Effect of etomidate added to propofol target-controlled infusion in bidirectional endoscopy: A randomized clinical trial

BACKGROUND

Propofol has been widely used in bidirectional gastrointestinal endoscopy sedation; however, it frequently leads to cardiovascular adverse events and respiratory depression. Propofol target-controlled infusion (TCI) can provide safe sedation but may require higher dosages of propofol. On the contrary, etomidate offers hemodynamic stability.

AIM

To evaluate the effect of different dose etomidate added to propofol TCI sedation during same-visit bidirectional endoscopy.

METHODS

A total of 330 patients from Fujian Provincial Hospital were randomly divided into three groups: P, 0.1EP, and 0.15EP. Patients in the P group received propofol TCI only, with an initial effect-site concentration of the propofol TCI system of 3.0 mg/mL. Patients in the 0.1EP and 0.15EP groups received 0.1 and 0.15 mg/kg etomidate intravenous injection, respectively, followed by propofol TCI.

RESULTS

Patients in the 0.15EP group had higher mean blood pressure after induction than the other groups (P group: 78 mmHg, 0.1EP group: 82 mmHg, 0.15EP group: 88 mmHg; P < 0.05). Total doses of propofol consumption significantly decreased in the 0.15EP group compared with that in the other groups (P group: 260.6 mg, 0.1EP group: 228.1 mg, 0.15EP group: 201.2 mg; P < 0.05). The induction time was longer in the P group than in the other groups (P group: 1.9 ± 0.7 minutes, 0.1EP group: 1.2 ± 0.4 minutes, 0.15EP group: 1.1 ± 0.3 minutes; P < 0.01). The recovery time was shorter in the 0.15EP group than in the other groups (P group: 4.8 ± 2.1 minutes, 0.1EP group: 4.5 ± 1.6 minutes, 0.15EP group: 3.9 ± 1.4 minutes; P < 0.01). The incidence of hypotension (P group: 36.4%, 0.1EP group: 29.1%, 0.15EP group: 11.8%; P < 0.01) and injection pain was lower in the 0.15EP group than in the other groups (P < 0.05). Furthermore, the incidence of respiratory depression was lower in the 0.15EP group than in the P group (P < 0.05). Additionally, the satisfaction of the patient, endoscopist, and anesthesiologist was higher in the 0.15EP group than in the other groups (P < 0.05).

CONCLUSION

Our findings suggest that 0.15 mg/kg etomidate plus propofol TCI can significantly reduce propofol consumption, which is followed by fewer cardiovascular adverse events and respiratory depression, along with higher patient, endoscopist, and anesthesiologist satisfaction.

Adult juvenile polyp bleeding detected by extravascular contrast leakage and treated with endoscopic clipping: A case report

BACKGROUND

Juvenile polyps (JPs) are non-neoplastic polyps. In adults, JPs present with hematochezia in only approximately half the patients and are often found incidentally during endoscopic screening. JPs have no mucosal fascia at the tip, and spontaneous shedding and massive gastrointestinal hemorrhage may occur. Thus, the JP bleeding detected in this case by extravascular contrast leakage on computed tomography scans and treated with endoscopic clipping is rare.

CASE SUMMARY

A previously healthy 31-year-old male patient presented with a 2-day history of bloody stools. Upon hospital arrival, rectal examination revealed fresh blood, and abdominal computed tomography scans showed extravascular contrast leakage from the lower rectum's left-side wall. His blood pressure was slightly low at 104/62 mmHg. However, his pulse rate (69 bpm) and oxygen level (99% on room air) were within normal limits. Emergency endoscopy revealed a pedunculated lesion in the rectum covered by a non-neoplastic mucosal epithelium. No neoplastic lesions were observed at the tip of the polyp; however, pulsatile bleeding was detected at the distal end. We performed endoscopic hemostasis by clipping the stem and then performed a polypectomy above the stem to examine the lesion tissue. Histopathological evaluation revealed a cystically dilated gland without neoplastic lesions. A subsequent total colonoscopy revealed two JPs with characteristic edematous, smooth, and reddish surfaces close to the hemorrhagic lesion. Subsequent histopathological evaluation indicated findings characteristic of JP, such as severe inflammatory cell infiltration of the stroma and cystic dilatation of the glandular ducts.

CONCLUSION

There are no reports of adult JPs presenting with contrast extravasation where endoscopic hemostasis was successful, as in this case.

