more needle passes and more frequent use of 22-gauge needles as compared to ROSE-P;however, there was no difference in other important outcomes such as diagnostic yield, procedure time, and adverse events. (Table Presented)

Impact of the Pandemic COVID-19 on Digestive Endoscopic Activity: Experience of a Moroccan Service

OBJECTIVES: In Morocco, in order to prepare health facilities for the upcoming influx of COVID-19 patients, it was necessary to minimize non-COVID-19 related activities, which led to a significant reduction of non-urgent procedures. The aim of the study was to describe the impact of the COVID-19 pandemic on the digestive endoscopic activity in our department by comparing it to the previous year. Study design: This was a retrospective study. METHODS: We performed a retrospective study, comparing endoscopic procedures performed (excluding emergencies) in both 2019 and 2020, especially the periods from March 20 to June 30 (lockdown period). Statistical analysis was performed by SPSS 21.0 software. RESULTS: 5018 endoscopy procedures were performed in 2019 and 2020, but only 1869 performed in 2020. For the lockdown period, a large decrease in the number of patients undergoing endoscopy was seen in 2020 compared with 2019 (179 vs 863). Gastroscopy, colonoscopy, and rectosigmoidoscopy volumes experienced a 59%, 53%, and 67% reduction, respectively. A reduction of 50% in the number of echo-endoscopy was also seen, especially during the lockdown period 11 versus 21 in 2019 (p = 0.006), whereas the number of ERCPs remained relatively unchanged, with 22 during the lockdown period versus 29 in 2019 (p < 0.001). We also compared the different endoscopy procedures performed during the post-lockdown period compared to the same period in 2019. CONCLUSION: The COVID-19 pandemic had a significant impact on endoscopy services, its staff and especially on patients following the reduction and limitation of endoscopy indications and procedures.

HYBRID ENDOSCOPIC ULTRASOUND IN THE COVID-19 ERA FOR THE TISSUE DIAGNOSIS OF SOLID LESIONS: AN INITIAL EXPERIENCE FROM A TERTIARY CARE CENTRE IN PAKISTAN

AIM: Endoscopic Ultrasound (EUS) is well-established mode of intervention for tissue acquisition in solid organs with rapid on-site evaluation (ROSE). In the Covid-19 era implementation of infection control mechanisms has led modified hybrid technique to get high diagnostic yield for tissue sampling. Combination of Covid-19 SOPs and tissue acquisition method outline this hybrid technique to get high diagnostic Yield.We share our initial experience of EUS cases performed with this approach without ROSE. METHODS: All 84 cases who underwent EUS guided biopsy from June 2020 till December 2021 were included. The Procedure was done in a negative pressure room with all SOPs as per institutional guidelines for patient and staff safety with a minimum number of persons during procedure. RESULTS: Among these cases, 55 were male, mean age 56 years (range 22-90), Mean duration of procedure 25 min mean (10-90 min). 63 came for organ targeted for malignant pathology include pancreas 35, liver 02, lymph nodes 17, subepithelial lesions 06, mediastinal lesions 08, common-bile duct/gall bladder 04. 17 cases had a multi-targeted biopsy for the additional staging of disease. The number of 'passes' with the needle was average 02 with single pass 17, two pass 39, three passes 11, multitarget single pass in 17. Needle size (Franseen design) used for procedures was 22G in 78 cases and 25G in 6. Common tissue diagnoses include pancreatic adenocarcinoma 26, neuroendocrine tumours 04, tuberculosis 05, gastrointestinal stromal tumours 02, leiomyoma 03, lymphoma 03, metastatic renal cell carcinoma 04, squamous cell carcinoma 04, cholangiocarcinoma/ gall bladder adenocarcinoma 07, Sarcoma 02 and solid pseudopapillary epithelial neoplasm of pancreas (SPEN) 01. There were no immediate or early complications in all cases. CONCLUSIONS: Hybrid EUS in Covid 19 Era has emerged as a useful/cost-effective and safe approach to get tissue yield without the need for ROSE.

