ObjectiveThe diagnosis of autoimmune pancreatitis (AIP) is challenging. Sonographic and cross-sectional imaging findings of AIP closely mimic pancreatic ductal adenocarcinoma (PDAC) and techniques for tissue sampling of AIP are suboptimal. These limitations often result in delayed or failed diagnosis, which negatively impact patient management and outcomes. This study aimed to create an endoscopic ultrasound (EUS)-based convolutional neural network (CNN) model trained to differentiate AIP from PDAC, chronic pancreatitis (CP) and normal pancreas (NP), with sufficient performance to analyse EUS video in real time.DesignA database of still image and video data obtained from EUS examinations of cases of AIP, PDAC, CP and NP was used to develop a CNN. Occlusion heatmap analysis was used to identify sonographic features the CNN valued when differentiating AIP from PDAC.ResultsFrom 583 patients (146 AIP, 292 PDAC, 72 CP and 73 NP), a total of 1 174 461 unique EUS images were extracted. For video data, the CNN processed 955 EUS frames per second and was: 99% sensitive, 98% specific for distinguishing AIP from NP; 94% sensitive, 71% specific for distinguishing AIP from CP; 90% sensitive, 93% specific for distinguishing AIP from PDAC; and 90% sensitive, 85% specific for distinguishing AIP from all studied conditions (ie, PDAC, CP and NP).ConclusionThe developed EUS-CNN model accurately differentiated AIP from PDAC and benign pancreatic conditions, thereby offering the capability of earlier and more accurate diagnosis. Use of this model offers the potential for more timely and appropriate patient care and improved outcome.

Background and Aims: Patients presenting with nonhematemesis GI bleeding (NHGIB) represent a diagnostic challenge for physicians. We performed a randomized controlled trial to assess the benefits of deployment of a video capsule soon after admission in the management of patients presenting with melena, hematochezia, or severe anemia compared with standard of care management. Methods: Patients admitted with NHGIB were randomized and placed into 1 of 2 study groups. In the experimental group, patients ingested a video capsule soon after admission to the hospital. These patients had further endoscopic workup based on the findings from the capsule. Patients in the control group underwent endoscopic evaluation (ie, upper endoscopy, capsule endoscopy, and/or colonoscopy) to identify the source of bleeding as directed by the attending gastroenterologist’s interpretation of their clinical presentation. The primary endpoint for this study was the rate of localization of bleeding during hospitalization. Results: Eighty-seven patients were included in this study: 45 randomized to the standard of care arm and 42 to the early capsule arm. A bleeding source was localized in 64.3% of the patients in the early capsule arm and in 31.1% of the patients in the standard of care arm (P < .01). The likelihood of endoscopic localization of bleeding over time was greater for patients receiving early capsule endoscopy compared with those in the standard of care arm (adjusted hazard ratio, 2.77; 95% confidence interval, 1.36–5.64). Conclusions: For patients admitted to the hospital for NHGIB, early capsule endoscopy is a safe and effective alternative for the detection of the source of bleeding. (Clinical trial registration number: NCT02442830.) (Gastrointest Endosc 2019;89:33–43.)

No abstract

Background and Aims: Closure of endoscopic resection defects can be achieved with through-the-scope clips, over-the-scope clips, or endoscopic suturing. However, these devices are often limited by their inability to close large, irregular, and difficult-to-reach defects. Thus, we aimed to assess the feasibility and safety of a novel through-the-scope, suture-based closure system developed to overcome these limitations.Methods: This was a retrospective multicenter study involving 8 centers in the United States. Primary outcomes were feasibility and safety of early use of the device. Secondary outcomes were assessment of need for additional closure devices, prolonged procedure time, and technical feasibility of performing the procedure with an alternative device(s).Results: Ninety-three patients (48.4% women) with mean age 63.6 AE 13.1 years were included. Technical success was achieved in 83 patients (89.2%), and supplemental closure was required in 24.7% of patients (n Z 23) with a

