Background and aims: It is essential for endoscopists, technologists, and nurses to understand radiation protection. However, protective equipment usage is still low, and there is little awareness of radiation protection in practice.Methods: We conducted a questionnaire survey on radiation protection from January to February 2020. The participants were medical staff, including medical doctors, nurses, and radiological and endoscopy technician in endoscopy‐fluoroscopy departments. The questionnaire included 14 multiple‐choice questions divided among three parts: background, equipment, and knowledge.Results: We surveyed a total of 282 subjects from 26 institutions. There were 168 medical doctors (60%), 90 nurses (32%), and 24 technologists (9%). Although almost all staff members (99%) always wore a lead apron, only a few wore a thyroid collar (32%) and lead glasses (21%). The rate of wearing a radiation dosimeter was insufficient (69%), especially among doctors (52%). A few subjects knew the radiation exposure dose of each procedure (15%), and slightly over half had attended lectures on radiation protection (64%) and knew about the three principles of radiation protection (59%). Protection adherence did not differ by years of experience, knowledge of fluoroscopy, awareness of radiation exposure doses, or attendance at basic lectures on radiation protection. However, medical doctors who were aware of the radiation exposure dose of each procedure were significantly more likely to wear dosimeters than those who were not (p = 0.0008).Conclusion: Medical staff in endoscopy departments in Japan do not have enough radiation protection equipment or education.

INTRODUCTION: No bowel preparation (BP) for colonoscopy achieves optimal efficacy and tolerability. Combining polyethylene glycol plus ascorbic acid (PEG-Asc) with adjuvants has been explored to enhance cleansing efficacy and reduce the required volume. The aim of this study was to evaluate whether adding 0.5 mg linaclotide to 1 L PEG-Asc (1 L-PEG/AL) improves superior cleansing compared with adding 24 mg senna (1 L-PEG/AS), which we previously reported to be noninferior to the standard regimen of 2 L PEG-Asc. METHODS: A multicenter, endoscopist-blinded, randomized controlled trial was conducted at 5 centers in Japan with outpatients scheduled for colonoscopy. The primary outcome was adequate BP, evaluated using the Boston Bowel Preparation Scale. Analyses were stratified based on low-risk and high-risk groups for inadequate BP. RESULTS: Between April 2022 and April 2023, 1,464 patients were randomized to the 1L-PEG/AL (n = 731) or 1L-PEG/AS (n = 733). The 1L-PEG/AL demonstrated higher adequate BP rates (92% vs 86%, P = 0.001) compared with 1L-PEG/AS. Both groups experienced similar adverse events and expressed high willingness for repeat BP (83% vs 81%, P = 0.49). In high-risk patients (n = 892), 1L-PEG/AL had significantly higher adequate BP rates (94% vs 86%, P < 0.001), whereas rates were comparably high in low-risk patients (n = 539) (94% vs 94%, P = 0.66). DISCUSSION: The linaclotide regimen was superior to the senna regimen reagrding BP efficacy without reducing tolerability. It can be a promising new option for BP, especially in patients at a high risk of inadequate BP.

