Impact of COVID-19 infection and vaccination in pancreatobiliary IgG4-related disease patients: An international multicenter study.

BACKGROUND AND AIM: Dedicated studies evaluating the impact of COVID-19 on outcomes of pancreatobiliary IgG4 related disease (IgG4-RD) patients are scarce. Whether COVID-19 infection or vaccination would trigger IgG4-RD exacerbation remains unknown. METHODS: Pancreatobiliary IgG4-RD patients ≥ 18 years old with active follow-up since January 2020 from nine referral centers in Asia, Europe, and North America were included in this multicenter retrospective study. Outcome measures include incidence and severity of COVID-19 infection, IgG4-RD disease activity and treatment status, interruption of indicated IgG4-RD treatment. Prospective data on COVID-19 vaccination status and new COVID-19 infection during the Omicron outbreak were also retrieved in the Hong Kong cohort. RESULTS: Of the 124 pancreatobiliary IgG4-RD patients, 25.0% had active IgG4-RD, 71.0% were on immunosuppressive therapies and 80.6% had ≥ 1 risk factor for severe COVID. In 2020 (pre-vaccination period), two patients (1.6%) had COVID-19 infection (one requiring ICU admission), and 7.2% of patients had interruptions in indicated immunosuppressive treatment for IgG4-RD. Despite a high vaccination rate (85.0%), COVID-19 infection rate has increased to 20.0% during Omicron outbreak in the Hong Kong cohort. A trend towards higher COVID-19 infection rate was noted in the non-fully vaccinated/unvaccinated group (17.6% vs 33.3%, P = 0.376). No IgG4-RD exacerbation following COVID-19 vaccination or infection was observed. CONCLUSION: While a low COVID-19 infection rate with no mortality was observed in pancreatobiliary IgG4-RD patients in the pre-vaccination period of COVID-19, infection rate has increased during the Omicron outbreak despite a high vaccination rate. No IgG4-RD exacerbation after COVID-19 infection or vaccination was observed.

Changing perspectives in the training of endoscopic ultrasonography in Asia.

Training of endoscopic ultrasound (EUS) in Asia faces challenges of the ever-increasing demand for skills to handle a growing range of both diagnostic and interventional EUS procedures, and a continual shortage of EUS training programs. To keep up with the pace of development in EUS, more short-term EUS programs have been conducted across Asia in recent years. In this aspect, the Asian EUS Group (AEG) has taken the lead to fast-track the dissemination of EUS knowledge and skills across Asia through its multinational network of training centers. AEG's programs are brought to wherever there is demand. Its versatile modular structure allows the program to be easily customized and scaled up or down to align to local needs, making it highly adaptable to the changing and varying needs in different countries. Even with the current pandemic situation, it has been able to continue its training efforts through the use of technology, including webinars, and live case demonstration.

Endoscopic treatment modalities and outcomes in nonvariceal upper gastrointestinal bleeding.

BACKGROUND: In nonvariceal upper gastrointestinal bleeding (NVUGIB), the optimal volume of adrenaline, the optimal number of hemoclips, and the application of thermal coagulation in determining patient outcomes have not been well studied. AIM: To demonstrate a dose-response relationship between the commonly used endoscopic modalities for the treatment of non-variceal upper gastrointestinal bleeding and various clinical outcomes. METHODS: Patients presenting with NVUGIB were retrospectively identified and analyzed. These patients were stratified as follows: (1) > 10 mL of adrenaline injected vs ≤ 10 mL; (2) > 1 hemoclip placed vs ≤ 1 hemoclip; (3) Heater probe used or not; and (4) > 2 treatment modalities used vs ≤ 2. The primary outcomes were rebleeding and the need for repeat endoscopy. The secondary outcomes were the need for surgery, required transfusions, length of hospital stay, death during the same admission period and 30 d mortality. Patients with NVUGIB who required endoscopic therapy were included. Those who did not require endoscopic therapy or were initially treated with surgery or embolization were excluded. RESULTS: In all, 501 patients with NVUGIB were treated. One hundred sixty-one (32.1%) patients needed endoscopic therapy. The injection of < 10 mL of adrenaline was associated with less rebleeding (P < 0.0001), the need for repeat endoscopy (P = 0.001) and a decreased length of hospital stay (P = 0.026). The use of > 2 treatment modalities were associated with increased rebleeding (P = 0.009) and the need for repeat endoscopy (P = 0.048). The placement of > 1 hemoclip was associated with a decreased length of hospital stay (P = 0.044). The rates of surgery and death were low, and there were no other significant differences between the patient groups. CONCLUSION: The more restrictive use of adrenaline and number of endoscopic modalities to treat NVUGIB with the more liberal use of hemoclips was associated with better patient outcomes.

