Deconstructing the steps of pull-type PEG tube insertion.

Video 1Deconstructed steps of the pull-type PEG insertion technique.

Deconstructing the steps of PEG tube insertion using the introducer technique.

Video 1Deconstructed steps of the introducer-type PEG insertion technique.

Double balloon enteroscopy versus single balloon enteroscopy: A comparative study.

Device assisted enteroscopy (DAE) like the double balloon enteroscopy (DBE) and single balloon enteroscopy (SBE) are postulated to ease small bowel examination and performance of therapy. However, studies comparing the effectiveness of these 2 modalities have yielded varying results. The aim of this study is to compare the efficacy and safety of SBE and DBE. We retrospectively reviewed records of patients who underwent DBE (n = 82) or SBE (n = 45) for small bowel exam in our unit from January 2014 to January 2022. Our primary outcomes were to compare the technical success and diagnostic success rates between DBE and SBE. Our secondary outcomes were to compare the therapeutic success, and complication rates. The main indications were suspected GI bleeding (DBE 41.5% vs SBE 48.9%), iron deficiency anemia (DBE 9.8% vs SBE 4.4%) and small bowel lesions (DBE 28.0% vs SBE 44.4%) detected either from prior capsule endoscopy or radiological imaging. Majority of the enteroscopy exam was by antegrade approach (DBE 67.1% vs SBE 77.8%). We found no significant difference in the technical success (DBE 95.1% vs SBE 97.8%, P = .46), diagnostic success (DBE 69.5% vs SBE 77.8%, P = .36) and the therapeutic success rate (DBE 63.2% vs SBE 54.3%, P = .09) between the groups. Complications occurred in 1 case from each group (mucosal tear). None of the complications were major. In patients who underwent enteroscopy, the diagnostic and therapeutic performance of SBE is similar to DBE. Both procedures were safe with low complication rates.

Efficacy of international web-based educational intervention in the detection of high-risk flat and depressed colorectal lesions higher (CATCH project) with a video: Randomized trial.

OBJECTIVES: Three subcategories of high-risk flat and depressed lesions (FDLs), laterally spreading tumors non-granular type (LST-NG), depressed lesions, and large sessile serrated lesions (SSLs), are highly attributable to post-colonoscopy colorectal cancer (CRC). Efficient and organized educational programs on detecting high-risk FDLs are lacking. We aimed to explore whether a web-based educational intervention with training on FIND clues (fold deformation, intensive stool/mucus attachment, no vessel visibility, and demarcated reddish area) may improve the ability to detect high-risk FDLs. METHODS: This was an international web-based randomized control trial that enrolled non-expert endoscopists in 13 Asian countries. The participants were randomized into either education or non-education group. All participants took the pre-test and post-test to read 60 endoscopic images (40 high-risk FDLs, five polypoid, 15 no lesions) and answered whether there was a lesion. Only the education group received a self-education program (video and training questions and answers) between the tests. The primary outcome was a detection rate of high-risk FDLs. RESULTS: In total, 284 participants were randomized. After excluding non-responders, the final data analyses were based on 139 participants in the education group and 130 in the non-education group. The detection rate of high-risk FDLs in the education group significantly improved by 14.7% (66.6-81.3%) compared with -0.8% (70.8-70.0%) in the non-education group. Similarly, the detection rate of LST-NG, depressed lesions, and large SSLs significantly increased only in the education group by 12.7%, 12.0%, and 21.6%, respectively. CONCLUSION: Short self-education focusing on detecting high-risk FDLs was effective for Asian non-expert endoscopists. (UMIN000042348).

Pancreatic cancer masquerading as ischemic enteritis on endoscopy.

Pancreatic tumors usually produce painless jaundice. Other associated symptoms may be secondary, from a direct extension of the tumor, resulting in bowel obstruction. It is extremely rare that pancreatic malignancy presents with ischemic enteritis by invasion of the major arteries, and no report has documented it endoscopically. We present a rare case of pancreatic adenocarcinoma masquerading as ischemic enteritis diagnosed on enteroscopy and endoscopic ultrasound. An initial computed tomography (CT) scan performed in another hospital showed long segmental wall thickening involving the third part of the duodenum to the proximal segment of the jejunum. The patient was referred to our institution for enteroscopy, which showed a poorly distensible third part of the duodenum with purplish mucosa starting at the fourth part of the duodenum until the proximal jejunum. With suspicion of ischemic enteritis, a mesenteric CT angiography was performed, which showed a long segment circumferential wall thickening of the duodenum to jejunum with fullness of the pancreatic head and uncinate process that encases the superior mesenteric artery. Endoscopic ultrasound (EUS) showed a hypoechoic lesion at the head of the pancreas. EUS-guided fine-needle biopsy was performed, which revealed pancreatic adenocarcinoma on histopathology.

Moving Forward: Gradual Return of Gastroenterology Practice during the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has caused disruption of routine gastroenterology practice, which has resulted in the suspension of elective endoscopic procedures and outpatient consults. For the past months, the strategy was to mitigate infection risk for the healthcare team while still providing essential service to patients. Prolonged suspension of the outpatient clinics and endoscopy practice, however, is deemed unsustainable and could even be detrimental. It can compromise patient care and result in poor outcomes; hence, a well-crafted plan is needed for the gradual resumption of clinic operations and endoscopic procedures. SUMMARY: As the world begins to transition to the "new normal," there are new health and safety issues to consider. Adaptive measures like telemedicine and electronic health records should be utilized to facilitate patient care while minimizing exposure. Careful patient screening, adequate supply of personal protective equipment, effective infection-control policies, as well as appropriate administrative modifications are needed for a safe return of gastroenterology practice. Key Messages: Ensuring the safety of patients, caregivers, and healthcare workers should remain as top priority. To help ease the transition as we move forward from this pandemic, we present a review of recommendations to guide gastroenterologists and endoscopy unit administrators in the gradual return to gastroenterology practice.

COVID-19 and its effects on the digestive system and endoscopy practice.

The Coronavirus Disease 2019 (COVID-19) is a respiratory illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has been classified as a pandemic by the World Health Organization in March 2020. Several studies have demonstrated that the gastrointestinal (GI) tract is also a potential route. As the pandemic is continuously evolving, and more data are made available, this article highlights the best evidence and practices regarding the effects of the SARS-CoV-2 virus relevant to GI practice. Published clinical studies have supported that SARS-CoV-2 affects the GI tract and the liver. The largest published dataset comprised of 4243 patients and showed a pooled prevalence of GI symptoms at 17.6%. GI symptoms varied and usually preceded pulmonary symptoms by 1-2 days. These include anorexia (26.8%), nausea and vomiting (10.2%), diarrhea (12.5%), and abdominal pain (9.2%). Incidence of liver injury ranges from 15 to 53%. Evidence shows that the severity of COVID-19 infection is compounded by its effects on nutrition, most especially for the critically ill. As such, nutrition societies have recommended optimization of oral diets and oral nutritional supplements followed by early enteral nutrition if nutritional targets are not met, and parenteral nutrition in the distal end of the spectrum. In addition to possible fecal-oral transmission, GI endoscopy procedures, which are considered to be aerosol-generating procedures, contribute to increased risk to GI health-care professionals. Infection prevention measures and guidelines are essential in protecting both patients and personnel.