Orientation in upper gastrointestinal endoscopy—the only way is up

BACKGROUND

Oesophagogastroduodenoscopy is the gold standard investigation for the upper gastrointestinal (UGI) tract. Orientation during endoscopy is challenging and United Kingdom training focusses on technical competence and procedural safety. The reported location of UGI pathologies is crucial to post-endoscopic planning.

AIM

To evaluate endoscopists’ ability to spatially orientate themselves within the UGI tract.

METHODS

A cross sectional descriptive study elicited, using an anonymised survey, the ability of endoscopists to orientate themselves within the UGI tract. The primary outcome was percentage of correct answers from all surveyed; secondary outcomes were percentage of correct answers from experienced vs novice endoscopists. Pearson’s χ² test was applied to compare groups.

RESULTS

Of 188 respondents, 86 were experienced endoscopists having completed over 1000 endoscopies. 44.4% of respondents correctly identified the anterior stomach and 47.3% correctly identified the posterior of the second part of the duodenum (D2). Experienced endoscopists were significantly more likely than novice to identify the anterior stomach correctly [61.6% vs 31.3%, X² (1, n = 188) = 11.10, P = 0.001]. There was no significant difference between the two groups in identifying the posterior of D2.

CONCLUSION

The majority of endoscopists surveyed were unable to identify key landmarks within the UGI tract. Endoscopic orientation appears to improve with experience yet there are some areas still not well recognised. This has potential considerable impact on post-endoscopic management of patients with posterior duodenal ulcers being more likely to perforate and associated with a higher rebleeding risk. We suggest the development of a consensus statement on endoscopic description.

Giant Brunner's gland hyperplasia of the duodenum successfully resected en bloc by endoscopic mucosal resection: A case report

BACKGROUND

Duodenal Brunner's gland hyperplasia (BGH) is a therapeutic target when complications such as bleeding or gastrointestinal obstruction occur or when malignancy cannot be ruled out. Herein, we present a case of large BGH treated with endoscopic mucosal resection (EMR).

CASE SUMMARY

An 83-year-old woman presented at our hospital with dizziness. Blood tests revealed severe anemia, esophagogastroduodenoscopy showed a 6.5 cm lesion protruding from the anterior wall of the duodenal bulb, and biopsy revealed the presence of glandular epithelium. Endoscopic ultrasonography (EUS) demonstrated relatively high echogenicity with a cystic component. The muscularis propria was slightly elevated at the base of the lesion. EMR was performed without complications. The formalin-fixed lesion size was 6 cm × 3.5 cm × 3 cm, showing nodular proliferation of non-dysplastic Brunner's glands compartmentalized by fibrous septa, confirming the diagnosis of BGH. Reports of EMR or hot snare polypectomy are rare for duodenal BGH > 6 cm. In this case, the choice of EMR was made by obtaining information on the base of the lesion as well as on the internal characteristics through EUS.

CONCLUSION

Large duodenal lesions with good endoscopic maneuverability and no evident muscular layer involvement on EUS may be resectable via EMR.

Efficacy and safety of endoscopic gastroplasty for treatment of obesity: An overview of comparative meta-analyses

BACKGROUND

There is a scarcity of evidence and systematic reviews on endoscopic gastroplasty (EG) compared to other management options for the treatment of obesity.

AIM

To assess the published meta-analyses through a systematic review approach and provide further insight into the current status of available evidence through a critical appraisal.

METHODS

PubMed/MEDLINE, Scopus, Embase and Cochrane Library were searched from inception to November 2022. The meta-analyses that compared the efficacy and safety of EG to other interventions were considered for this overview. The outcomes of interest were total body weight loss (TBWL), excessive weight loss, and average weight loss along with occurrence of adverse effects. Methodological quality, heterogeneity, and limitations were also reviewed.

RESULTS

A total of six meta-analyses out of 364 records were considered for this review with a major contribution from the United States. Overall methodological quality of included studies were moderate to good. EG treatments were significantly better in terms of TBWL, excessive weight loss, and average weight loss. However, there was no significant difference between endoscopic transoral outlet reduction and full-thickness suturing plus argon plasma mucosal coagulation. Lack of comparative studies and randomized trials, lack of long-term follow-up, reporting bias, selection bias, lack of control groups, and considerable level of heterogeneity were the major limitations in the available evidence.

CONCLUSION

Though EG was significantly effective for treatment of obesity, there is limited comparative evidence on this topic. High-quality well-controlled evidence is required to strengthen the current evidence base on EG treatment for obesity.