Predictors of suboptimal bowel preparation in asymptomatic patients undergoing average-risk screening colonoscopy.

AIM: To identify risk factors for a suboptimal preparation among a population undergoing screening or surveillance colonoscopy. METHODS: Retrospective review of the University of Michigan and Veteran's Administration (VA) Hospital records from 2009 to identify patients age 50 and older who underwent screening or surveillance procedure and had resection of polyps less than 1 cm in size and no more than 2 polyps. Patients with inflammatory bowel disease or a family history of colorectal cancer were excluded. Suboptimal procedures were defined as procedure preparations categorized as fair, poor or inadequate by the endoscopist. Multivariable logistic regression was used to identify predictors of suboptimal preparation. RESULTS: Of 4427 colonoscopies reviewed, 2401 met our inclusion criteria and were analyzed. Of our population, 16% had a suboptimal preparation. African Americans were 70% more likely to have a suboptimal preparation (95%CI: 1.2-2.4). Univariable analysis revealed that narcotic and tricyclic antidepressants (TCA) use, diabetes, prep type, site (VA vs non-VA), and presence of a gastroenterology (GI) fellow were associated with suboptimal prep quality. In a multivariable model controlling for gender, age, ethnicity, procedure site and presence of a GI fellow, diabetes [odds ratio (OR) = 2.3; 95%CI: 1.6-3.2], TCA use (OR = 2.5; 95%CI: 1.3-4.9), narcotic use (OR = 1.7; 95%CI: 1.2-2.5) and Miralax-Gatorade prep vs 4L polyethylene glycol 3350 (OR = 0.6; 95%CI: 0.4-0.9) were associated with a suboptimal prep quality. CONCLUSION: Diabetes, narcotics use and TCA use were identified as predictors of poor preparation in screening colonoscopies while Miralax-Gatorade preps were associated with better bowel preparation.

Adherence to recommended intervals for surveillance colonoscopy in average-risk patients with 1 to 2 small (<1 cm) polyps on screening colonoscopy.

BACKGROUND: Among average-risk patients, repeat colonoscopy in 5 years is recommended after 1 to 2 small (<1 cm) adenomas are found on screening colonoscopy or in 10 years if hyperplastic polyps are found. However, sparse quantitative data are available about adherence to these recommendations or factors that may improve adherence. OBJECTIVE: To quantify adherence to recommended intervals and to identify factors associated with lack of adherence. DESIGN: Retrospective endoscopic database analysis. SETTING: Tertiary-care institution and Veterans Affairs Health System. PATIENTS: Average-risk individuals undergoing screening colonoscopy found to have 1 to 2 small polyps on screening colonoscopy. MAIN OUTCOME MEASUREMENTS: Frequency of recommending repeat colonoscopy in 5 years if 1 to 2 small adenomas are found and in 10 years if hyperplastic polyps are found. RESULTS: Of 922 outpatient screening colonoscopies with 1 to 2 small polyps found, 90.2% received appropriate recommendations for timing of repeat colonoscopy. Eighty-four percent of patients with 1 to 2 small adenomas and 94% of patients with 1 to 2 hyperplastic polyps received recommendations that were consistent with guidelines. Based on logistic regression analysis, patients aged >70 years (odds ratio [OR] 2.4, 95% confidence interval [CI], 1.0-5.7), fair bowel preparation (OR 12.7; 95% CI, 7.3-22.4), poor bowel preparation (OR 10.0; 95% CI, 4.3-23.6), and the presence of 2 small adenomas versus 1 small adenoma (OR 3.6; 95% CI, 2.2-6.0) were factors associated with "overuse" or recommendations inconsistent with guidelines. LIMITATIONS: Retrospective study design. CONCLUSION: More than 90% of endoscopists' recommendations for timing of surveillance colonoscopy in average-risk patients with 1 to 2 small polyps are consistent with guideline recommendations. Quality of preparation is strongly associated with deviation from guideline recommendations.

