In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.

Background and Aims-Minimum EUS and ERCP volumes that should be offered per trainee in "high quality" advanced endoscopy training programs (AETPs) are not established. We aimed to define the number of procedures required by an "average" advanced endoscopy trainee (AET) to achieve competence in technical and cognitive EUS and ERCP tasks to help structure AETPs. Methods-ASGE-recognized AETPs were invited to participate; AETs were graded on every fifth EUS and ERCP examination using a validated tool. Grading for each skill was done using a 4-point scoring system and learning curves (LCs) using cumulative sum (CUSUM) analysis for overall, technical, and cognitive components of EUS and ERCP were shared with AETs and trainers quarterly. Generalized linear mixed effects models with a random intercept for each AET were used to generate aggregate LCs allowing us to use data from all AETs to estimate the average learning experience for trainees. Results-Among 62 invited AETPs, 37 AETs from 32 AETPs participated. The majority of AETs reported hands-on EUS (52%, median 20 cases) and ERCP (68%, median 50 cases) experience before starting an AETP. The median number of EUS and ERCPs performed/AET was 400 (range 200-750) and 361 (250-650), respectively. Overall, 2616 examinations were graded

With the recent availability of removable esophageal stents, endoscopic stenting has been utilized to treat refractory benign esophageal strictures (RBES). The objective of this study was to review the feasibility and effectiveness of removable esophageal stents to treat RBES. Patients who received removable esophageal stents for the treatment of RBES at the institution between 2004-2010 using its stent implantation logs and endoscopic database were retrospectively identified. Patient demographics, stricture etiology and location, stent and procedure characteristics, and clinical outcomes were obtained. Twenty-five patients with a mean age of 70 (72% male) underwent initial stent placement; 24 were successful. Overall clinical success was achieved in five of the 19 patients (26%) ultimately undergoing stent removal. RBES etiologies included anastomotic (13), radiation (5), peptic (3), chemotherapy (1), scleroderma (1), and unknown (2). Alimaxx-E (Merit-Endotek, South Jordan, UT, USA) stents were placed in 20 patients and Polyflex (Boston Scientific, Natick, MA, USA) stents were used in five patients. Immediate complications included failed deployment (1) and chest pain (7). Five patients died prior to stent removal. Stent migration was found in 53% (10/19) of patients who underwent stent removal: nine required additional therapy and one had symptom resolution. Out of the nine patients without stent migration, five required additional therapy and four had symptom resolution. Although placement of removable esophageal stents for RBES is technically feasible, it is frequently complicated by stent migration and chest pain. In addition, few patients achieved long-term stricture resolution after initial stenting. In this study, most patients ultimately required repeated stenting and/or dilations to maintain relief of dysphagia.

HighlightsCholedocholithiasis may present as many as 33 years after a patient has undergone a cholecystectomy.Potential etiologies of choledocholithiasis after cholecystectomy include surgical clip migration, remnant cystic duct lithiasis, and primary choledocholithiasis.Choledocholithiasis is rare after a patient has undergone a cholecystectomy, but must be ruled out nevertheless.

A 66-year-old woman underwent open-access upper endoscopy indicated for a two-month history of odynophagia and dysphagia for solids and liquids, described as difficulty in initiating a swallow followed by the subsequent sensation of food and liquids ''holding up'' in her mid-chest. Past medical history included type 2 diabetes mellitus, hypertension, and dyslipidemia; medications consisted of aspirin, rosuvastatin, losartan, hydrochlorothiazide, omeprazole, glipizide, metformin, oral potassium chloride, thyroid hormone, and insulin glargine. There had been no recent changes in medications or dosages. A focused physical examination prior to the endoscopy was unremarkable. Laboratory evaluation includes a complete blood cell count and basic metabolic panel that also revealed no abnormality. Endoscopy revealed an area of healing confluent ulceration extending over several centimeters in the hypopharynx (Fig. 1a). There was also severe, circumferential, erosive esophagitis that extended 5 cm proximally from the gastroesophageal junction (Fig. 1b). Biopsies of the distal esophagus were taken due to the possibility of a viral etiology of the severe ulceration.Following one of the esophageal biopsies, a prominent mucosal defect concerning for a superficial tear was noted for which an endoscopic hemoclip was deployed; no other complications of endoscopy occurred. In addition to standard anti-reflux measures, the patient was prescribed omeprazole.The esophageal biopsies were reported as showing a focally ulcerated fragment of squamous mucosa with associated fibropurulent material, consisting of mixed inflammatory cells. No nuclear or cytoplasmic inclusions were reported. After endoscopy, her primary care provider prescribed topical treatments for suspected aphthous hypopharyngeal ulceration. Four weeks after endoscopy, she complained of worsening oral pain without improvement of her initial symptoms of odynophagia and dysphagia. An oropharyngeal examination during a clinic visit revealed exudative hypopharyngeal erythema with cracking and ulceration of the buccal mucosa, consistent with the appearance of severe aphthous stomatitis. In view of these findings, buccal biopsies were obtained, which were reported as suprabasal epidermal acantholysis compatible with pemphigus vulgaris (Fig. 2a). Review of the first esophageal biopsy identified a single mucosal fragment with similar suprabasal acantholysis in the buccal specimen, confirming the diagnosis of esophageal pemphigus vulgaris (Fig. 2b). Direct immunofluorescence stain of the buccal specimen revealed a strong, intercellular, intramucosal deposition of IgG and C3, confirming the diagnosis of pemphigus vulgaris (Fig. 3). ManagementAfter the diagnosis of pemphigus vulgaris was confirmed, additional dermatologic evaluation revealed numerous skin and groin lesions, including a violaceous papule on the inferior surface of her abdominal pannus, and papular