MULTI-TARGET ENDOSCOPIC ULTRASOUND EUS-M GUIDED BIOPSY IS SUPERIOR TO PET SCAN FOR STAGING MALIGNANCIES

AIM: EUS modality to get tissue diagnosis and with multi-target approach can help stage disease more accurately with histopathological results. METHODS: Total of 15 cases underwent EUS-M from June 2020 till Dec 2021. Informed consent was obtained, with Covid screen test with PCR was performed before procedure. Procedures were done with all SOPs as per institutional guidelines. 22G FNB needle with Franseen design with capillary suction method used to obtain visible core samples for histopathology without ROSE. All cases have confirmed histopathological diagnosis with same pathology from other site of Biopsy. Order of Biopsy was Nodes→Liver metatatic lesion→Primary Tumor. In cases of nodes mediastinal→portahepatis/ pancreatic→Para-aortic RESULTS: Among total 15 cases, Age 55 Mean (22-74) with 08 Males. Duration of procedure 41 min Mean (20-85). Cases with multiple lymphadenopathy from different anatomical regions were 05 while other sites include Liver for metastasis and Primary tumor from pancreas/CBD in 10 cases. Multiple site single pass was performed in 14 cases. Final diagnosis of Disease was pancreatic adenocarcinoma 05, NETs 01, Lymphoma 03, GB Adenocarcinoma/Cholangiocarcinoma 05 and metastatic RCC 01. All procedures were done under Conscious sedation as day care procedure. There were no immediate or early complication in all cases. CONCLUSIONS: EUS-M is safe and accurate modality to stage malignancy with superiority over PET Scan to obtain histological diagnosis.

Rare case of cystic schwannoma presenting as right upper lobe lung cyst

Background: Schwannomaare benign tumors arising from Schwann cells of nerve root sheaths. Schwannomasare mostly solid / heterogeneous solid tumours, rarely cystic. Presentation of cystic schwannomainthorax is extremely rare. Case Study: A 62-year-old female came to our hospital withthe complaint of right sided chest pain for 2 months, which is dull, non-radiating. She had history of fever 4 months back, diagnosed to have covid and took treatment at home. Chest x-ray showed a homogenous opacity in the right upper lobe extending up to 1stintercostal space. Ct reported well-defined thick-walled cyst, hypodensewith central low attenuation, forming acute angles with lung parenchyma in apical segments of right upper lobe towards mediastinum. Mild perilesional atelectasis is seen.On contrast, cyst is non enhancing. Patient is evaluated for the possibilities of Foregut duplication cyst, Hydatidcyst, Neoplasm. Endoscopic ultrasonography revealed a 5cms×5cms cyst, which is not communicating, infiltrating to esophagus. Patient was referred to ctvswhere excision of cyst is done by right thoracotomy .A 6cms×6cms×2cms unilocularcyst with wall thickness ranging from 0.1- 0.4cms. Its outer surface is congested, inner surface showed dark-brown hemorrhagic contents. Histopathological examination revealed cystic schwannoma. Discussion: Schwannomasare mostly benign in nature .Treatment includes excision of Bronchogenic cyst, Brachial cyst, neurogenic tumours, apical lung tumour, hydatid cyst, foregut duplication cyst are to be considered as differential diagnosis. It is important to consider cystic schwannomasin the differential diagnosis of thoracic cystsince the best surgical outcome is strongly related to earlier diagnosis and total resection of the lesion.

Local closed loop audit: COVID-19 screening before endoscopic ultrasound

Aim: Endoscopic Ultrasound (EUS) is one of the important diagnostic tests in patients with probable hepatobiliary or lung diseases. As it is an airborne procedure and due to the current COVID-19 pandemic, British Society of Gastroenterology and NICE guidelines have stated that patients who are undergoing EUS must be tested for COVID-19 within 3 days before the procedure. EUS must be considered deferring if the patient tests positive. The aim of this audit is to increase the proportion of patients being swabbed within 3 days/72 hours of the procedure to > 90% by the end of 2021. Method: A list of patients who underwent elective EUS in January (initial audit) and mid-May to mid-June (re-audit) were collected using Endosoft software. Afterwards, electronic patient record system was checked for the date of the COVID-19 swab and its results. This data was then recorded in a password-protected Excel spreadsheet and the proportion of the patients meeting the standard was calculated. Results: The results of the initial audit indicated that although 95.7% of swabs were done within 3 days of the procedure, only 40.9% were done within 72 hours. These results were discussed at a mortality and morbidity meeting, and recommendations were. Hence, in the re-audit, 98.4% of the swabs were done within 3 days of the procedure and the percentage of swabs being done within 72 hours increased to 95.2%. Conclusions: The target of increasing the proportion of patients being swabbed within 3 days/72 hours of the EUS procedure to >90% was met in mid-2021.

