OBJECTIVE: Dieulafoy\'s lesions (DLs) are a rare but potentially life-threatening source of gastrointestinal (GI) haemorrhage. They are responsible for roughly 1%-6.5% of all cases of acute non-variceal GI bleeding.Here, we describe retrospectively the clinical and endoscopic features, review the short-term and long-term outcomes of endoscopic management of bleeding DLs and we identify rate and risk factors, of recurrence and mortality in our endoscopic unit.
METHODS: Data were collected from patients presenting with GI haemorrhagic secondary to DLs between January 2018 and August 2023. Patients\' medical records as well as endoscopic databases were retrospectively reviewed. Demographic data, risk factors, bleeding site, outcomes of endoscopy techniques, recurrence and mortality rate were taken into account.
RESULTS: Among 1170 cases of GI bleeding, we identified only seven cases involving DLs. Median age was 74 years, with a male-to-female ratio of 2.5. 75% of patients had significant comorbidities, mainly cardiovascular diseases. Only anticoagulant and antiplatelet agents were significantly associated with DLs. All patients were presented with GI bleeding as their initial symptom. The initial endoscopy led to a diagnosis in 85% of the cases. Initial haemostasis was obtained in all patients treated endoscopically. Nevertheless, the study revealed early recurrence in two out of three patients treated solely with epinephrine injection or argon plasma coagulation. In contrast, one of three patients who received combined therapy, experienced late recurrence (average follow-up of 1 year). Pathological diagnosis was necessary in one case. One patient (14%) died of haemorrhagic shock. Average length of hospital stay was 3 days.
CONCLUSIONS: Although rare, DLs may be responsible for active, recurrent and unexplained GI bleeding. Thanks to the emergence of endoscopic therapies, the recurrence rate has decreased and the prognosis has highly improved. Therefore, the endoscopic approach remains the first choice to manage bleeding DLs.

To assess the efficacy and surgical outcomes of the simultaneous single-trajectory endoscopic biopsy and third ventriculostomy (ETV) in pineal region tumors.
A systematic review and meta-analysis adhering to Cochrane Standards and PRISMA framework were conducted. PubMed, Embase, and Web Of Science databases were searched until December 2023. Outcomes included rate of histopathologic diagnosis success, ETV success, complications, required VPS, and mortality.
Seventeen studies (N = 388) met inclusion criteria. Histopathologic diagnosis success rate was 90% for general population (95% CI: 86%-95%; I2 = 42%) and 94% for pediatric patients (95% CI: 89%-98%; I2 = 19%). ETV Success rate was 93% (95% CI: 88%-97%; I2 = 60%). An estimated risk of postoperative ETV complications was found to be 16% for the general population (95% CI: 5%-28%; I2 = 90%) and 5% for pediatric patients (95% CI: 0%-13%; I2 = 51%). The risk of requiring VPS was estimated as 2% (95% CI: 0%-4%; I2 = 39%) and for the pediatric population it was 7% (95% CI: 0%-16%; I2 = 69%). Mortality risk was found to be 1% (95% CI: 0%-3%; I2 = 0%).
Simultaneous endoscopic biopsy and ETV demonstrated high diagnostic and therapeutic success rates. The procedure\'s safety profile, with low mortality and complications, supports its role in treating hydrocephalus associated to pineal region tumors. Subgroup analyses revealed higher diagnostic success rates and required VPS in the pediatric population, whilst it had lower complication rates.

