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Introduction: Endoscopically placed common bile duct stents are used for biliary decompression. Studies have reported median patency of plastic stents between 77 to 126 days. It is advisable to remove or exchange these stents within three months of the index procedure to prevent complications such as stent occlusion, dysfunction, migration, and cholangitis. We hypothesized that the risk of retained biliary stents might be high in the underserved population owing to low socio-economic status, language and intellectual barriers, and demographical distribution. Methods: A retrospective study was conducted amongst all patients who underwent ERCP-guided plastic biliary stent placement between January 2016 and December 2021 at our community-based institution. Charts were reviewed to collect demographics, index ERCP, removal/exchange procedure, complications, and follow-up office visits. Retained biliary stents were defined as patients who did not show up for their follow-up ERCP for stent removal (missed stent group) or those who presented for stent removal later than the recommended time frame of 3 months (Delayed stent removal group). Descriptive analysis was performed. Chi-square and Fisher exact tests were used to compare categorical variables and t-tests for continuous variables. Results: A total of 431 ERCPs were performed, out of which 46 (10.7%) patients had retained stents. Fifty percent of the cohort (n523) were white and 63% (n529) were females. 10 patients (21.8%) were non-English speakers, and 10 patients (21.8%) were non-insured. 32 (69.6%) of the index ERCPs performed were done in the outpatient setting. Our ERCP reports stated the recommended follow-up time for stent removal for all patients whether performed in the inpatient or outpatient setting. However, 8/14 (57%) of the inpatients did not have these instructions included in their discharge summaries. No statistical significance was seen when comparing missed versus delayed stent removal groups, except for the ERCP location (Table ). Conclusion: Socio-economic and demographic factors, including the language barrier and lack of insurance as well as the absence of specific and clear follow-up dates on the discharge instructions from the hospital, could be associated with retained biliary stents.

Contact force (CF) is a novel approach developed to increase the safety and efficacy of catheter ablation. However, the value of CF-sensing technology for atrial flutter (AFL) cavo-tricuspid isthmus ablation (CTIA) is inconclusive. To generate a comprehensive assessment of optimal extant data on CF for AFL, we synthesized randomized controlled trials (RCTs) and observational studies from Web of Science, SCOPUS, EMBASE, PubMed, and Cochrane until 29 November 2022, using the odds ratio (OR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with a corresponding 95% confidence interval (CI). Two RCTs and three observational studies with a total of 376 patients were included in our analysis. CF-guided ablation was associated with (A) a higher rate of AFL recurrence (OR: 2.26 with 95% CI [1.05, 4.87]) and total CF (MD: 2.71 with 95% CI [1.28, 4.13]); (B) no effect on total procedure duration (MD: −2.88 with 95% CI [−7.48, 1.72]), fluoroscopy duration (MD: −0.96 with 95% CI [−2.24, 0.31]), and bidirectional isthmus block (BDIB) (OR: 1.50 with 95% CI [0.72, 3.11]); and (C) decreased radiofrequency (RF) duration (MD: −1.40 with 95% CI [−2.39, −0.41]). We conclude that although CF-guided CTIA was associated with increased AFL recurrence and total CF and reduced RF duration, it did not affect total procedure duration, fluoroscopy duration, or BDIB. Thus, CF-guided CTIA may not be the optimal intervention for AFL. These findings indicate the need for (A) providers to balance the benefits and risks of CF when utilizing precision medicine to develop treatment plans for individuals with AFL and (B) clinical trials investigating CF-guided catheter ablation for AFL to provide definitive evidence of optimal CF-sensing technology.

Introduction: Acute esophageal necrosis, or black esophagus, is a rare clinical entity manifesting as upper gastrointestinal bleeding and complicating various conditions. However, black esophagus in the setting of diabetic ketoacidosis (DKA) has been rarely reported. We present a case of a 36-year-old male with black esophagus presenting as hematemesis complicating an episode of DKA. Case Description/Methods: A 36-year-old male with uncontrolled type 1 diabetes mellitus complicated by end-stage renal disease and hypertension presented to the emergency department with abdominal pain, nausea, and vomiting. Patient reported worsening abdominal pain and associated blood-tinged emesis. On presentation, patient was hemodynamically stable. Physical exam included an abdomen that was diffusely tender to palpation without peritoneal signs. Initial labs remarkable for serum glucose 1491, anion gap 41, bicarbonate 9, and hemoglobin 7.5. Patient was admitted to Critical Care for insulin drip and intravenous fluid resuscitation for DKA. Later, patient had an episode of hematemesis resulting in tachycardia, hypotension, and drop in hemoglobin to 5.6. Patient was further resuscitated with blood transfusions with improvement in hemodynamics and hemoglobin to 8.9. Continuous pantoprazole infusion was initiated. Upper endoscopy demonstrated severe, ulcerative necrotizing circumferential esophagitis in the middle and lower third esophagus and a medium size blood clot without evidence of active bleeding. No biopsies were taken due to concern for possible false lumen; CT chest with contrast demonstrated no signs of esophageal perforation. Following EGD, patient had several small self-limiting episodes of hematemesis and melena, while maintaining hemodynamics. He was continued on pantoprazole infusion and placed on strict nothing by mouth (NPO) precautions for 3 days with gradual advancement of diet. He received 6 days of empiric antimicrobial therapy with ampicillin-sulbactam and fluconazole. Patient reported no further episodes of hematemesis. Hemoglobin stabilized around 8.0 (Figure). Discussion: DKA is a rare but life-threatening cause of acute esophageal necrosis which may develop due to a combination of tissue hypoperfusion, impaired mucosal defenses, and gastric reflux. Upper gastrointestinal bleeding in the setting of DKA should raise suspicion for black esophagus which is a potential cause of mortality. Early diagnosis and treatment of underlying etiology are the key factors in management.

Background and Objective: Endoscopic polypectomy is an excellent tool for colon cancer prevention. With the innovation of novel resection techniques, the best method is still being investigated. Hence, we aim to evaluate the efficacy and safety of cold snare polypectomy (CSP) versus hot snare polypectomy (HSP) for colorectal polyp resection. Methods: A systematic review and meta-analysis synthesizing evidence from randomized controlled trials retrieved from PubMed, EMBASE, WOS, SCOPUS, and CENTRAL until July 16, 2022. We pooled dichotomous outcomes using risk ratio (RR) with the corresponding CI. This review’s protocol was prospectively registered in PROSPERO with ID: CRD42022347496. Results: We included 18 randomized controlled trials with a total of 4317 patients and 7509 polyps. Pooled RR favored HSP regarding the complete resection rate (RR: 0.96 with 95% CI: 0.95, 1, P = 0.03) and local recurrence incidence (RR: 5.74 with 95% CI: 1.27, 25.8, P = 0.02). Pooled RR favored CSP regarding the colonoscopy time (mean difference: −6.50 with 95% CI: −7.55, −5.44, P = 0.00001) and polypectomy time (mean difference: −57.36 with 95% CI: −81.74, −32.98, P = 0.00001). There was no difference regarding the incidence of immediate bleeding (P = 0.06) and perforation (P = 0.39); however, HSP was associated with more incidence of delayed bleeding (P = 0.01), abdominal pain (P = 0.007), and postresection syndrome (P = 0.02). Discussion: HSP is associated with a higher complete resection and lower recurrence rates; however, HSP is also associated with a higher incidence of adverse events. Therefore, improving the complete resection rate with CSP still warrants more innovation, giving the technique safety and shorter procedure duration.