Advancement of haemostatic self-assembling peptides in the treatment of gastrointestinal bleeding: What role for PuraStat®?

PuraStat® is a novel self-assembling peptide (SAP) used as a haemostatic agent in endoscopy, with widespread application in surgical settings. While the current evidence, though deserving further expansion, demonstrates a good haemostatic performance profile for this substance, there remains significant heterogeneity among studies, and an analysis of this SAP as monotherapy is not always available. The recent study by Bellester et al in the World Journal of Gastrointestinal Endoscopy provided an optimal effectiveness profile of this SAP in 45 patients treated for gastrointestinal (GI) bleeding, particularly highlighting data on its use as monotherapy in upper GI bleeding. This invited article outlines the current evidence on PuraStat® and offers a commentary on the recently published study.

Interference between pacemakers/implantable cardioverter defibrillators and video capsule endoscopy

Our Letter to the Editor, related to the article “Small bowel capsule endoscopy in patients with cardiac pacemakers and implantable cardioverter defibrillators: Outcome analysis using telemetry” by Cuschieri et al, comments on some small errors, that slipped into the authors discussions. The given informations concerning the pacemaker- and implantable cardioverter defibrillators modes were inaccurate and differ between the text and the table. Moreover, as 8 of 20 patient’s pacemakers were programmed to VOO or DOO (“interference mode”) and one patient was not monitored by telemetry during capsule endoscopy, 9 of 20 patients (45%) lack the informations of possible interference between capsule endoscopy their implanted device. Another objection refers to the interpretation of an electrocardiogram (figure 1, trace B) presented: in contrast to the author’s opinion the marked spike should be interpreted as an artefact and not as ”undersensing of a fibrillatory wave”. Finally, three comments to cited reviews were not complete respectively not quoted correctly.

Contribution of endosonography in an uncommon case of pancreatic cysts

Here we present the case of a 35-year-old female patient with long standing dyspepsia and imaging studies showing the presence of multiple cysts in the head and tail of the pancreas. The patient underwent endosonography that confirmed the presence of multiple simple cysts throughout the entirety of the pancreas without dilation of the pancreatic duct. The majority of the cysts were less than one centimeter in size, and the largest cyst showed a honeycomb appearance. Cytology of aspirates from the two largest cysts was compatible with benign pancreatic cysts. Endosonography also revealed cysts within the left kidney and spleen. Genetic testing confirmed Von Hippel-Lindau disease. We highlight this case because it is unusual for Von Hippel-Lindau disease, a rare clinical entity, to present solely with cysts in the absence of more common manifestations, such as hemangioblastomas in the central nervous system and malignancy.

Laparoscopic Janeway gastrostomy as preferred enteral access in specific patient populations: A systematic review and case series

BACKGROUND

Nutrition is one of the fundamental needs of both patient and non-patient populations. General trends promote enteral feeding as a superior route, with the most common enteral access being the percutaneous endoscopic gastrostomy (PEG) as the first-line procedure, with surgical access including Witzel gastrostomy, Stamm Gastrostomy, Janeway gastrostomy (JG) as secondary means.

AIM

To describe cases and technique of laparoscopic Janeway gastrostomy (LJG) and perform a systematic review of the data.

METHODS

We successfully performed two LJG procedures, after which we conducted a literature review of all documented cases of LJG from 1991 to 2022. We surveyed these cases to show the efficacy of LJG and provide comparisons to other existing procedures with primary outcomes of operative time, complications, duration of gastrostomy use, and application settings. The data were then extracted and assessed on the basis of the Reference Citation Analysis (https://www.referencecitationanalysis.com/).

RESULTS

We presented two cases of LJG, detailing the simplicity and benefits of this technique. We subsequently identified 26 articles and 56 cases of LJG and extrapolated the data relating to our outcome measures. We could show the potential of LJG as a viable and preferred option in certain patient populations requiring enteral access, drawing reference to its favorable outcome profile and low complication rate.

CONCLUSION

The LJG is a simple, reproducible procedure with a favorable complication profile. By its technical ease and benefits relating to the gastric tube formed, we propose this procedure as a viable, favorable enteral access in patients with the need for permanent or palliative gastrostomy, those with neurologic disease, agitation or at high risk of gastrostomy dislodgement, or where PEG may be infeasible.

