Intricacy of Crohn’s disease: Incongruity between diagnostic modalities and histopathologic assessment

Crohn’s disease (CD) is a chronic and recurrent inflammatory condition. Histologic healing is associated with better outcomes in CD, while less is known regarding the assessment of histological condition. Recently, a study has examined the discordance between endoscopic and histopathologic assessment in ileal CD, revealing a poor correlation between endoscopic and histologic evaluations in assessing mucosal inflammation and disease activity. However, the involvement of CD can span the entire gastrointestinal tract, as well as numerous clinical manifestations and extraintestinal complications, and the patchy nature of transmural inflammation is a well-established characteristic of this disease. The diagnosis of CD relies on a comprehensive evaluation that includes clinical, biochemical, stool, endoscopic, cross-sectional imaging, and histological investigations due to the incomplete understanding of its etiology and pathogenesis. Upon diagnosis, complimentary investigations should focus on markers of disease activity. Since transmural inflammation can only be assessed in resections, therefore, we primarily focused on the evaluation value of clinical aspects, histological scoring systems, particular in vivo imaging evaluation such as computed tomography enterography, magnetic resonance elastography, scintigraphy, sonographically measurement, endoscopic ultrasonography, and advanced endoscopic imaging techniques.

Endoscopic intervention in hematologic malignancy patients with severe thrombocytopenia: Methodological concerns, clinical implications, and future research directions

Gastrointestinal bleeding (GIB) presents a significant challenge for patients with hematologic malignancies, especially those with severe thrombocytopenia. Although endoscopic intervention is frequently used in managing GIB, its safety and effectiveness in this high-risk group remain unclear. A recent study by Alhumayyd et al provided insight into this issue. However, it has notable limitations, including its retrospective nature, small sample size, and failure to adjust for important confounding factors such as disease severity, hemodynamic status, and platelet function. The study’s findings indicated that urgent endoscopy may help decrease the incidence of recurrent bleeding; however, it did not show a clear benefit in terms of mortality. Future research ought to prioritize prospective, multicenter studies that employ standardized protocols and incorporate risk stratification models to better understand the impact of endoscopic treatment for GIB in these patients. Additionally, integrating platelet function assays could improve clinical decision-making. Addressing these research gaps is essential for improving patient outcomes and developing effective guidelines for managing GIB in individuals with thrombocytopenia.

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.

Clinical, endoscopic and histopathological observation of a rare case of esophageal submucosal gland duct adenoma: A case report

BACKGROUND

Esophageal submucosal gland duct adenoma (ESGDA) is very rare, and easily diagnosed as adenocarcinoma.

CASE SUMMARY

A 70-year-old man presented with abdominal discomfort and intermittent dull pain during swallowing for 10 days. Digestive endoscopy revealed a polypoid bulge at the esophago-gastric junction, which was resected by endoscopic submucosal dissection (ESD). Routine pathological examination showed intestinal metaplasia of the glandular epithelium on the mucosal surface, with serous tumor-like complex glands in the submucosa which showing significant hyperplasia. This initially diagnosis was early gastric adenocarcinoma. However, we still observed a few points that did not meet the criteria for cancer such as lack of malignant features. Following multidisciplinary discussion and consultation with the experienced specialist pathologists, we finally diagnosed the lesion as a rare ESGDA by further immunohistochemistry. The follow-up examination results for the patient were satisfactory, with no evidence of tumor recurrence. And we summarize the ESGDAs reported in the literature, aiming to enhance understanding of this tumor type.

CONCLUSION

ESGDA is a benign tumor that can be cured by ESD. Accurate diagnosis can prevent unnecessary extensive therapeutic interventions.

Prospective randomized study comparing Franseen 22-gauge vs standard 22-gauge needle for endoscopic ultrasound guided sampling of pancreatic solid lesions

BACKGROUND

This is a randomized study to compare the diagnostic accuracy of endoscopic ultrasound (EUS)-guided sampling of pancreatic solid lesions obtained with the 22-gauge Franseen (EUS-fine needle biopsy) vs the 22-gauge standard needle (EUS-fine needle aspiration) without rapid onsite evaluation (ROSE), since, in most endoscopy units around the world ROSE is not routinely available.

