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.

Initial multicenter experience using a novel endoscopic tack and suture system for challenging GI defect closure and stent fixation (with video).

BACKGROUND AND AIMS: Closure of endoscopic resection defects can be achieved with through-the-scope clips, over-the-scope clips, or endoscopic suturing. However, these devices are often limited by their inability to close large, irregular, and difficult-to-reach defects. Thus, we aimed to assess the feasibility and safety of a novel through-the-scope, suture-based closure system developed to overcome these limitations. METHODS: This was a retrospective multicenter study involving 8 centers in the United States. Primary outcomes were feasibility and safety of early use of the device. Secondary outcomes were assessment of need for additional closure devices, prolonged procedure time, and technical feasibility of performing the procedure with an alternative device(s). RESULTS: Ninety-three patients (48.4% women) with mean age 63.6 ± 13.1 years were included. Technical success was achieved in 83 patients (89.2%), and supplemental closure was required in 24.7% of patients (n = 23) with a mean defect size of 41.6 ± 19.4 mm. Closure with an alternative device was determined to be impossible in 24.7% of patients because of location, size, or shape of the defect. The use of the tack and suture device prolonged the procedure in 8.6% of cases but was considered acceptable. Adverse events occurred in 2 patients (2.2%) over a duration of follow-up of 34 days (interquartile range, 13-93.5) and were mild and moderate in severity. No serious adverse events or procedure-related deaths occurred. CONCLUSIONS: The novel endoscopic through-the-scope tack and suture system is safe, efficient, and permits closure of large and irregularly shaped defects that were not possible with established devices.

EUS-directed transgastric ERCP with EUS-guided rendezvous for difficult biliary cannulation in a patient with Roux-en-Y gastric bypass.

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Use of helical tack system for management of a high-risk fibrotic peptic ulcer.

Background and Aims: GI bleeding because of peptic ulcer disease is a well-described entity in its diagnosis and management. Although hemostatic clips and thermal therapy have been the primary tools in bleeding from peptic ulcer disease, some bleeds remain refractory. New data have shown that obliteration of the underlying arterial blood flow is needed to control refractory peptic ulcer bleeding. Although this has been shown with over-the-scope clips, we present a case where GI bleeding is controlled via a helical tack system. Although there are several available tools that can be used for treatment of upper GI bleeds, there remains a need for devices that can be used when standard methods of closure, such as with clips, cannot be performed because of a challenging location or friable mucosa. The aim of this video case is to demonstrate the use of a novel helical tack system as a salvage technique in the treatment of challenging upper GI bleeds. Methods: One case of a bleeding GI ulcer that was refractory to standard endoscopic clips was identified. Results: In this case, the ulcer closure was achieved using the helical tack system. There were no adverse events. The patient did not require additional surgical or endoscopic interventions. Conclusions: The helical tack system is a novel device that may be useful as a salvage method for the cessation of GI bleeds refractory to standard clips. Additional comparative studies are needed to better understand the advantages and disadvantages of this system relative to other closure tools.

Management of an iatrogenic duodenal perforation with a helical tack system in a patient with pancreatic cancer complicated by gastric outlet obstruction.

Video 1Closure of an iatrogenic perforation with helical tack system and subsequent EUS-guided choledochoduodenostomy.

Catheter-based deployment of vascular plugs for the management of challenging gastric fistulae.

Video 1Case demonstrations of endoscopic vascular plug placement for challenging gastrointestinal fistulae.

EUS-guided rendezvous technique for pancreas divisum.

Video 1EUS-guided rendezvous technique for pancreas divisum.

Single-session EUS-guided gastroenterostomy and EUS-guided gallbladder drainage in a patient with concomitant gastric outlet obstruction and acalculous cholecystitis.

Video 1Video presentation of a single session EUS-guided cholecystoduodenostomy and gastrojejunostomy.

Use of a novel helical tack system for the management of challenging upper gastrointestinal defects.

BACKGROUND AND AIMS: Increasingly, gastroenterologists are being asked to assist in the closure of defects. Although there are several available tools that can be used for defect closure, there remains a need for devices that are easy to use, effective, and durable. The aim of this case series is to demonstrate the use of a novel helical tack system in the closure of upper GI defects. METHODS: Two cases of challenging upper GI defects were identified. One case involved a perforated duodenal ulcer, and the other involved a nonhealing marginal ulcer. In both cases, the helical tack system was used for defect closure. RESULTS: In both cases, defect closure was achieved using the helical tack system; however, 2 series of tacks were required in each case. There were no adverse events. Neither patient has required additional surgical or endoscopic interventions. CONCLUSIONS: The helical tack system is a new device that may be useful for the closure of challenging upper GI defects. Additional comparative studies are needed to better understand the advantages and disadvantages of this system relative to other closure tools.

Assessment of Video Capsule Endoscopy in the Management of Acute Gastrointestinal Bleeding During the COVID-19 Pandemic.