Endoscopic procedures are essential in gastroenterology but pose significant risks for thrombocytopenic patients who have lower platelet counts, increasing the likelihood of bleeding complications. This systematic review and meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess bleeding risks in thrombocytopenic patients undergoing various endoscopic procedures. A comprehensive search was conducted across databases like PubMed, MEDLINE, and EBSCO, using stringent criteria for inclusion and exclusion, with study quality assessed via the Newcastle-Ottawa Scale and thrombocytopenia severity classified by Common Terminology Criteria for Adverse Events (CTCAE) criteria. Statistical analysis focused on bleeding event incidence rates at different platelet count thresholds, utilizing RevMan Web (Cochrane, London, UK) and Excel (Microsoft® Corp., Redmond, WA). The search yielded 1,675 potential articles, but only three retrospective cohort studies were selected. Results showed a significant increase in bleeding risk for patients with platelet counts below 50,000/mm3, particularly under 25,000/mm3, with a 5.5% prevalence of post-procedure bleeding in moderate to severe thrombocytopenic patients versus 4.0% in those with higher counts, and a threefold higher risk in severe thrombocytopenia. The study highlights the need for meticulous pre-procedure assessments in thrombocytopenic patients and points out disparities in guideline recommendations, suggesting personalized approaches based on patient-specific risks. It underscores balancing diagnostic yield against bleeding risks, especially in severe thrombocytopenia, and discusses the controversial role of prophylactic platelet transfusions, advocating for a nuanced approach. In conclusion, this meta-analysis provides critical insights into managing thrombocytopenia in endoscopic procedures, emphasizing the importance of individualized patient assessment and adherence to evolving guidelines, and underlining the necessity of further research to refine these guidelines and improve patient safety and outcomes in this challenging clinical scenario.

An isolated or trapped fourth ventricle is a relatively rare, although serious, adverse effect of hemorrhagic, infectious, or inflammatory processes that involve the central nervous system. This entity usually occurs after successful shunting of the lateral ventricles and may become clinically evident with the development of delayed clinical deterioration. This decline of the neurological status of the patient is evident after an initial period of improvement of the relevant symptoms. Surgical treatment options include cerebrospinal fluid shunting procedures, along with open surgical and endoscopic approaches. Complications related to its management are common and are related with obstruction of the fourth ventricular catheter, along with cranial nerve or brainstem dysfunction. We used the keywords: \"isolated fourth ventricle,\" and \"trapped fourth ventricle,\" in PubMed® and Web of Science®. Treatment of the trapped fourth ventricle remains a surgical challenge, although the neurosurgical treatment armamentarium has broadened. However, prompt recognition of the clinical and neurological findings that accompany any individual patient, in conjunction with the relevant imaging findings, is mandatory to organize our treatment plan on an individual basis. The current experience suggests that any individual intervention plan should be mainly based on the underlying pathological substrate of hydrocephalus. This could help us to preserve the patient\'s life, on an emergent basis, as well as to ensure an uneventful neurological outcome, maintaining at least the preexisting level of neurological function.

Wide-area transepithelial sampling (WATS) is a new technique that uses an abrasive brush to obtain samples from a larger surface area of the oesophagus. Studies have shown promising results that WATS in adjunct to forceps biopsy (FB) increases the detection rate of Barrett\'s oesophagus (BE) as well as oesophageal dysplasia (ED). We conducted a systematic review and meta-analysis to compare the detection rates of BE and ED between FB and WATS in adjunct to FB.
A Literature search was done using electronic databases, including PubMed, Embase, Scopus, Cochrane and CINAHL from inception to 26 April 2020. A meta-analysis comparing detection rates of WATS in adjunct to FB versus FB using the random-effects model was done using RevMan V.5.3.
Pooled data from 20 392 endoscopies across 11 studies showed an absolute increase in detection of 16% (95% CI 0.10% to 0.22%, p<0.00001). A relative increase of 1.62 was seen in detection rates of BE (95% CI 1.28 to 2.05, p<0.0001) when WATS was used with FB with the number needed to test (NNT) of 6.1 patients. For ED, a 2% absolute increase (95% CI 0.01 to 0.03, p=0.001) in additional diagnostic yield from WATS. A relative increase of 2.05 was seen in the detection rate of ED (95% CI 1.42 to 2.98, p=0.0001) yielding an NNT of 50 patients.
Our study shows that WATS, as an adjunct to FB, improves both the absolute detection rate and relative detection rate of both BE and ED as compared to FB alone.