AIM

To investigate the accuracy of EUS-guided sampling of pancreatic solid lesions obtained between two different needles without ROSE.

METHODS

Patients with a solid pancreatic were included. Patients were biopsied in a randomized order. The primary endpoint was the diagnostic sensitivity for pancreatic malignancy (PM). Secondary outcomes were adequacy of the sample, the mean tissue area, the mean tumor area, and the adverse event rate.

RESULTS

The final diagnosis was pancreatic adenocarcinoma in 38 (76%), neuroendocrine tumor in 4 (8%), chronic pancreatitis in 3 (6%) patients. The sensitivity for PM with Franseen needle was 0.91 [95% confidence interval (CI): 0.80-0.98], vs 0.8 (95%CI: 0.67-0.91) (P = 0.025) with standard needle. The specificity for PM did not differentiate. The accuracy of the standard needle for PM was 0.80 (95%CI: 0.66-0.90), and the Franseen group was 0.90 (95%CI: 0.78-0.97) (P = 0.074). The technical success rates for the standard and Franseen needle groups were 94% (95%CI: 0.83-0.99) and 100% (95%CI: 0.92-1.00), respectively. The mean total tissue area in mm² (SD) was greater in the Franseen group, 2.07 (0.22) vs 1.16 (0.17) (P < 0.01). The mean tumor area in mm² (SD) was not different in Franseen group vs standard group, 0.42 (0.09) vs 0.47 (0.09) (P = 0.80). There were no adverse events.

CONCLUSION

The sensitivity for PM and mean total tissue area, was greater in the as compared with standard needle. The mean tumor area did not differ between the groups.

Endoscopists and endoscopic assistants’ qualifications, but not their biopsy rates, improve gastric precancerous lesions detection rate

BACKGROUND

Detecting gastric precancerous lesions (GPLs) is critical for the early diagnosis and treatment of gastric cancer. Endoscopy combined with tissue examination is an important method for detecting GPLs. However, negative biopsy results often increase patients’ risks, economic burdens, and lead to additional healthcare costs. Improving the detection rate of GPLs and reducing the rate of negative biopsies is currently a key focus in endoscopic quality control.

AIM

To explore the relationships between the endoscopist biopsy rate (EBR), qualifications of endoscopists and endoscopic assistants, and detection rate of GPLs.

METHODS

EBR, endoscopists, and endoscopic assistants were divided into four groups: Low, moderate, high, and very high levels. Multivariable logistic regression analysis was used to analyze the relationships between EBR and the qualifications of endoscopists with respect to the detection rate of positive lesions. Pearson and Spearman correlation analyses were used to evaluate the correlation between EBR, endoscopist or endoscopic assistant qualifications, and the detection rate of positive lesions.

RESULTS

Compared with those in the low EBR group, the odds ratio (OR) values for detecting positive lesions in the moderate, high, and very high EBR groups were 1.12 [95% confidence interval (CI): 1.06-1.19, P < 0.001], 1.22 (95%CI: 1.14-1.31, P < 0.001), and 1.38 (95%CI: 1.29-1.47, P < 0.001), respectively. EBR was positively correlated with the detection rate of gastric precancerous conditions (atrophic gastritis/intestinal metaplasia) (ρ = 0.465, P = 0.004). In contrast, the qualifications of the endoscopists were positively correlated with GPLs detection (ρ = 0.448, P = 0.005). Compared to endoscopists with low qualification levels, those with moderate, high, and very high qualification levels endoscopists demonstrated increased detection rates of GPLs by 13% (OR = 1.13, 95%CI: 0.98-1.31), 20% (OR = 1.20, 95%CI: 1.03-1.39), and 32% (OR = 1.32, 95%CI: 1.15-1.52), respectively. Further analysis revealed that the qualifications of endoscopists were positively correlated with the detection rates of GPLs in the cardia (ρ = 0.350, P = 0.034), angularis (ρ = 0.396, P = 0.015) and gastric body (ρ = 0.453, P = 0.005) but not in the antrum (ρ = 0.292, P = 0.079). Moreover, the experience of endoscopic assistants was positively correlated with the detection rate of precancerous lesions by endoscopists with low or moderate qualifications (ρ = 0.427, P = 0.015).