Endoscopic full-thickness resection of rectal schwannoma: A case report

BACKGROUND

Rectal schwannoma (RS) is a rare subtype of schwannoma that presents diagnostic challenges owing to its clinical rarity. The absence of typical symptoms, specific signs, and distinctive radiographic findings often hinders clinicians from reaching a definitive diagnosis before surgical intervention. Herein, we report a case of RS who underwent complete resection through endoscopic full-thickness resection (EFTR) and discuss the clinical, imaging, and pathological features for differential diagnosis.

CASE SUMMARY

A 71-year-old Chinese woman presented to our outpatient clinic with a 4-year history of a rectal mucosal mass for a follow-up surveillance colonoscopy. A neurogenic tumor with extraluminal growth was considered based on the imaging findings. Resection was required, and an EFTR was performed. On endoscopic exploration, a smooth surface extruding mass was identified at the rectum. The patient was discharged 48 hours after the operation without infection or bleeding. Based on the pathological and immunohistochemical findings of the resected mass, a rectal benign schwannoma was diagnosed. The patient did not undergo any adjuvant therapy. Nearly one year later, a follow-up surveillance colonoscopy and an abdominal and pelvic plain plus enhancement scan were performed, and no tumor recurrence or metastasis was noted.

CONCLUSION

EFTR is safe and effective for resecting gastrointestinal stromal tumors, especially those with extraluminal growth and no lymph node involvement.

Endoscopic calabash technique for gastric mesenchymal tumours: A low hanging fruit or a novel endoscopic technique?

The term subepithelial lesions encompasses a wide array of pathology of which numerous benign and malignant pathologies are grouped. A subset of these lesions are termed gastric mesenchymal tumours of which some have innate malignant potential. Currently there is various guidance on the recommended approach to the investigation and management of these lesions and there exists multiple methods of resection. Lin et al have developed and proposed a new method of resection of these gastric mesenchymal tumours within the field of endoscopy, a procedure they have termed endoscopic calabash ligation and resection. This editorial aims to outlay the current landscape for gastric mesenchymal tumours with regards to the various guidelines and resection techniques while comparing Lin et al's new technique to those that are already established in the field of endoscopy. Advancements in endoscopy that maintain or improve patient outcomes compared to the gold standard approach are exciting developments. Lin et al's study suggests that their technique is comparable in regard to patient outcomes while simultaneously being more efficient in its use of hospital resources including procedural time. Whilst the data and analysis proposed in the study is promising, there are areas that need to be addressed before advocating the procedure for widespread use. However, with further studies and analysis this may be foreseeable in the future.

Advancements in endoscopic hemostasis for non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal (GI) bleeding is a significant cause of morbidity and mortality. Traditionally, through-the-scope (TTS) clips, thermal therapy, and injection therapies are used to treat GI bleeding. In this review, we provide an overview of novel endoscopic treatments that can be used to achieve hemostasis. Specifically, we discuss the efficacy and applicability of over-the-scope clips, hemostatic agents, TTS doppler ultrasound, and endoscopic ultrasound, each of which offer an effective method of reducing rates of GI rebleeding.

Hidden local recurrence of colorectal adenocarcinoma diagnosed by endoscopic ultrasound: A case series

BACKGROUND

Almost half of the patients with colorectal cancer (CRC) will experience local-regional recurrence after standard surgical excision. Many local recurrences of colorectal cancer (LRCC) do not grow intraluminally, and some may be covered by a normal mucosa so that they could be missed by colonoscopy. Early detection is crucial as it offers a chance to achieve curative reoperation. Endoscopic ultrasound (EUS) is mainly used in CRC staging combined with cross-section imaging study. EUS can provide an accurate assessment of sub-mucosal lesions by demarcating the originating wall layer and evaluating its echostructure. EUS fine-needle aspiration (FNA) provides the required tissue examination and confirms the diagnosis.

CASE SUMMARY

We report a series of five cases referred to surveillance for LRCC with negative colonoscopy and/or negative endoscopic biopsies. EUS-FNA confirmed LRCC implanted deep into the third and fourth wall layer with normal first and second layer.

CONCLUSION

Assessment for LCRR is still problematic and may be very tricky. EUS and EUS-FNA may be useful tools to exclude local recurrence.

Endoscopic ultrasound-guided gallbladder drainage in pancreatic cancer and cholangitis: A case report

BACKGROUND

Head pancreatic cancers often present with clinical challenges requiring biliary drainage for chemotherapy or palliative scope. If usual endoscopic modalities fail or if percutaneous approach is not feasible, endoscopic ultrasound (EUS) guided biliary drainage can be considered. Here we describe and discuss an interesting clinical case in which EUS-guided gallbladder drainage (EUS-GBD) was chosen to treat acute severe cholangitis in a patient with advanced pancreatic cancer.