Importance: Evaluation of acute gastrointestinal (GI) bleeding using invasive endoscopic procedures comprising the standard of care (SOC)-upper endoscopy and colonoscopy-can expose the endoscopy staff to SARS-CoV-2. Video capsule endoscopy (VCE) does not generate aerosols and only requires 1 person to manage the procedure. Objective: To examine the safety of VCE for the initial evaluation of GI bleeding at the peak of the COVID-19 pandemic to identify signs of active bleeding while minimizing patient and personnel exposure, saving personal protective equipment, and avoiding invasive or unnecessary procedures. Design, Setting, and Participants: A multicenter (UMass Memorial Medical Center and Louisiana State University Health Sciences Center) retrospective cohort study including 146 patients with COVID-19 who received VCE as the first-line diagnostic modality was conducted from March 15 to June 15, 2020, compared with SOC in January 2020 for evaluation of GI bleeding. The association between treatment and outcomes was estimated using multivariable regression adjusting for potential confounders. Propensity score matching was used to verify the results. Main Outcomes and Measures: The primary end point was detection of active bleeding or stigmata of recent bleeding. Secondary end points included the number of patients requiring any invasive procedures, number of additional procedures, rates of rebleeding and rehospitalization, transfusion requirements, and mortality. Results: Among 146 patients, 92 (63.0%) were men; mean (SD) age was 64.93 (14.13) years in the COVID-19 group and 61.33 (13.39) years in the SOC group. Active bleeding or stigmata of recent bleeding was observed in 44 (59.5%) patients in the COVID-19 group compared with 18 (25.0%) in the SOC group (adjusted odds ratio, 5.23; 95% CI, 2.23 to 12.27). Only 36 patients (48.7%) in the COVID-19 group required any invasive procedure during the hospitalization compared with 70 (97.2%) in the SOC group (adjusted odds ratio, 0.01; 95% CI, 0.001 to 0.08). The mean (SD) number of invasive procedures was 0.59 (0.77) per patient in the COVID-19 group compared with 1.18 (0.48) per patient in the SOC group (adjusted difference, -0.54; 95% CI, -0.77 to -0.31). Both approaches appeared to be safe and there was no significant difference in transfusion requirements, rebleeding, rehospitalization, or in-hospital mortality. No mortality was attributed to GI bleeding in either group. Conclusions and Relevance: In this cohort study, first-line diagnostic evaluation of acute GI bleeding using VCE appeared to be a safe and useful alternative to the traditional approach of upper endoscopy and colonoscopy. Use of VCE was associated with increased detection of active bleeding and a reduced number of invasive procedures and unnecessary exposure of personnel to SARS-CoV-2 and use of personal protective equipment.

Novel dilation technique and stent selection to reduce periprocedural adverse events in left hepaticogastrostomy.

Video 1Video demonstration of left hepaticogastrostomy with the assistance of an angioplasty balloon.

Proton pump inhibitors increase the severity of hepatic encephalopathy in cirrhotic patients.

BACKGROUND: Liver cirrhosis is the late stage of hepatic fibrosis and is characterized by portal hypertension that can clinically lead to decompensation in the form of ascites, esophageal/gastric varices or encephalopathy. The most common sequelae associated with liver cirrhosis are neurologic and neuropsychiatric impairments labeled as hepatic encephalopathy (HE). Well established triggers for HE include infection, gastrointestinal bleeding, constipation, and medications. Alterations to the gut microbiome is one of the leading ammonia producers in the body, and therefore may make patients more susceptible to HE. AIM: To investigate the relationship between the use of proton pump inhibitors (PPIs) and HE in patients with cirrhosis. METHODS: This is a single center, retrospective analysis. Patients were included in the study with an admitting diagnosis of HE. The degree of HE was determined from subjective and objective portions of hospital admission notes using the West Haven Criteria. The primary outcome of the study was to evaluate the grade of HE in PPI users versus non-users at admission to the hospital and throughout their hospital course. Secondary outcomes included rate of infection, gastrointestinal bleeding within the last 12 mo, mean ammonia level, and model for end-stage liver disease scores at admission. RESULTS: The HE grade at admission using the West Haven Criteria was 2.3 in the PPI group compared to 1.7 in the PPI nonuser group (P = 0.001). The average length of hospital stay in PPI group was 8.3 d compared to 6.5 d in PPI nonusers (P = 0.046). Twenty-seven (31.8%) patients in the PPI user group required an Intensive Care Unit admission during their hospital course compared to 6 in the PPI nonuser group (16.7%) (P = 0.138). Finally, 10 (11.8%) patients in the PPI group expired during their hospital stay compared to 1 in the PPI nonuser group (2.8%) (P = 0.220). CONCLUSION: Chronic PPI use in cirrhotic patients is associated with significantly higher average West Haven Criteria for HE compared to patients that do not use PPIs.