CONCLUSION

Endoscopists and endoscopic assistants with high/very high qualifications, but not EBR, can improve the detection rate of GPLs. These results provide reliable evidence for the development of gastroscopic quality control indicators.

Advancements in the diagnosis of biliopancreatic diseases: A comparative review and study on future insights

Owing to the complex and often asymptomatic presentations, the diagnosis of biliopancreatic diseases, including pancreatic and biliary malignancies, remains challenging. Recent technological advancements have remarkably improved the diagnostic accuracy and patient outcomes in these diseases. This review explores key advancements in diagnostic modalities, including biomarkers, imaging techniques, and artificial intelligence (AI)-based technologies. Biomarkers, such as cancer antigen 19-9, KRAS mutations, and inflammatory markers, provide crucial insights into disease progression and treatment responses. Advanced imaging modalities include enhanced computed tomography (CT), positron emission tomography-CT, magnetic resonance cholangiopancreatography, and endoscopic ultrasound. AI integration in imaging and pathology has enhanced diagnostic precision through deep learning algorithms that analyze medical images, automate routine diagnostic tasks, and provide predictive analytics for personalized treatment strategies. The applications of these technologies are diverse, ranging from early cancer detection to therapeutic guidance and real-time imaging. Biomarker-based liquid biopsies and AI-assisted imaging tools are essential for non-invasive diagnostics and individualized patient management. Furthermore, AI-driven models are transforming disease stratification, thus enhancing risk assessment and decision-making. Future studies should explore standardizing biomarker validation, improving AI-driven diagnostics, and expanding the accessibility of advanced imaging technologies in resource-limited settings. The continued development of non-invasive diagnostic techniques and precision medicine approaches is crucial for optimizing the detection and management of biliopancreatic diseases. Collaborative efforts between clinicians, researchers, and industry stakeholders will be pivotal in applying these advancements in clinical practice.

Assessing endoscopic remission in small bowel Crohn's disease: Are markers enough?

Mucosal healing in Crohn’s disease (CD) has been established as a crucial target of treatment, leading to long term remission and decrease in complication rates. Endoscopy still serves as the gold standard for assessment, particularly in the small bowel where balloon or capsule enteroscopy is frequently needed. However, these modalities are often unavailable, expensive, and invasive, posing risks to patients. Consequently, the identification of accessible and reliable biomarkers, especially in small intestinal CD, remains a challenge. The study by Ohno et al, published in this issue, further illuminates this field. It confirms the potential role of fecal biomarker leucine-rich α2 glycoprotein (LRG) and validates findings from previous smaller trials. Comparing to other markers LRG showed a much higher predictive value for mucosal healing of the small bowel, making it a useful option for small intestinal CD follow up. In this editorial, we explore the optimal marker of inflammation or mucosal healing in CD, particularly in the small bowel. We provide an overview of available conventional biomarkers and introduce several novel biomarkers, including an update on emerging technologies and innovations.

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.

Effects of a training system that tracks the operator's gaze pattern during endoscopic submucosal dissection on hemostasis

BACKGROUND

The early acquisition of skills required to perform hemostasis during endoscopy may be hindered by the lack of tools that allow assessments of the operator's viewpoint. Understanding the operator's viewpoint may facilitate the skills.

AIM

To evaluate the effects of a training system using operator gaze patterns during gastric endoscopic submucosal dissection (ESD) on hemostasis.