Coronavirus disease (COVID-19) transmission occurs primarily through direct contact or air droplets [1] [2], and endoscopic procedures are high risk. In this era of “with COVID-19,” establishing simple infection prevention measures within an endoscopy department to protect both patients and personnel is strongly recommended. Hence, we proposed a simple method using a modified surgical mask. We made a hole (10 mm diameter) in the center of a surgical mask ([Fig. 1]). Next, simulated endoscopy was performed with and without the modified surgical mask using a mannequin with the mouthpiece in place ([Video 1]). Video 1 A simple infection prevention measure using a modified surgical mask during endoscopy. Cough was simulated using a 0.4-MPa pressure accumulation sprayer containing 10 mL of fluorescent dye [3] [4] [5]. An endoscopist (height 173 cm) wearing standard personal protective equipment (PPE) performed upper gastrointestinal endoscopy. A nurse (height 163 cm) wearing standard PPE stood on the other side of the “patient.” The scattered dye droplets produced by the simulated cough were visualized using ultraviolet light. Without the modified surgical mask, contamination of the floor occurred within approximately 1.5 m from the bed, and the dye was clearly identified on the gloves, right arm, upper chest, abdomen, and shoe covers of the endoscopist ([Fig. 2]). There was no dye on the endoscopist’s eye shield, mask, or cap. The dye was identified on the gloves of the nurse ([Fig. 3]). When the modified surgical mask was worn by the “patient,” excessive amounts of dye were found inside the mask ([Fig. 4]). There was no contamination of the floor, and only a minimum amount of dye was found on the endoscopist’s upper chest and abdomen ([Fig. 5]). No dye was found on the nurse. In summary, upper gastrointestinal endoscopy could be performed on a “patient” wearing a modified surgical mask. This method can substantially reduce contamination by splash and aerosol droplets produced by patients during endoscopy, and is simple and cost-effective. Endoscopy_UCTN_Code_TTT_1AU_2AC Publication Date: 20 August 2020 (online) © 2020. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Objectives: We surveyed and reported low protective equipment usage and insufficient knowledge among endoscopy‐fluoroscopy departments in Japan in 2020. Two years later, we conducted a follow‐up survey of doctors, nurses, and technologists in Japan.Methods: We conducted a questionnaire survey on radiation protection from May to June 2022. The participants were medical staff, including doctors, nurses, and radiological and endoscopy technicians in endoscopy‐fluoroscopy departments. The questionnaire included 17 multiple‐choice questions divided into three parts: background, equipment, and knowledge.Results: We surveyed 464 subjects from 34 institutions. There were 267 doctors (58%), 153 nurses (33%), and 44 technologists (9%). The rate of wearing a lead apron was 98% in this study. The rates of wearing a thyroid collar, lead glasses, and radiation dosimeter were 27%, 35%, and 74%, respectively. The trend of the protective equipment rate was similar to that of our previous study; however, radiation dosimetry among doctors was still low at 58%. The percentage of subjects who knew the radiation exposure (REX) dose of each procedure was low at 18%. Seventy‐six percent of the subjects attended lectures on radiation protection, and 73% knew about the three principles of radiation protection; however, the concept of diagnostic reference levels was not well known (18%). Approximately 60% of the subjects knew about the exposure dose increasing cancer mortality (63%) and the 5‐year lens REX limit (56%).Conclusions: There was some improvement in radiation protection equipment or education, but relatively little compared to the 2020 survey of endoscopy departments.

Fully covered self-expandable metal stents (FCSEMSs) are usually used for malignant hilar biliary obstruction because they can be removed if required and provide longer stent patency by preventing tissue ingrowth [1] [2]; however, their use in the hepatic hilum carries the risk of blocking the side branches of the hepatic ducts and stent migration [3] [4] [5]. Furthermore, stent-in-stent techniques are unfeasible. A new FCSEMS with multiple holes was introduced to address these problems. We report successful stent-in-stent bilateral metal stent deployment using this novel FCSEMS (HANARO Biliary Multi-Hole NEO; M.I. Tech Co., Ltd, Pyeongtaek, South Korea) ([Fig. 1]) for malignant hilar biliary obstruction. A 64-year-old man with pancreatic tail cancer and liver metastases was referred because of jaundice. He was diagnosed with obstructive jaundice due to hepatic hilum metastases on computed tomography ([Fig. 2]) followed by endoscopic retrograde cholangiopancreatography ([Video 1]). First, we inserted a 0.025-inch guidewire into the common bile duct (CBD) and identified a Bismuth type IIIa hepatic hilar obstruction fluoroscopically. Stent-in-stent placement was performed using the novel covered metal stent. A guidewire was placed in the left and anterior bile ducts, and a stent was deployed from the left into the CBD. Another guidewire was placed from the stent lumen through a side hole and into the anterior bile duct. A second stent was deployed anteriorly into the CBD ([Fig. 3]). The obstructive jaundice improved, and no adverse events were observed. Video 1 Successful stent-in-stent deployment using newly designed covered metal stents to treat malignant hepatic hilar biliary obstruction. These FCSEMSs can be inserted into contralateral bile ducts through side holes in the stent because the stent tip is tapered to 1.25 mm and it has multiple holes of 1.8 mm. The stent-in-stent technique using this stent prevents both blockage of the side branches of the hepatic ducts and tumor ingrowth. There are no previous reports of this novel technique, which may be a promising new treatment option. Endoscopy_UCTN_Code_TTT_1AR_2AZ Article published online: 21 September 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany