Background Resection techniques for small polyps include cold snare polypectomy (CSP) and hot snare polypectomy (HSP). This study compared CSP and HSP in 5–9 mm polyps in terms of complete resection and adverse events. Methods This was a multicenter, randomized trial conducted in seven Spanish centers between February and November 2019. Patients with ≥ 1 5–9 mm polyp were randomized to CSP or HSP, regardless of morphology or pit pattern. After polypectomy, two marginal biopsies were submitted to a pathologist who was blinded to polyp histology. Complete resection was defined as normal mucosa or burn artifacts in the biopsies. Abdominal pain was only assessed in patients without < 5 mm or > 9 mm polyps. Results 496 patients were randomized: 237 (394 polyps) to CSP and 259 (397 polyps) to HSP. Complete polypectomy rates were 92.5 % with CSP and 94.0 % with HSP (difference 1.5 %, 95 % confidence interval –1.9 % to 4.9 %). Intraprocedural bleeding occurred during three CSPs (0.8 %) and seven HSPs (1.8 %) (P = 0.34). One lesion per group (0.4 %) presented delayed hemorrhage. Post-colonoscopy abdominal pain presented similarly in both groups 1 hour after the procedure (CSP 18.8 % vs. HSP 18.4 %) but was higher in the HSP group after 5 hours (5.9 % vs. 16.5 %; P = 0.02). A higher proportion of patients were asymptomatic 24 hours after CSP than after HSP (97 % vs. 86.4 %; P = 0.01). Conclusions We observed no differences in complete resection and bleeding rates between CSP and HSP. CSP reduced the intensity and duration of post-colonoscopy abdominal pain.

An increased risk of lymphoma has been described in patients with inflammatory bowel disease (IBD). The aims of our study were to determine the clinical presentation, the previous exposure to immunosuppressive and biologic therapies, and the evolution of lymphomas in patients with IBD. IBD patients with diagnosis of lymphoma from October 2006 to June 2021 were identified from the prospectively maintained ENEIDA registry of GETECCU. We identified 52 patients (2.4 cases of lymphoma/1000 patients with IBD; 95% CI 1.8–3.1). Thirty-five were men (67%), 52% had ulcerative colitis, 60% received thiopurines, and 38% an anti-TNF drug before lymphoma diagnosis. Age at lymphoma was lower in those patients treated with thiopurines (53 ± 17 years old) and anti-TNF drugs (47 ± 17) than in those patients not treated with these drugs (63 ± 12; p < 0.05). Five cases had relapse of lymphoma (1.7 cases/100 patient-years). Nine patients (17%) died after 19 months (IQR 0–48 months). Relapse and mortality were not related with the type of IBD or lymphoma, nor with thiopurines or biologic therapies. In conclusion, most IBD patients had been treated with thiopurines and/or anti-TNF agents before lymphoma diagnosis, and these patients were younger at diagnosis of lymphoma than those not treated with these drugs. Relapse and mortality of lymphoma were not related with these therapies.