CASE SUMMARY

An 84-year-old female with a previous EUS-biopsy proven diagnosis of head pancreatic cancer presented with clinical signs of acute cholangitis. In September 2018 she had positioned a biliary and duodenal stent to relieve jaundice and an initial duodenal substenosis. In the emergency ward, an abdominal computed tomography scan showed proximal biliary stent occlusion due to neoplastic progression, but endoscopic retrograde cholangiopancreatography was impossible because of worsening duodenal stenosis and the absence of a chance to reach the Vater’s papilla area. EUS-guided choledocoduodenostomy was not technically feasible but because the cystic duct was free of neoplastic infiltration, an EUS-GBD using an Axios™ stent was successfully performed. The patient started to feed after 48 h and was discharged 1 wk later. No other hospitalizations due to cholangitis or symptoms of Axios™ stent occlusion/dysfunction were observed up until her death 6 mo later due to underlying disease.

CONCLUSION

This case demonstrated how different EUS therapeutic approaches could have a key role to treat critical and seemingly unsolvable situations and that they could play a more fundamental role in the next future.

Acute pancreatitis following endoscopic ampullary biopsy: A case report

BACKGROUND

Endoscopic biopsy is mandatory for the diagnosis of malignant and premalignant ampullary tumours. The commonly reported inadvertent complications following routine mucosal biopsy include perforation and haemorrhage. Acute pancreatitis is an extremely rare complication following this procedure.

CASE SUMMARY

This report details the case of a 59-year-old man who underwent biopsy of the ampulla for a suspected periampullary tumour. Following the procedure, the patient presented with symptoms of acute pancreatitis which was substantiated by laboratory and radiological investigations. He was conservatively managed and discharged following complete resolution of symptoms.

CONCLUSION

This case report serves to highlight the importance of this potential complication following routine endoscopic biopsy of the ampulla.

Safety of endoscopy in patients undergoing treatments with antiangiogenic agents: A 5-year retrospective review

BACKGROUND

Antiangiogenic agents (AAs) are increasingly used to treat malignant tumors and have been associated with gastrointestinal (GI) bleeding and perforation. Elective surgeries and endoscopy are recommended to be delayed for 31 d until after AAs treatment. Data regarding the safety of endoscopy while on antiangiogenic agents is extremely limited. No guidelines are in place to address the concern about withholding these anti-angiogenic drugs.

AIM

To evaluate the risks of endoscopy in patients on antiangiogenic agents from 2015 to 2020 at our institution.

METHODS

This is a single centered retrospective study approved by the institutional review board statement of the institution. Patients that underwent endoscopy within 28 d of antiangiogenic agents’ treatment were included in the study. Primary outcome of interest was death, and secondary outcomes included perforation and GI bleeding. Data were analyzed utilizing descriptive statistics. Fifty-nine patients were included in the final analysis and a total of eighty-five procedures were performed that were characterized as low risk and high risk.

RESULTS

Among the 59 patients a total of 85 endoscopic procedures were performed with 24 (28.2%) categorized as high-risk and 61 (71.8%) procedures as low-risk. Of the total number of patients, (50%) were on bevacizumab and the rest were on imatinib (11.7%), lenvatinib (6.7%) and, ramucirumab (5%). The average duration between administration of AAs and the performance of endoscopic procedures was 9.9 d. No procedure-related adverse events were noted among our study population. We did observe two deaths with one patient, on lenvatinib for metastatic hepatocellular carcinoma, who had persistent bleeding despite esophageal variceal banding and died 4 d later from hemorrhagic shock. Another patient was diagnosed with acute myeloid leukemia died 24 d after an esophagogastroduodenoscopy with biopsy after transition to comfort care.

CONCLUSION

As per this single center retrospective study, the rate of endoscopic procedure-related adverse events and death within 28 d of AA administration appears to be low.

