Ahmed Kayal

Background and Aims: Endoscopic mucosal resection (EMR) is not systematically taught during most training programs. The aim of this study was to evaluate the effectiveness and clinical utility of a 1-day didactic and simulation-based EMR curriculum for practicing endoscopists without prior formal training in advanced endoscopic tissue resection. Methods: We designed a 1-day lecture and simulation-based EMR course. Twelve participants completed the course. Effectiveness and clinical utility were evaluated using sequential explanatory mixed methods. All participants completed a pre-course multiple choice question (MCQ) examination followed by a separate, post-course MCQ examination with a similar blueprint. A survey was also conducted to assess cognitive fatigue, perceived benefit, and potential for change in EMR practice. Finally, a delayed MCQ examination was administered 10-14 weeks later to assess knowledge retention and qualitative data were sequentially collected from 3 candidates via semi-structured interviews. Results: The mean pre-course score was 47.8% (SD 12.4%). The mean post-course score was 75% (9.9%) and the mean delayed score was 70.8% (13.6%), both significantly higher than the mean pre-course score (P < .001; Cohen’s d = 1.86 and P < .001; Cohen’s d = 1.47, respectively). There was no significant difference between the mean post- and delayed-course test scores (P = .2). Three themes emerged from the interviews: (1) a need for EMR training, (2) improved knowledge evaluating polyps, and (3) changed or refined EMR technique after the course. Conclusions: This study demonstrates significant knowledge acquisition and retention of cognitive skills and suggests a change in practice following a 1-day focused didactic and simulation-based EMR course.

Background and Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is performed using anaesthesia or conscious sedation, though the effectiveness, adverse events (AEs), and tolerability of each approach remain unclear. Thus, we compared these approaches prospectively. Methods: We performed a multi-centre prospective cohort study including patients with native papillae undergoing ERCP for biliary indications between 2018 and 2023. The primary outcome was sedation-related AEs, defined as sustained hypoxaemia or hypotension, unplanned mask ventilation or intubation, vasopressor or reversal agent use, cardiorespiratory arrest, or death. Secondary outcomes included other AEs, technical success measures, and patient-reported tolerability using a validated scale. Multivariable logistic regression was performed in addition to propensity score-matched analyses. Results: At 8 centres, a total of 3174 first-time biliary ERCPs were performed, 433 (13.6%) employing anaesthesia. Nine sedation-related AEs occurred with conscious sedation (0.3%), while 2 (0.5%) occurred with anaesthesia (odds ratio, OR, 0.35, 0.07-2.37). Only 25 (0.9%) conscious sedation-supported ERCPs were aborted due to the inability to appropriately sedate patients. There were no significant differences in other AE rates, cannulation success, time, or attempts, use of pre-cut or needle-knife access methods, or inadvertent pancreatic duct cannulation. Odds of significant patient-reported intra-procedural awareness and discomfort were both higher with conscious sedation (ORs 16.19, 4.81-54.53, and 21.25, 4.44-101.61, respectively). Propensity score-matched analyses yielded no differences in any outcome compared with primary analyses. Conclusions: Routine biliary ERCP is equally safe and effective with conscious sedation (vs anaesthesia). Given regional resource limitations, conscious sedation is justified as a primary option for routine biliary ERCP.

INTRODUCTION: Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding (CSPEB) is common. Contemporary estimates of risk are lacking. We aimed to identify risk factors of and outcomes after CSPEB. METHODS: We analyzed multicenter prospective ERCP data between 2018 and 2024 with 30-day follow-up. The primary outcome was CSPEB, defined as hematemesis, melena, or hematochezia resulting in (i) hemoglobin drop ≥ 20 g/L or transfusion and/or (ii) endoscopy to evaluate suspected bleeding and/or (iii) unplanned healthcare visitation and/or prolongation of existing admission. Firth logistic regression was used. P values 12 inhibitors were held for a median of 4 days (interquartile range 4) before higher risk ERCP. After higher risk interventions, P2Y₁₂ inhibitors (OR 3.33, 1.26–7.74), warfarin (OR 8.54, 3.32–19.81), dabigatran (OR 13.40, 2.06–59.96), rivaroxaban (OR 7.42, 3.43–15.24), and apixaban (OR 4.16, 1.99–8.20) were associated with CSPEB. Significant intraprocedural bleeding after sphincterotomy (OR 2.32, 1.06–4.60), but not after sphincteroplasty, was also associated. Concomitant cardiorespiratory events occurred more frequently within 30 days after CSPEB (OR 12.71, 4.75–32.54). DISCUSSION: Risks of antiplatelet-related CSPEB may be underestimated by endoscopists based on observations of suboptimal holding before higher risk ERCP. Appropriate periprocedural antithrombotic management is essential and could represent novel quality initiative targets.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure in the management of pancreatic and biliary disease. While its role is firmly established, further well-designed prospective ERCP research is required, as a large portion of previous work has employed retrospective or administrative methodologies, both prone to potential biases. The aim of the Calgary Registry for Advanced and Therapeutic Endoscopy (CReATE) is to be a high-fidelity prospective multicentre registry. Methods: The study population consisted of consecutive adult ERCP patients from September 2018 to September 2019. Informed consent was acquired for each patient. All relevant preprocedural, procedural, peri-procedural and postprocedural data were captured in real time by a full-time third-party research assistant directly observing procedures. Outcomes were ascertained by comprehensive medical record review and patient phone interview 30 days after the index procedure. Results: Five endoscopists performed 895 ERCP procedures, 90.1% of which were deemed successful. Suspected choledocholithiasis was the most common indication for ERCP, followed by suspected or confirmed stricture(s), at 61.0% and 29.5%, respectively. 61.0% of procedures were performed on ERCP-naive patients. Post-ERCP pancreatitis occurred following 4.9% of procedures, with clinically significant bleeding or perforation occurring following 1.8% and 0.1% of procedures, respectively. Discussion: Through 12 months, CReATE captured 895 procedures prospectively, with each entry containing over 300 data fields. Active expansion to additional tertiary centres is underway, and this will enhance the existing data pool. CReATE has the potential to improve multiple facets of ERCP, including training, optimal procedural techniques, mitigation of adverse events and personalized patient care.

We report a case of 32-year-old man with Acetaminophen induced liver failure who did not meet King’s College criteria for liver transplantation but showed progressive worsening cerebral edema and encephalopathy despite improving biochemical parameters. The patient was managed with urgent liver transplantation and made an excellent recovery. To our knowledge, there is no literature or reported cases for worsening cerebral edema in the setting of acute liver failure and improving liver function tests.