EUS-GUIDED GALLBLADDER DRAINAGE: A VALUABLE OPTION IN THE COVID-19 ERA

Background and aim: In the beginning of 2020 COVID-19 pandemic rapidly affected every country and overwhelmed many healthcare systems. In 2020 in northern Italy, the first western country to be affected, the prevalence was high and it brought a burden beyond the capacity of hospitals to manage, particularly in intensive care units (ICUs) [1]. This experience has shown that intensive care and ventilator support may be needed for extended durations. Patients experience consequences of severe respiratory illness and post-intensive care illness. Endoscopic procedures, such as endoscopic ultrasound-guided gallbladder transmural drainage (EUSGBD), can reduce surgical interventions, intensive care admissions, and longterm complications. In accordance with Tokyo guidelines, laparoscopic surgical cholecystectomy is the best treatment for acute cholecystitis (AC). Alternatives for high-risk patients must be considered, since morbidity and mortality are not negligible, and the traditional alternative is percutaneous trans-hepatic gallbladder drainage. EUS-GBD is efficient and safe, with a low rate of adverse events. A 2016 systematic review by Anderloni and others that evaluated stent outcomes showed pooled technical and clinical success rates in 98.6% and 94.4% of cases, respectively. Materials and methods: A 54-year-old man who had been admitted to a rehabilitation unit after prolonged ICU hospitalization for severe COVID-19 pneumonia, was referred to the surgical unit for AC and sepsis. Medical therapy could not improve his condition, and he rapidly worsened. Results: Due to his recent ICU admission, further intubation was strongly discouraged. Following multidisciplinary evaluation, he was moved to the endoscopy suite for drainage. EUS-GBD was achieved using a 10x15-mm electrocautery-enhanced lumen-apposing metal stent (Video 1). Up to now his follow-up is regular and after prolonged rehabilitation he can be considered for elective surgery. Conclusions: The patient didn't experience any symptom related to recurrent cholecystitis nor long term complications. EUS-GBD is a valuable option in order to reduce surgical interventions and intensive-care admissions. The Covid-19 pandemic has prompted further use of interventional endoscopic ultrasound as an alternative to surgery.

ASSESSMENT OF THE EUS PROCEDURES IN A NORTH ITALIAN ENDOSCOPY UNIT DURING THE 2020 COVID PANDEMIC

Background and aim: During the COVID pandemic the daily practice of endoscopic services has deeply changed. The risk of viral transmission to healthcare professionals and patients has strongly influenced the patient triage before endoscopy, the setting of the waiting rooms, the hygienic protocols for the endoscopic suites and the instruments, the use of the personal protective devices. Since government restrictions, the need to limit the access to hospitals only for urgent or oncological treatments, either for ambulatory procedures or for admissions to wards, has postponed many elective exams. Aim of the study was to assess how the EUS procedures have changed as compared to 2019 in an endoscopy unit of a provincial capital hospital in Lombardy (Italy). Materials and methods: We retrospectively compared our EUS procedures in the COVID period (March 2020 - February 2021) to those in the pre-COVID period (March 2019 - February 2020). less than the previous 12 months (-17.7%);this decrease concerned (-20.3%) than the inpatients (-15.6%). In detail we identified 3 four-month phases with a different trend. In the first one (March 2020–June 2020) we performed 88 exams;during March 2019 - June 2019 they had been 145 (-39.3%). In the second phase our procedures did not decrease (160 from July 2020 to October 2020, 151 from July 2019 to October 2019). In the third phase (November 2020 - February 2021) the procedures were 123, while from November 2019 to February 2020 they had been 155 (-20.6%). As regards the final EUS diagnosis, in the COVID period 25.2% of cases resulted neoplastic diseases, whereas in the 12-months before malignancy was detected in 23.4% of Conclusions: The drop rate in our EUS activity was parallel to the COVID incidence in Lombardy, that showed a first peak (with up to 6000 new cases / day) from March 2020 to May 2020, a following low-incidence plateau (with <1000 cases / day) from June 2020 to September 2020, and a successive second peak (with >10000 cases / day) from October 2020 to February 2021. This tendency could reflect either the outpatients’ low propensity to schedule exams in the riskiest periods, or the transformation of some internal medicine or surgical wards in COVID divisions when the need for such admissions was greater. Despite this decreased overall EUS activity, in the COVID period the oncological EUS procedures have been relatively guaranteed.