Reality named endoscopic ultrasound biliary drainage

Endoscopic ultrasound (EUS) is used for diagnosis and evaluation of many diseases of the gastrointestinal (GI) tract. In the past, it was used to guide a cholangiography, but nowadays it emerges as a powerful therapeutic tool in biliary drainage. The aims of this review are: outline the rationale for endoscopic ultrasound-guided biliary drainage (EGBD); detail the procedural technique; evaluate the clinical outcomes and limitations of the method; and provide recommendations for the practicing clinician. In cases of failed endoscopic retrograde cholangiopancreatography (ERCP), patients are usually referred for either percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. Both these procedures have high rates of undesirable complications. EGBD is an attractive alternative to PTBD or surgery when ERCP fails. EGBD can be performed at two locations: transhepatic or extrahepatic, and the stent can be inserted in an antegrade or retrograde fashion. The drainage route can be transluminal, duodenal or transpapillary, which, again, can be antegrade or retrograde [rendezvous (EUS-RV)]. Complications of all techniques combined include pneumoperitoneum, bleeding, bile leak/peritonitis and cholangitis. We recommend EGBD when bile duct access is not possible because of failed cannulation, altered upper GI tract anatomy, gastric outlet obstruction, a distorted ampulla or a periampullary diverticulum, as a minimally invasive alternative to surgery or radiology.

Improved visibility of colorectal tumor by texture and color enhancement imaging with indigo carmine

BACKGROUND

Accurate diagnosis and early resection of colorectal polyps are important to prevent the occurrence of colorectal cancer. However, technical factors and morphological factors of polyps itself can lead to missed diagnoses. Image-enhanced endoscopy and chromoendoscopy (CE) have been developed to facilitate an accurate diagnosis. There have been no reports on visibility using a combination of texture and color enhancement imaging (TXI) and CE for colorectal tumors.

AIM

To investigate the visibility of margins and surfaces with the combination of TXI and CE for colorectal lesions.

METHODS

This retrospective study included patients who underwent lower gastrointestinal endoscopy at the Toyoshima Endoscopy Clinic. We extracted polyps that were resected and diagnosed as adenomas or serrated polyps (hyperplastic polyps and sessile serrated lesions) from our endoscopic database. An expert endoscopist performed the lower gastrointestinal endoscopies and observed the lesion using white light imaging (WLI), TXI, CE, and TXI + CE modalities. Indigo carmine dye was used for CE. Three expert endoscopists rated the visibility of the margin and surface patterns in four ranks, from 1 to 4. The primary outcomes were the average visibility scores for the margin and surface patterns based on the WLI, TXI, CE, and TXI + CE observations. Visibility scores between the four modalities were compared by the Kruskal-Wallis and Dunn tests.

RESULTS

A total of 48 patients with 81 polyps were assessed. The histological subtypes included 50 tubular adenomas, 16 hyperplastic polyps, and 15 sessile serrated lesions. The visibility scores for the margins based on WLI, TXI, CE, and TXI + CE were 2.44 ± 0.93, 2.90 ± 0.93, 3.37 ± 0.74, and 3.75 ± 0.49, respectively. The visibility scores for the surface based on WLI, TXI, CE, and TXI + CE were 2.25 ± 0.80, 2.84 ± 0.84, 3.12 ± 0.72, and 3.51 ± 0.60, respectively. The visibility scores for the detection and surface on TXI were significantly lower than that on CE but higher than that on WLI (P < 0.001). The visibility scores for the margin and surface on TXI + CE were significantly higher than those on CE (P < 0.001). In the sub-analysis of adenomas, the visibility for the margin and surface on TXI + CE was significantly better than that on WLI, TXI, and CE (P < 0.001). In the sub-analysis of serrated polyps, the visibility for the margin and surface on TXI + CE was also significantly better than that on WLI, TXI, and CE (P < 0.001).

CONCLUSION

TXI + CE enhanced the visibility of the margin and surface compared to WLI, TXI, and CE for colorectal lesions.

Prospective evaluation of the hemorrhoid energy treatment for the management of bleeding internal hemorrhoids

BACKGROUND

The hemorrhoid energy treatment (HET) system is a non-surgical bipolar electrotherapy device, which has previously demonstrated efficacy in the management of bleeding Grade I and II internal hemorrhoids; however, data is limited.

AIM

To prospectively assess the safety and efficacy of the HET device.

METHODS

This was an IRB-approved prospective study of 73 patients with Grade I or II internal hemorrhoids who underwent HET from March 2016 to June 2019. Patient factors and procedural data were obtained. A post-procedure questionnaire was administered by telephone to all patients at 1-wk and 3-mo following HET to assess for improvement and/or resolution of rectal bleeding and adherence to a stool softener regimen. A chart review was performed to observe recurrent symptoms and durability of response. Statistical analyses were performed using SPSS software (IBM; SPSS Version 25.0).

