These results demonstrate the feasibility of establishing a centralized database to report individualized learning curves and confirm the substantial variability in time to achieve competence among AETs in EUS and ERCP. ClinicalTrials.gov: NCT02509416.

Duodenal polyps or lesions are uncommonly found on upper endoscopy. Duodenal lesions can be categorized as subepithelial or mucosally-based, and the type of lesion often dictates the work-up and possible therapeutic options. Subepithelial lesions that can arise in the duodenum include lipomas, gastrointestinal stromal tumors, and carcinoids. Endoscopic ultrasonography with fine needle aspiration is useful in the characterization and diagnosis of subepithelial lesions. Duodenal gastrointestinal stromal tumors and large or multifocal carcinoids are best managed by surgical resection. Brunner's gland tumors, solitary Peutz-Jeghers polyps, and non-ampullary and ampullary adenomas are mucosally-based duodenal lesions, which can require removal and are typically amenable to endoscopic resection. Several anatomic characteristics of the duodenum make endoscopic resection of duodenal lesions challenging. However, advanced endoscopic techniques exist that enable the resection of large mucosally-based duodenal lesions. Endoscopic papillectomy is not without risk, but this procedure can effectively resect ampullary adenomas and allows patients to avoid surgery, which typically involves pancreaticoduodenectomy. Endoscopic mucosal resection and its variations (such as cap-assisted, cap-band-assisted, and underwater techniques) enable the safe and effective resection of most duodenal adenomas. Endoscopic submucosal dissection is possible but very difficult to safely perform in the duodenum.

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A 51-year-old Asian man with metastatic gastric adenocarcinoma presented with a 3-month history of profound diarrhea and weight loss. Laboratory evaluation was significant for anemia and hypokalemia. Computed tomography showed large tumor burden from the gastric antrum with invasion into the ascending colon. Esophagogastroduodenoscopy (EGD) revealed a gastrocolic fistula 30 mm in diameter within the posterior wall of the gastric antrum, extending for 6 cm and opening into the ascending colon (• " Fig. 1) along with partial obstruction of the pyloric channel. Following discussion of therapeutic options, the patient consented to off-label use of an atrial septal defect (ASD) occlusion device to treat the fistula. Endoscopically, a guidewire was advanced through the fistula tract into the transverse colon. After fluoroscopic sizing with a 34-mm sizing balloon, a 36-mm ASD occlusion device (Amplatzer, St. Jude Medical, St. Paul, Minnesota, USA) was deployed into the tract over the wire alongside the scope. The distal (left atrial) disc was seated within the tract with the proximal (right atrial) disc within the gastric lumen. Injection of contrast revealed little passage of contrast into the fistula. A duodenal stent was then deployed across the pylorus (• " Fig. 2). At 6 weeks later the patient had no further diarrhea and his weight had stabilized. Abdominal films showed both devices in stable position.Gastrocolic fistulas have been reported as a very rare complication of malignant tumors. In a review of 1500 cases of cancer of the stomach and 3200 cases of carcinoma in the colon, only 11 cases of gastrocolic fistula were found, of which only one case was caused by gastric carcinoma [1]. This case illustrates the novel (but offlabel) use of an ASD closure device combined with a duodenal stent for palliation of a large inoperable malignant gastrocolic fistula and gastric outlet obstruction. Endoscopy_UCTN_Code_TTT_1AO_2AICompeting interests: None