A patient with metastatic pancreatic adenocarcinoma underwent combined endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and endoscopic biliary drainage. Tumor involvement of a creased papilla precluded endoscopic retrograde cholangiopancreatography (ERCP). EUS-cholangiography revealed a dilated common bile duct (CBD) and a patent cystic duct above a distal stricture ([Fig. 1]). EUS-choledochoduodenostomy was performed with an 8 × 8-mm lumen-apposing metal stent (LAMS). Bile and contrast outflow into the duodenum confirmed satisfactory placement of the LAMS ([Video 1]). The LAMS was balloon dilated prior to the intended insertion of an axis-orienting double-pigtail stent. However, during dilation, the distal flange of the LAMS dislodged from the CBD and guidewire access was lost. Duct decompression and aerobilia prevented repeat EUS-guided CBD puncture being performed. Video 1 Endoscopic ultrasound (EUS)-guided choledochoduodenostomy is performed, but dislodgement of the lumen-apposing metal stent occurs, resulting in a choledochal perforation. A salvage procedure consisting of EUS-guided gallbladder drainage as a portal for antegrade transcystic guidewire passage, followed by rendezvous endoscopic retrograde cholangiopancreatography is then performed, with eventual placement of a biliary metal stent and clips to seal the perforation. The gallbladder was imaged from the antrum and drained under EUS guidance with a cautery-enhanced 15 × 10-mm LAMS. A gastroscope was passed through the cholecystogastric LAMS after successful balloon dilation. The cystic-duct orifice was identified using cholecystoscopy. A guidewire was advanced in an antegrade fashion through the cystic duct until it was coiled in the duodenum. The gastroscope was removed over the wire. A duodenoscope was advanced to the papilla alongside the wire. A parallel guidewire was placed into the CBD ([Fig. 2]) through a homemade monorail sphincterotome, as previously described [1]. A covered biliary metal stent was placed over the second guidewire across the malignant stricture and the choledochal perforation that had resulted from the dislodgement of the LAMS ([Fig. 3]). The dislodged LAMS was retrieved, with clip closure of the duodenal perforation being performed ([Fig. 4]). The patient was given intravenous antibiotics and analgesia, and recovered within 48 hours. Acute LAMS dislodgment from nonadherent organs results in a double perforation. LAMS are increasingly used for EUS-choledochoduodenostomy, with 10 % unplanned procedural events reported [2]. Standard salvage strategies include a bridging stent if the guidewire is in place or repeat EUS-guided CBD puncture to create a new tract. Unfortunately, neither of these was possible in this case. In malignant biliary obstruction, EUS-guided gallbladder drainage allows symptomatic decompression when the cystic duct is involved [3] and rescue biliary drainage when it is patent [4]. Two-stage transluminal cholecystoscopy for biliary rendezvous was reported after failed cannulation in a poor operative candidate with acute cholecystitis and choledocholithiasis [5]. We similarly used transluminal–transcystic rendezvous to perform a single-session ERCP with biliary stenting to seal the CBD perforation that had resulted from the dislodgement of the LAMS. Endoscopy_UCTN_Code_TTT_1AS_2AD Publication Date: 05 March 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

The use of premedication for upper gastrointestinal endoscopy (UGE) is not widely established in western countries. The primary aim of the study was to compare gastric visibility according to the total visibility score (TVS). The secondary aim was to assess complications, diagnostic yield, endoscopic procedure time, sedation dose and patient satisfaction. A single center prospective cohort study was performed of consecutive adults undergoing an UGE in the afternoon working shift. After completing enrolment in the control group, patients were administered 200 mg simethicone and 500 mg N-acetylcysteine diluted in 100 ml of water >15 minutes before the procedure. All procedures were recorded and a single, blinded endoscopist evaluated the TVS after recruitment of both cohorts. Patient satisfaction was evaluated using the Spanish translation of the American Society of Gastrointestinal Endoscopy satisfaction questionnaire. 205 patients were included in the study, 103 females (50.2%) with a median age of 54.8-years (IQR: 41.2-65.2). 104 were enrolled to the control group and 101 to the intervention group. Patients receiving premedication presented a higher rate of adequate (74.3% vs 45.2; difference 95% CI: 16,3-41,9%, p<0.001) and excellent gastric visibility (23.8% vs 7.7%; difference 95% CI: 6,3-25,8%, p=0.002). Propofol dose was similar, although the median procedure time was lower in the group of no intervention [5 (IQR: 4-7) vs 6 minutes (IQR: 5-7); p=0.03]. Procedure related adverse events were similar, except that patient without premedication experienced more nausea episodes. Major and minor endoscopic findings and the satisfaction questionnaire showed no differences between both groups. Patients receiving premedication with simethicone and N-acetylcysteine had a better gastric visibility score, without any increase in adverse events or affecting the patients' satisfaction.

INTRODUCTION: The aim of this study was to compare the effectiveness of glucagon vs placebo in resolving esophageal foreign body impaction (EFBI), as well as the length of the procedure and adverse events. METHODS: This was a multicenter, randomized, double-blind trial involving consecutive patients diagnosed with alimentary EFBI. Participants were randomized to receive either 1 mg of intravenous glucagon or placebo. All patients underwent upper endoscopy, and adverse events were assessed through a protocolized telephonic interview 7 days later. RESULTS: The study included 72 subjects in the glucagon group and 68 in the placebo group. The foreign body was not identified in 23.6% of subjects in the glucagon group and 20.6% of subjects in the placebo group (difference 3%, 95% confidence interval −10.7% to 16.8%, P = 0.67). The median time required to remove the foreign body was similar in both groups 4 minutes (range 2–10) in the glucagon group and 3.5 minutes (range 2–7) in the placebo group (difference 0.5 minutes, 95% confidence interval −1.3 to 2.3; P = 0.59). The most common adverse event reported in both groups was mild pharyngeal pain. DISCUSSION: Glucagon is no more effective than placebo in resolving EFBI or shortening the time required to remove the foreign body (EUDRA-CT number 2019-004920-40).