RESULTS

Seventy-three patients underwent HET during the study period. Mean post-HET follow-up was 1.89 years. Complete resolution of bleeding was reported in 65% at 1 wk (n = 48), with improvement in bleeding in 97.2% (n = 71) of patients. At 3-mo, resolution and/or improvement in bleeding was reported in 90% (n = 64) of patients. No procedure-related pain or adverse events were reported.

CONCLUSION

HET is well tolerated, safe and highly effective in the majority of our patients presenting with Grade I and II symptomatic internal hemorrhoids.

Cronkhite-Canada syndrome: First case report from Egypt and North Africa

BACKGROUND

Gastrointestinal (GI) polyposis is a rare condition in GI diseases. To date about 500 cases of Cronkhite-Canada syndrome (CCS) have been reported worldwide.

CASE SUMMARY

We report a 60-year-old female patient who presented with dyspepsia, abdominal pain, and weight loss of 1-year duration. Her physical examination showed alopecia and onychodystrophy. Upper endoscopy revealed diffuse markedly thickened gastric mucosa involving the whole stomach with thickened gastric rugae and numerous polypoidal lesions. Histopathological examination showed marked hyperplasia of the foveolar glands with inflammatory cell infiltration. Endoscopic ultrasound showed a significantly hypertrophic mucosa and muscularis mucosa, while the submucosa and the muscularis propria were spared, favouring its benign nature. Colonoscopy showed multiple sessile polyps scattered at different parts of the colon. Histopathological examination revealed tubular adenomatous polyps with low-grade dysplasia. Differential diagnoses included CCS, Menterier disease (MD), other polyposis syndromes, lymphoma, amyloidosis, and gastric malignancies. The presence of alopecia, nail dystrophy, GI polyposis, markedly thickened gastric mucosa and folds, abdominal pain, weight loss, and marked foveolar gland hyperplasia; all was in favour of CCS. Lymphoma was excluded due to sparing of the muscularis propria. The presence of colonic polyps and antral and duodenal infiltration, and the absence of hypoproteinaemia decreased the possibility for MD.

CONCLUSION

The patient was diagnosed as having CCS.

Non-invasive monitoring of inflammatory bowel disease using intestinal ultrasound

BACKGROUND

Intestinal ultrasound (IUS) is a safe and effective way for the diagnosis and surveillance of patients with inflammatory bowel disease (IBD). It allows a noninvasive and reproducible follow-up for patients with IBD.

AIM

To compare the outcomes of colonoscopy and IUS in diagnosing and monitoring patients with IBD.

METHODS

A prospective study was conducted over a three-year period (January 2021 to April 2024) comparing endoscopic and IUS findings. A total of 101 patients were included in the study (68 with Crohn's disease and 33 with ulcerative colitis). All patients underwent both IUS and colonoscopy within a 10-day period.

RESULTS

The study found a strong correlation between bowel thickening on IUS and inflammatory activity (P = 0.004), IUS remission and endoscopic remission (P = 0.03), IUS and endoscopic location (P = 0.04), as well as IUS and computed tomography scan findings for collection diagnosis (P < 0.01).

CONCLUSION

The study's findings demonstrated excellent results for using IUS in the diagnosis and follow-up of IBD patients.

Safety and efficacy of modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension

BACKGROUND

Gastric variceal hemorrhage is one of the primary manifestations of left-sided portal hypertension (LSPH). The hemorrhage is fatal and requires safe and effective interventions.

AIM

To evaluate the clinical safety and efficacy of modified endoscopic ultrasound (EUS)-guided selective N-butyl-2-cyanoacrylate (NBC) injections for gastric variceal hemorrhage in LSPH.

METHODS

A retrospective observational study of patients with LSPH-induced gastric variceal hemorrhage was conducted. Preoperative EUS evaluations were performed. Enrolled patients were divided into modified and conventional groups according to the NBC injection technique. The final selection of NBC injection technique depended on the patients' preferences and clinical status. The technical and clinical success rates, operation time, NBC doses, perioperative complications, postoperative hospital stay, and recurrent bleeding rates were analyzed, respectively.

RESULTS

A total of 27 patients were enrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. In comparison to patients in the conventional group, patients in the modified group demonstrated significantly reduced NBC doses (2.0 ± 0.6 mL vs 3.1 ± 1.0 mL; P = 0.004) and increased endoscopic operation time (71.9 ± 11.9 min vs 22.5 ± 6.7 min; P < 0.001). Meanwhile, the two groups had no significant difference in the technical and clinical success rates, perioperative complications, postoperative hospital stay, and recurrent bleeding rates.