METHODS

An eye-tracking system was developed to record the operator's viewpoints during gastric ESD, displaying the viewpoint as a circle. In phase 1, videos of three trainees' viewpoints were recorded. After reviewing these, trainees were recorded again in phase 2. The videos from both phases were retrospectively reviewed, and short clips were created to evaluate the hemostasis skills. Outcome measures included the time to recognize the bleeding point, the time to complete hemostasis, and the number of coagulation attempts.

RESULTS

Eight cases treated with ESD were reviewed, and 10 video clips of hemostasis were created. The time required to recognize the bleeding point during phase 2 was significantly shorter than that during phase 1 (8.3 ± 4.1 seconds vs 23.1 ± 19.2 seconds; P = 0.049). The time required to complete hemostasis during phase 1 and that during phase 2 were not significantly different (15.4 ± 6.8 seconds vs 31.9 ± 21.7 seconds; P = 0.056). Significantly fewer coagulation attempts were performed during phase 2 (1.8 ± 0.7 vs 3.2 ± 1.0; P = 0.004).

CONCLUSION

Short-term training did not reduce hemostasis completion time but significantly improved bleeding point recognition and reduced coagulation attempts. Learning from the operator's viewpoint can facilitate acquiring hemostasis skills during ESD.

Establishing and popularizing a standard pathological diagnostic model of endoscopic submucosal dissection specimens in China

BACKGROUND

Endoscopic submucosal dissection (ESD) is a standardized therapeutic approach for early carcinoma of the digestive tracts. In this regard, the process of histopathological diagnosis requires standardization. However, the uneven development of healthcare in China, especially in eastern and western China, creates challenges for sharing a standardized diagnostic process.

AIM

To optimize the process of ESD specimen sampling, embedding and slide production, and to provide complete and accurate pathological reports.

METHODS

We established a practical process of specimen sampling, created standardized reporting templates, and trained pathologists from neighboring hospitals and those in the western region. A training effectiveness survey was conducted, and the collected data were assessed by the corresponding percentages.

RESULTS

A total of 111 valid feedback forms have been received, among which 58% of the participants obtained photographs during specimen collection, whereas the percentage increased to 79% after training. Only 58% and 62% of the respondents ensured the mucosal tissue strips were flat and their order remained unchanged; after training, these two proportions increased to 95% and 92%, respectively. Approximately half the participants measured the depth of the submucosal infiltration, which significantly increased to 95% after training. The percentage of pathologists who did not evaluate lymphovascular invasion effectively reduced. Only 22% of the participants had fixed clinic-pathological meetings before training, which increased to 49% after training. The number of participants who had a thorough understanding of endoscopic diagnosis also significantly increased.

CONCLUSION

There have been significant improvements in the process of specimen collection, section quality, and pathology reporting in trained hospitals. Therefore, our study provides valuable insights for others facing similar challenges.

Three-dimensional reconstruction under computed tomography and myopectineal orifice measurement under laparoscopy for quality control of inguinal hernia treatment

BACKGROUND

Inguinal hernias are common after surgery. Tension-free repair is widely accepted as the main method for managing inguinal hernias. Adequate exposure, coverage, and repair of the myopectineal orifice (MPO) are necessary. However, due to differences in race and sex, people's body shapes vary. According to European guidelines, the patch should measure 10 cm × 15 cm. If any part of the MPO is dissected, injury to the nerves, vascular network, or organs may occur during surgery, thereby leading to inguinal discomfort, pain, and seroma formation after surgery. Therefore, accurate localization and measurement of the boundary of the MPO are crucial for selecting the optimal patch for inguinal hernia repair.

AIM

To compare the size of the MPO measured on three-dimensional multislice spiral computed tomography (CT) with that measured via laparoscopy and explore the relevant factors influencing the size of the MPO.