ESGE news and upcoming events February 2022

This ESGE-ESGENA updated Position Statement is intended to provide ongoing guidance during the pandemic to help assure the highest level of GI endoscopy care and protection against COVID-19 for both our patients and endoscopy unit personnel. B Early Bird registration deadline is approaching! Apply here: www.esge.com/grants/esge-norgine-research-award/ New ESGE position statement ESGE and ESGENA Position Statement on gastrointestinal endoscopy and COVID-19: Updated guidance for the era of vaccines and viral variants. [Extracted from the article] Copyright of Endoscopy is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

RISK OF COVID-19 INFECTION TO BOTH PATIENTS AND ENDOSCOPY UNIT STAFF FOLLOWING ENDOSCOPY: A SINGLE-CENTER PROSPECTIVE COHORT STUDY

Introduction The risk of 2019 novel coronavirus (COVID-19) infection among patients and health care workers (HCWs) following endoscopy remains unclear. Methods We prospectively evaluated the incidence of COVID-19 infection among patients undergoing outpatient endoscopy and endoscopy unit staff between March and October 2020 at one tertiary care center in New York City. The primary outcome was COVID-19 infection within two weeks post-procedure. The clinical history, demographics, laboratory data, treatment, procedural data, and outcome measures were obtained from patients’ medical records. All patients had undergone nasopharyngeal nucleic-acid amplification testing swabs for COVID-19 prior to their procedures. Patients were then contacted 2 weeks after the procedure, via phone by research teams and nurses, with a specific list of questions (adapted from Repici et al.) to assess who had either tested positive for COVID-19 or developed symptoms ofCOVID-19 within 2 weeks after endoscopic procedures.1 Patients who screened positive for symptoms were directed for testing. Results A total of 850 endoscopic procedures were performed at our center between March and October of 2020. 131 were inpatients and were excluded from the analysis. Among the 719 outpatients, 231 were ERCPs, 111 were EUS, 207 were colonoscopies, and 170 were upper endoscopies. Post-procedure follow-up was obtained in 73% (n=524) of the patients. Of 719, 2 patients (0.38%) tested positive for COVID-19 within 2 weeks following endoscopy. Both patients had interval chemotherapy and were admitted to the hospital, so it is unclear when or where they converted. No advanced endoscopy attending or their associated nurses or technologists were subsequently infected with COVID-19 during the study period.Discussion Endoscopy procedures with appropriate PPE and preoperative testing appears to be associated with a low risk of periprocedural COVID-19 infection for outpatients and endoscopy unit staff. Diligence should continue with appropriate universal precaution and preoperative patient testing during this pandemic. References 1. Repici A, Aragona G, Cengia G, et al. Low risk of COVID-19 transmission in GI endoscopy. Gut. 2020;69(11):1925-1927. doi:10.1136/gutjnl-2020-321341

Impact of COVID-19 pandemic on key performance indicators in pancreatobiliary endoscopy: prioritise, minimise risk, keep scoping and training.

BACKGROUND: The COVID-19 pandemic has profoundly affected endoscopy services including pancreatobiliary (PB) endoscopy across the UK. The British Society of Gastroenterology and Joint Advisory Group have issued guidance for managing endoscopy services safely throughout this period. There have been perceived concerns among the PB endoscopists that wearing full personal protective equipment might have an adverse impact on key performance indicators (KPIs) in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) procedures leading to non-compliance with the national guidelines. The aim of the study was to assess the impact of COVID-19 pandemic on KPIs in ERCP and EUS and ascertain the risk of procedure-related complications. METHODS: A retrospective audit of a prospectively maintained endoscopy database was carried out between 18 March and 31 July 2020. RESULTS: 146 ERCP procedures (common bile duct (CBD) cannulation rate of naïve papilla 89.2%, complete CBD stone extraction rate at first ERCP 88.2%, biliary stricture decompression rate 91%) and 87 EUS procedures (diagnostic accuracy of EUS-fine needle aspiration 92%) were carried out during this period. ERCP-related complications included pancreatitis (4.8%), bleeding (0.68%) and cholangitis (0.68%). 30-day ERCP procedure-related mortality was 0.68%. There were no complications or procedure-related mortality in the EUS group. CONCLUSION: This is the first study looking at the impact of COVID-19 on KPIs and procedure-related complications in ERCP and EUS in the literature. Our study confirms that a high-quality PB endoscopy service can be delivered safely and effectively during the COVID-19 pandemic.