Introduction: Large walled-off necrosis (WON) are challenging to manage endoscopically even with the use of large caliber lumen-apposing metal stents (LAMS). Therefore, some experts suggest percutaneous drainage (PCD) to facilitate endoscopic management with LAMS. The aim of this study is to determine the impact of PCD on WON resolution in patients undergoing LAMS drainage. Methods: A retrospective cohort study was performed for patients who underwent Endoscopic Ultrasound (EUS)-guided LAMS drainage of WON from 4/2014 to 10/2019. Demographic and procedural information and patient clinical outcomes were recorded. Cross-sectional imaging was reviewed by two abdominal radiologists blinded to patient outcome to independently determine size and percentage of solid necrosis within the WON. Wilcoxon rank sum test and Fisher's exact tests were used to compare continuous and categorical variables, respectively. A 2-sided p-value <0.05 was regarded as statistically significant. Results: A total of 62 patients underwent LAMS drainage for WON >10cm during the study period, of whom 54 (87%) did not undergo PCD. Baseline characteristics were similar between both groups including size, rate of paracolic gutter extension, percentage of solid necrosis, and presence of disconnected pancreatic duct (Table 1). Both groups were noted to contain a median of 60% solid necrosis (pZ0.66). Although no statistical procedural differences were noted between the groups (Table 2), use of a multigateway technique was more common in those without PCD (30% vs 0%; pZ0.21). Patients with PCD had no observed improvement in time to WON resolution (103 vs 78 days; pZ0.63) and did not reduce the number of endoscopic necrosectomy procedures (3.5 vs 1.0; pZ0.12) compared to those without PCD. Conclusions: In this cohort study, the majority of patients with large WON were successfully managed endoscopically with LAMS drainage and necrosectomy without the need for additional percutaneous drainage. Further studies are needed to clarify the role of percutaneous drainage in the setting of LAMS placement for WON.

BACKGROUND: Wireless video capsule endoscopy allows the noninvasive visualization of the small intestine. Currently, capsules do not provide localization information while traversing the GI tract. OBJECTIVE: To report on the radiological validation of 3-dimensional localization software incorporated in a newly developed capsule. By using radiofrequency transmission, the software measures the strength of the capsule\u27s signal to locate the position of the capsule. SETTING: This study was performed at the University of Massachusetts Medical Center, Worcester, Mass. PATIENTS: Thirty healthy volunteers consented to the experimental procedure. DESIGN: After ingestion of the capsule, subjects had 5 sets of anteroposterior and lateral radiographs taken every 30 minutes while the software calculated the position of the capsule. By using the radiographs, we calculated the location of the capsule in the abdominal cavity and compared the results with those generated by the software. RESULTS: Average error (and standard deviation) among the 3-dimensional coordinates was X, 2.00 cm (1.64); Y, 2.64 cm (2.39); and Z, 2.51 cm (1.83). The average total spatial error among all measurements was 13.26 cm(3) (22.72). There was a correlation between increased subject body mass index and the 3-dimensional software measurement error. LIMITATIONS: This study was performed in healthy volunteers and needs further validation in patients with small intestinal disorders. CONCLUSIONS: The new 3-dimensional software provides localization of the capsule consistent with radiological observations. However, further validation of the software\u27s clinical utility is required with a prospective clinical trial. Mosby, Inc. All rights reserved

No abstract

Background and aims Endoscopic resections are associated with bleeding and perforation and may be managed with through-the-scope (TTS) clips, over-the-scope clips and endoscopic suturing. The aim of this preclinical study was to compare technical success of closure using a novel TTS tissue helix tack and suture device (X-Tack) to TTS clips in a porcine model. Materials and methods Four subjects underwent 40 mucosal resections, diameter range 25–50 mm, in the stomach (n = 24) and colon (n = 16). Closures were randomized to X-Tack (n = 24) or clip (n = 16). Animals underwent weekly endoscopic follow-up for 4 weeks. Results Technical closure with X-Tack was successful in 24 of 24 (100 %) cases and with clips in 13 of 16 cases (81.3 %) (P = 0.0001). One colonic perforation occurred and was successfully managed using X-Tack. The rate of healing was not statistically different between the groups, and all sites healed at 4 weeks including the perforation and were confirmed by histology. Conclusions Compared to TTS clip, X-Tack is superior for effecting large mucosal defect closure, including durable sealing of full-thickness perforation. There was no difference in rate of healing between devices.