Gastric outlet obstruction (GOO) is a potential complication of pancreatic or distal gastric malignancy and may present in as many as 15%-20% of patients with pancreatic adenocarcinoma. [1,2] Ampullary cancer, lymphoma, and biliary malignancy may also cause GOO. There are also several benign etiologies of GOO including chronic pancreatitis, peptic ulcer ABSTRACT Gastric outlet obstruction (GOO) is characterized by epigastric pain and postprandial vomiting secondary to mechanical obstruction. Management of GOO is usually focused on alleviating the symptoms of obstruction and can be achieved by surgical gastrojejunostomy or enteral stenting. Recent studies have shown success with EUS-guided gastroenterostomy (EUS-GE) in the management of GOO but data is limited. We, therefore, conducted a meta-analysis to evaluate the safety and efficacy of EUS-GE in the management of GOO. A comprehensive literature review was conducted by searching the Embase and PubMed databases from inception to January 2019 to identify all studies that evaluate the efficacy and safety of EUS-GE in GOO. Our primary outcome was to evaluate technical success and clinical success. Secondary outcomes were to evaluate the need for reintervention and adverse events of the procedure. Twelve studies including 285 patients were included in the meta-analysis. Technical success was achieved in 266 patients with a pooled technical success of 92% (95% confidence interval [CI]: 88%-95%). Clinical success was achieved in 90% of the patients (95% CI: 85%-94%). Recurrence of symptoms or unplanned reintervention was needed in 9% of the patients (95% CI: 6%-13%) and adverse events were reported in 12% of the patients (95% CI: 8%-16%). The heterogeneity tests among studies were nonsignificant with I 2 = 0. EUS-GE is a safe and efficacious treatment modality for the management of benign and malignant GOO. Larger prospective studies are needed to further evaluate its utility in GOO.

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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

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