Obesity is a leading global epidemic. Bariatric surgery is the only treatment demonstrating substantial long-term weight loss and medical benefits. However, there is limited research on the psychological outcomes following surgery. Therefore, the primary aim of this study was to systematically review depression, anxiety, and binge eating outcomes at different time points following bariatric surgery and identify whether bariatric surgery significantly reduces psychological symptoms over time. These outcomes were also examined among endoscopic bariatric procedures as a secondary aim. Forty-eight studies met inclusion criteria. Findings suggested that most patients experience a short-term reduction in anxiety and depression symptoms from pre-surgery. Over time, however, these symptoms increase and may even return to pre-surgery levels. Furthermore, while binge eating was uncommon after surgery, other disordered eating patterns may emerge. Binge eating may also restart over time as the stomach enlarges again. Overall, the complex psychological difficulties faced by individuals with obesity continue after surgery and may contribute to longer-term weight recidivism. More comprehensive and standardised psychological assessment procedures, including clinical interviews and longer-term follow-up, may provide insight into the psychological mechanisms maintaining weight management issues, and may serve as a starting point for improving the long-term success of patients with obesity.

The significantly increased risk of colorectal cancer (CRC) in longstanding colonic inflammatory bowel disease (IBD) justifies the need for endoscopic surveillance. Unlike sporadic CRC, IBD-related CRC does not always follow the predictable sequence of low-grade to high-grade dysplasia and finally to invasive carcinoma, probably because the genetic events shared by both diseases occur in different sequences and frequencies. Surveillance is recommended for patients who have had colonic disease for at least 8-10 years either annually, every 3 years or every 5 years with the interval dependant on the presence of additional risk factors. Currently, the recommended endoscopic strategy is high-definition chromoendoscopy with targeted biopsies, although the associated lengthier procedure time and need for experienced endoscopists has limited its uniform uptake in daily practice. There is no clear consensus on the management of dysplasia, which continues to be a challenging area particularly when endoscopically invisible. Management options include complete resection (and/or referral to a tertiary centre), close surveillance or proctocolectomy. Technical advances in endoscopic imaging such as confocal laser endomicroscopy, show exciting potential in increasing dysplasia detection rates but are still far from being routinely used in clinical practice.

Most patients with Crohn\'s disease present with either terminal ileal or colonic disease, with 70% requiring surgery by 10 years after diagnosis. Recurrent stricturing at the anastomotic site is common, often symptomatic and can require re-operation with its inherent risks. Balloon dilation has been shown to provide good symptom relief from such strictures. However, repeat dilations may be required, and further surgical intervention to an anastomotic stricture is needed in up to 30% of cases. Injection of corticosteroids has been suggested as an adjunct to dilation in order to improve outcomes. This paper reviews the current literature on the use of intralesional steroid injections following endoscopic balloon dilation of anastomotic and de novo Crohn\'s strictures. There have been only two randomised placebo controlled trials and five small non-controlled or retrospective studies. Study numbers vary from 10 to 29 patients. The two randomised trials conflict in their conclusions and numbers are small in these studies. Currently therefore, no firm support can be given to the routine use of intralesional steroid injections.

OBJECTIVE: Double balloon enteroscopy (DBE) is a relatively new endoscopic technique that allows endoscopic access into the small intestine. It has been studied in adults, but the literature remains scarce in the paediatric age group.
METHODS: We retrospectively assessed our experience with DBE in children.
RESULTS: We describe four procedures performed on three patients. The diagnostic yield was high (100%) with one major complication (perforation) encountered. A review of the benefits and risks in this cohort, and the available literature is included.
CONCLUSIONS: DBE is a promising endoscopic modality in children, but some aspects remain unanswered. There is a great need for a prospective study to better assess benefit and risk in this population.

While most gastroenterologists are aware of the more common complications of endoscopy such as bleeding, infection and perforation, air embolism remains an under-recognised and difficult to diagnose problem due to its varying modes of presentation. This is the case of a 55-year-old man with right upper quadrant pain and imaging notable for cholecystitis and choledocholithiasis, who underwent endoscopic retrograde cholangiopancreatography (ERCP). During the ERCP, and shortly after a sphincterotomy was performed, he became hypotensive and hypoxic, quickly decompensating into pulseless electrical activity. While advanced cardiac life support was initiated, the patient passed away. Autopsy revealed air in the pulmonary artery suggestive of a pulmonary embolism. While air embolism remains a rare complication of upper endoscopy, increased awareness and prompt recognition of signs that may point to this diagnosis may potentially save lives by allowing for earlier possible interventions.