Endoscopist-directed deep sedation during endoscopic retrograde cholangiopancreatography is safe. The presence of certain factors should be assessed before the procedure to identify patients who are high-risk for difficult sedation.

endoscopist-directed sedation is effective and safe for single balloon enteroscopy. Multi-center and wider studies are needed in order to better assess the efficacy, safety and efficiency of sedation controlled by a non-anesthetist during advanced endoscopy in this field.

Purpose It is difficult to repair a large complex recurrent hernia. TAR with anterior fascial re-approximation may not be possible because of more tissue loss, so we find that transverse abdominal muscle repair (TAR) with bridging is a suitable technique for such a condition. We aim to demonstrate the results of bridge works at our hospital after data collection Methods. Our patients were retrospectively matched from our institution board sheet, zagazig university hospital. One Hundredred ninety-two patients were available between 2015 and 2019 for our investigation. Aim of the work: Although the results of TAR with the bridge are not better with multiple recurrent, the life quality is improved; our outcome interesting are the quality of life (HerQLes) and pain severity(PROMIS pain intensity 3a), and recurrence, based on physical examinations and CT scans, Results. In our study, 192 patients were involved. The defect width of a hernia was typically 26±8 centimeters. Incisional hernias were the majority (93%). Recurrent type (71%) had, (21%) had five repeated prior hernia surgeries A total (of 70%) had data accessible. HerQLes rankings confirmed a regular enhancement in the postoperative restoration manner (26± 21, 44± 26, and 60±33 at six months to three years, respectively; P value (<0.001). as did the PROMIS Pain Intensity 3a scores (46±11 at baseline, 45±11 at 30-day follow-up, and 39±11 at ix months–3 years; P=0.001). At a mean follow-up at six months to three years, P = 0.001). A composite recurrence of 46% was detected shortly at a counseled follow-up of 20±10 months, mainly from patients reporting a "bulge" at the site. Conclusion. Synthetic mesh in bridging TAR repairs for patients with recurrent, complex hernias is associated with a higher rate of bulge perception but with improved quality of life. The preoperative cases must be discussed for the ideal decision

EUS-guided transmural endoscopic drainage It can treat the late stages of Acute Necrotizing Pancreatitis (ANP), Walled-off pancreatic necrosis ( WOPN). Still, in the initial stages of ANP, the endoscopic function s not completely clear. Our aim We are comparing endoscopic draining of WOPN with early endoscopic treatment of Acute Necrotizing Pancreatic Collection (ANCs). Methods There were 142 ANP patients with necrotizing pancreatic collection who received transmural endoscopic drainage. In 50 (35.21%) cases with ANC (Group 1) and 92 (64.79%) individuals with WOPN (Group 2), endoscopic drainage was carried out after the first 4 -5 weeks following ANP. Results The patient's average age was 49.9 years (range: 22–79), and 59%of them were male. In Groups 1 and 2, the mean active drainage timing was 26.8 and 16.9 days (P = 0.0001) in Group 1 and 270.8 and 164.2 days (P = 0.0001) in Group 2, there was a medium of 9.5 and 4.5 endoscopic drainages with (P = 0.0001). No significant differences in long-standing success rates between the two groups (P > 0.05 for each). Conclusion Within the first 4-5 weeks later, ANP, transmural endoscopic intervention is an sufficient treating of early ANCs. However, more procedures and a longer duration of treatment following endoscopy in WOPN of drainage are needed.

Background The management of fistulising perianal Crohn′s disease (pCD) is a challenging problem for patients and physicians. New therapeutic alternatives are needed, particularly in anti-TNF refractory patients. Data regarding ustekinumab (UST) effectiveness in pCD are scarce. Our aim was to evaluate the clinical and radiologic effectiveness of UST in pCD patients refractory or intolerant to anti-TNF. Methods We conducted a multi-center retrospective observational study. All patients with anti-TNF refractory pCD treated with UST were evaluated. Demographic and clinical variables including concomitant drugs were registered. Clinical response was evaluated at 16 weeks and 12 months and was defined as a reduction of 50% of draining fistulas or a marked reduction in fistula drainage. In patients with a magnetic resonance imaging (MRI) before and after treatment initiation, radiologic response was defined according to Ng Score (healed, partial response, unchanged, deterioration). Results Thirty-two patients were included, 68.8% female, median age 44,11 (IQR 36.28-48.56). Median time from diagnosis to UST initiation was 12.94 years (IQR 7.52-19.52), 90.6% had received previously 2 anti-TNF (37.5% also vedolizumab) and 46.9% had more than 2 fistulas. In 22 patients (68.8%) pCD was the main indication for UST treatment while in the remaining 31.2% the main indication was luminal disease. Fifteen patients (46.9%) received antibiotics at the initiation of UST, 8 (25%) combo therapy with thiopurines and 21 (65.6%) had setons. Patients received a 6mg/kg IV dose and 87.5% received 90mg/8 week SQ for maintenance. Dose intensification was needed in 20 patients (62.5%) at a median of 13 months (IQR 8.00-19.5). Fifteen patients (46,9%) achieved clinical response at week 16, while 18/30 (60%) had clinical response at 12 months (three of them were in clinical remission). Nineteen patients (59,4%) had an MRI performed pre and post-treatment at a median of 15 months (IQR 10-19). 10/19 patients (52.6%) achieved a radiological response although no patient had all fistulas healed. In the multivariate analysis the only factor associated with clinical response at 12 months was the presence of setons at UST initiation (OR 7.0; IC95% 1.3-37.9). There were no factors significantly associated with radiological response or clinical response at week 16. Four patients experienced adverse effects (three perianal abscesses and one transient skin rash). Conclusion Ustekinumab was effective in achieving clinical and radiological response in anti-TNF-refractory fistulising pCD patients, although clinical and radiological remission was rare. Most patients needed UST dose intensification in this highly refractory cohort. Adverse effects were infrequent, mainly perianal abscesses.