The impact of bowel cleansing on follow-up recommendations in average-risk patients with a normal colonoscopy.

OBJECTIVES: Repeat colonoscopy in 10 years after a normal screening colonoscopy is recommended in an average-risk patient, and it has been proposed by American Gastroenterological Association (AGA), American College of Gastroenterology (ACG), and American Society for Gastrointestinal Endoscopy (ASGE) as a quality measure. However, there are little quantitative data about adherence to this recommendation or factors that may improve adherence. Our study quantifies adherence to this recommendation and the impact of suboptimal bowel preparation on adherence. METHODS: In this retrospective database study, endoscopy reports of average-risk individuals ≥50 years old with a normal screening colonoscopy were reviewed. Quality of colon cleansing was recorded using the Aronchick scale as excellent, good, fair, or poor. Main outcome measurements were quality of bowel preparation and recommendation for timing of repeat colonoscopy. Recommendations were considered consistent with guidelines if 10-year follow-up was documented after excellent, good, or fair prep or if ≤1-year follow-up was recommended after poor prep. RESULTS: Among 1,387 eligible patients, recommendations for follow-up colonoscopy inconsistent with guidelines were seen in 332 (23.9%) subjects. By bowel preparation quality, 15.3% of excellent/good, 75% of fair, and 31.6% of poor bowel preparations were assigned recommendations inconsistent with guidelines (P<0.001). Patients with fair (odds ratio=18.0; 95% confidence interval 12.0-28.0) were more likely to have recommendations inconsistent with guidelines compared with patients with excellent/good preps. CONCLUSIONS: Recommendations inconsistent with guidelines for 10-year intervals after a normal colonoscopy occurred in >20% of patients. Minimizing "fair" bowel preparations may be a helpful intervention to improve adherence to these recommendations.

Cap-assisted ERCP with a forward-viewing gastroscope as a rescue endoscopic intervention in patients with Billroth II anatomy.

BACKGROUND: ERCP, especially therapeutic, is difficult in patients with Billroth II surgical reconstruction and is associated with a higher rate of complications. This has led to controversy on the choice between a forward-viewing and side-viewing endoscope for performing the procedure. A previous case series from Asia reported a high rate of success with a cap-fitted ERCP technique. To our knowledge, the utility of cap-assisted ERCP with a forward-viewing gastroscope when other techniques fail has not been reported. We describe and demonstrate a novel rescue approach using a cap-fitted, forward-viewing gastroscope in patients with Billroth II anatomy, when attempts with duodenoscopes, pediatric colonoscopes, and gastroscopes previously failed. METHODS: Retrospective case series. Inclusion criteria were: (a) documented Billroth II anatomy; and (b) use of cap-assisted ERCP as a rescue intervention on the first endoscopic encounter after failed attempts to perform ERCP with a duodenoscope. Patients were excluded if they successfully underwent ERCP with a duodenoscope. One advanced endoscopist and one advanced endoscopy fellow performed all but one of the procedures. RESULTS: Five cap-assisted ERCP procedures were performed in three patients with Billroth II anatomy. A wide variety of diagnostic and therapeutic endoscopic maneuvers were technically feasible and successful, including the endoscopic treatment of an afferent limb perforation caused by a duodenoscope. CONCLUSIONS: Cap-assisted ERCP is a novel and underutilized technique that adds to the armamentarium of experienced therapeutic endoscopists. This approach may help ensure a successful endoscopic outcome and spare patients with Billroth II anatomy a percutaneous or surgical approach when ERCP with a duodenoscope, pediatric colonoscope or non-cap-fitted gastroscope fails.