METHODS

Clinical data from 74 patients who underwent laparoscopic tension-free inguinal hernia repair at the General Surgery Department of the First Affiliated Hospital of Anhui University of Science and Technology between September 2022 and July 2024 were collected and analyzed retrospectively. Transabdominal preperitoneal was performed. Sixty-four males and 10 females, with an average age of 58.30 ± 12.32 years, were included. The clinical data of the patients were collected. The boundary of the MPO was measured on three-dimensional CT images before surgery and then again during transabdominal preperitoneal. All the preoperative and intraoperative data were analyzed via paired t-tests. A t-test was used for comparisons of age, body mass index, and sex between the groups. In the comparative analysis, a P value less than 0.05 indicated a significant difference.

RESULTS

The boundaries of the MPO on 3-dimensional CT images measured 7.05 ± 0.47 cm and 6.27 ± 0.61 cm, and the area of the MPO was 19.54 ± 3.33 cm2. The boundaries of the MPO during surgery were 7.18 ± 0.51 cm and 6.17 ± 0.40 cm. The errors were not statistically significant. However, the intraoperative BD (the width of the MPO, P = 0.024, P < 0.05) and preoperative AC (the length of the MPO, P = 0.045, P < 0.05) significantly differed according to sex. The AC and BD measurements before and during surgery were not significantly different according to age, body mass index, hernia side or hernia type (P > 0.05).

CONCLUSION

The application of this technology can aid in determining the most appropriate dissection range and patch size.

Challenges and limitations in assessing mucosal healing in Crohn's disease: Discrepancies between endoscopic and histologic evaluations

The recent study published by Lee et al examined the discrepancies between endoscopic and histologic evaluations of mucosal inflammation in active ileal Crohn's disease (CD). While this research contributes to our understanding of the limitations of current biopsy protocols, it raises several concerns about the generalizability of its findings, sample size, and methodology. One major limitation was the exclusion of patients with ileal strictures, ileostomies, or J-pouches, which reduced the applicability of the results to the wider CD population. Furthermore, the biopsy protocol's focus on single biopsies from specific locations may inadequately capture the patchy inflammation characteristic of CD. The study also uses histologic indices primarily developed for ulcerative colitis, which may not be suitable for assessing CD. It is recommended that multi-center studies be conducted and histologic indices specific to CD be developed to improve the relevance of future research. Additionally, researchers should consider the influence of treatment regimens on the findings. Addressing these limitations would enhance the clinical significance of the study and inform better diagnostic and therapeutic approaches for CD.

Comorbidities related to metachronous recurrence for early gastric cancer in elderly patients

BACKGROUND

A significant association between increased age and an increased risk of metachronous gastric cancer (MGC) following curative endoscopic submucosal dissection (ESD) has previously been reported.

AIM

To determine risk factors for the metachronous occurrence of early gastric cancer (EGC) in elderly individuals.

METHODS

This retrospective cohort study comprised 653 elderly patients (aged ≥ 65 years) who underwent curative ESD for EGC between January 2014 and June 2020 at Nanjing Drum Tower Hospital. Comprehensive analyses were conducted to compare lifestyle habits, comorbidities, and Helicobacter pylori (H. pylori) infections as potential indicators.

RESULTS

During a median follow-up of 38 months, 46 patients (7.0%, 20.46/1000 person-years) developed MGC in the elderly cohort. The cumulative incidences of MGC at 2, 3, and 5 years were 3.3%, 5.3%, and 11.5%, respectively. In multivariate Cox regression analyses, the independent risk factors for MGC included metabolic dysfunction-associated steatotic liver disease (MASLD) [hazard ratio (HR) = 2.44, 95% confidence interval (CI): 1.15-5.17], persistent H. pylori infection (HR = 10.38, 95%CI: 3.36-32.07), severe mucosal atrophy (HR = 2.71, 95%CI: 1.45-5.08), and pathological differentiation of EGC (well/moderately differentiated vs poorly differentiated: HR = 10.18, 95%CI: 1.30-79.65). Based on these risk factors, a risk stratification system was developed to categorize individuals into low (0-1 point), intermediate (2-3 points), and high (4-8 points) risk categories for MGC, with cumulative incidence rates of 12.3%, 21.6%, and 45%, respectively.