CONCLUSION

Modified EUS-guided selective NBC injections demonstrated safety and efficacy for LSPH-induced gastric variceal hemorrhage, with advantages of reduced injection dose and no radiation risk. Drawbacks were time consumption and technical challenge.

Endoscopic ultrasonography drainage and debridement of an infected subcapsular hepatic hematoma: A case report

BACKGROUND

Endoscopic ultrasonography (EUS) has evolved in the last years making it not only a diagnostic modality but a therapeutic procedure. EUS is now used as an alternative technique to percutaneous and surgical drainage. Even though EUS is a challenging procedure and not always suitable compared to percutaneous drainage, there is a need for developing new therapeutic approaches to the liver for when percutaneous drainage is not feasible.

CASE SUMMARY

We present the case of a 82 years old male who developed an infected subcapsular hepatic hematoma (SHH) of the left lobe following percutaneous biliary drainage. After 2 failed attempts of percutaneous drainage of the SHH and because the patients couldn’t withstand surgery, we conducted a EUS drainage and debridement of the SHH. Using a lumen apposing metal stent (LAMS) by a transgastric approach, we were able to gain endoscopic access to the SHH. With our experience in the debridement of walled off pancreatic necrosis using this technique, we were confident it was the right approach. After four debridement sessions, the computed tomography scan showed a clear regression of the SHH.

CONCLUSION

To our knowledge, this is the first case of successful endoscopic debridement of a SHH using a LAMS which appear to be feasible and safe in this specific case.

Role of endoscopic ultrasound in evaluation of patients with missed common bile duct stones

BACKGROUND

Choledocholithiasis develops in up to 20% of patients with gall bladder stones. The challenge in diagnosis usually occurs with small stones that may be missed by magnetic resonance cholangiopancreatography (MRCP). Endoscopic ultrasound (EUS) is accurate in detecting common bile duct (CBD) stones missed by MRCP, especially the small ones or those impacted at the distal CBD or the papillary region.

AIM

To evaluate the accuracy of EUS in detecting CBD stones missed by MRCP.

METHODS

Patients with an intermediate likelihood of choledocholithiasis according to ESGE guidelines and those with acute pancreatitis of undetermined cause were included. The presence of choledocholithiasis was evaluated by MRCP and EUS, and then results were confirmed by endoscopic retrograde cholangiopancreatography (ERCP). The sensitivity and specificity of EUS and MRCP were compared regarding the presence of stones, the size, and the number of detected stones.

RESULTS

Ninety out of 100 involved patients had choledocholithiasis, while ten patients were excluded as they had pancreatic or gall bladder masses during EUS examination. In choledocholithiasis patients, the mean age was 52.37 ± 14.64 years, and 52.2% were males. Most patients had biliary obstruction (74.4%), while only 23 (25.6%) patients had unexplained pancreatitis. The overall prevalence of choledocholithiasis was 83.3% by EUS, 41.1% by MRCP, and 74.4% by ERCP. Also, the number and size of CBD stones could be detected accurately in 78.2% and 75.6% by EUS and 41.1% and 70.3% by MRCP, respectively. The sensitivity of EUS was higher than that of MRCP (98.51% vs 55.22%), and their predictive value was statistically different (P < 0.001). Combination of both tools raised the sensitivity to 97.22% and specificity to 100%.

CONCLUSION

EUS could be a useful tool in assessing patients with suspected choledocholithiasis especially if combined with MRCP. However, its usefulness depends on its availability and the experience of the local centers.

Leucine-rich alpha-2 glycoprotein for detecting small bowel lesions in Crohn's disease: A critical review and the path forward

The study by Ohno et al provides valuable insights into the role of leucine-rich alpha-2-glycoprotein (LRG) as a potential biomarker for identifying small bowel lesions in Crohn's disease (CD). However, several methodological challenges hinder its immediate use in clinical practice. Notably, the current research was retrospective, lacks comparative studies with fecal calprotectin, and did not provide long-term predictive data. Further prospective studies are needed to improve the applicability of LRG. Moreover, integrating LRG with additional biomarkers and employing artificial intelligence techniques may improve its effectiveness in disease monitoring. Future research should address interobserver variability, assess LRG's cost-effectiveness, and standardize endoscopic healing definitions to ensure broader applicability. Advancing these areas is vital for establishing LRG's role in precision medicine strategies for the management of CD.