Background and Aims: EUS-directed transgastric ERCP (EDGE) has emerged as a viable, completely endoscopic method for performing pancreaticobiliary interventions in patients with Roux-en-Y gastric bypass anatomy. The aims of this systematic review are: 1) to describe indications, outcomes and complications of EDGE; and 2) to identify deficiencies in our knowledge of important technical approaches and clinical outcomes. Patients and methods: A systematic review was conducted via comprehensive search of MEDLINE, SCOPUS, CINAHL, and Cochrane to identify studies focused on EDGE outcomes. Simple descriptive statistics were derived from case series only. Case reports were only included to qualitatively describe additional indications, techniques, and adverse events (AE). Results: The initial search identified 2143 abstracts. Nine case series and eight case reports were included. In the nine case series, 169 patients underwent EDGE. Technical success was 99% (168/169) for gastrogastrostomy/jejunogastrostomy creation and 98% (166/169) for subsequent ERCP. Minor AE specifically related to EDGE occurred in 18% (31/169) and included intraprocedural stent migration/malposition (n=27) and abdominal pain (n=4). Moderate AE specific to EDGE occurred in 5% (9/169) and included: bleeding (2%); persistent fistula (1%); and perforation (1%). Severe AE occurred in one patient due to perforation requiring surgery. Deficiency in reporting on clinical significance of AE’s was identified. Conclusion: Based on limited observational data, in expert hands EDGE has a high rate of technical success and an acceptable rate of AE’s. As a novel procedure, many knowledge gaps need to be addressed to inform the design of meaningful comparative studies and guide informed consent.

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Background Existing evidence for disparities in inflammatory bowel disease is fragmented and heterogenous. Underlying mechanisms for differences in outcomes based on race and socioeconomic status remain undefined. We performed a systematic review of the literature to examine disparities in surgery for inflammatory bowel disease in the United States. Methods Electronic databases were searched from 2000 through June 11, 2021, to identify studies addressing disparities in surgical treatment for adults with inflammatory bowel disease. Eligible English-language publications comparing the use or outcomes of surgery by racial/ethnic, socioeconomic, geographic, and/or institutional factors were included. Studies were grouped according to whether outcomes of surgery were reported or surgery itself was the relevant end point (utilization). Quality was assessed using the Newcastle-Ottawa Scale for observational studies. Results Forty-five studies were included. Twenty-four reported surgical outcomes and 21 addressed utilization. Race/ethnicity was considered in 96% of studies, socioeconomic status in 44%, geographic factors in 27%, and hospital/surgeon factors in 22%. Although study populations and end points were heterogeneous, Black and Hispanic patients were less likely to undergo abdominal surgery when hospitalized; they were more likely to have a complication when they did have surgery. Differences based on race were correlated with socioeconomic factors but frequently remained significant after adjustments for insurance and baseline health. Conclusions Surgical disparities based on sociologic and structural factors reflect unidentified differences in multidisciplinary disease management. A broad, multidimensional approach to disparities research with more granular and diverse data sources is needed to improve health care quality and equity for inflammatory bowel disease.

Introduction There were an estimated 18.1 million new cancer cases in 2018, with colon cancer being the third most common worldwide. Colon cancer development is an accumulation of mutations resulting in normal epithelial cells transforming into adenomas and then adenocarcinomas. In certain scenarios, endoscopic interventions have gained considerable momentum over invasive surgery as an alternative to manage early gastrointestinal lesions. New techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection allow for removal of large, flat sessile polyps. Successful EMR is dependent on expanding the submucosal space to create adequate lift of the polyp to facilitate tissue capture and to avoid perforation and excess bleeding. ORISE gel (Boston Scientific) is a submucosal lifting agent currently in use in the United States. Methods We present three cases of gastrointestinal specimens obtained using ORISE gel. Histological analysis with hematoxylin and eosin revealed submucosal amorphous deposits that appeared to be mucin. Due to the concern for malignancy, additional stains were performed, including periodic acid–Schiff with diastase digestion (DPAS) to identify mucin. DPAS staining for mucin was negative, indicating the mucinous-appearing amorphous material seen on hematoxylin and eosin staining was not mucin but a likely remnant ORISE gel used during EMR. Additional immunohistochemical stains for epithelial cells (cytokeratin AE1/AE3) were also performed to exclude the presence of infiltrating tumor cells. Conclusion These three cautionary cases reveal the importance of good communication between endoscopists and pathology. In an effort to avoid overdiagnosis and/or the usage of unnecessary additional stains, pathologists should be alerted of ORISE gel usage.