CONCLUSION

Among elderly individuals, MASLD, persistent H. pylori infection, severe mucosal atrophy, and well/moderately differentiated EGC were associated with an increased risk of MGC. Elderly patients are recommended to adopt healthy lifestyle practices, and undergo regular endoscopic screening and H. pylori testing after curative ESD for EGC.

Efficacy and applications for PuraStat® use in the management of unselected gastrointestinal bleeding: A retrospective observational study

BACKGROUND

Hemostatic powders have been used as primary or salvage therapy to control gastrointestinal bleeding in a number of scenarios. PuraStat® is a novel, self-assembling peptide gel that has properties that differ from hemostatic powders. It is transparent, can be used in narrow spaces and combined with other modalities. Also, it is pre-filled in a syringe ready to use and easy to handle and deliver. PuraStat® has been shown to be effective and safe in treating gastrointestinal bleeding lesions. But, its role as a hemostatic agent in all bleeding indications remains to be clarified.

AIM

To evaluate PuraStat® efficacy and its applications, feasibility and safety in treating gastrointestinal bleeding lesions.

METHODS

We performed a retrospective single-centre analysis of all consecutive patients with gastrointestinal bleeding, that required endoscopic treatment and where PuraStat® was applied, from June 2020 to October 2022. Demographics, biochemical, endoscopic, endoscopist assessment and outcome data were collected. We analysed the whole cohort and the subgroup with upper gastrointestinal bleeding. The primary outcome was to evaluate the efficacy of PuraStat® at achieving initial hemostasis. The patients were followed-up for 30 days after the episode of bleeding.

RESULTS

In total 45 patients were included, and 17/45 (37.8%) females. The mean age was 65.8 years. Charlson score was > 2 in 27/45 (60%) and 26/45 (57.8%) required transfusion. The procedures were gastroscopy (77.8%), colonoscopy (15.5%), endoscopic retrograde cholangiopancreatography (4.4%) and enteroscopy (2.2%). The most common bleeding lesion was peptic ulcer (33.3%). PuraStat® was used alone in 36% of the cases. One hundred percent achieved initial hemostasis and no complications were documented. There were no significant differences between the use of PuraStat® alone or in combination in terms of re-bleeding (P = 0.64) or mortality (P = 0.69). In 46.6% of cases, the reason for applying PuraStat® was as addition to standard of care, in 35.5% as an alternative because standard of care was not possible and in 17.8% as a rescue therapy.

CONCLUSION

PuraStat® is an effective therapy for multiple etiologies and is considered very easy to use in the majority. Its role as front line agent should be considered in the future.

Stricture prevention after circumferential endoscopic submucosal dissection of the esophagus: Proactive vs reactive strategies

In this editorial, we explored currently available strategies for reducing the occurrence of esophageal strictures following circumferential endoscopic submucosal dissection. This manuscript provided a comprehensive overview of the various strategies including recent insights from Wang et al. To this end, stenosis-related symptoms such as dysphagia and vomiting can severely affect a patient's quality of life. Therefore, we assess the efficacy of both reactive and proactive measures, ranging from traditional approaches like endoscopic balloon dilation and steroid administration to more advanced techniques, including tissue engineering and polyglycolic acid sheet placement. However, no single treatment has shown high efficacy, particularly for resections involving the entire circumference. Despite these shortcomings, the combination of different strategies may improve patient outcomes, although further large-scale studies are needed for validation.

When ectopic bone forms in the abdomen: The diagnostic and management challenges of heterotopic mesenteric ossification

Heterotopic mesenteric ossification (HMO) is a rare medical condition, with < 100 cases reported globally by 2024. This disorder is characterized by abnormal bone tissue formation within the mesentery, often following abdominal trauma, ischemia, or infection. This editorial reviews the case presented by Zhang et al, involving a 34-year-old male who developed persistent left lower abdominal pain after sustaining blunt trauma to the abdomen. Diagnostic challenges arose due to the rarity and nonspecific presentation of HMO, which shares histopathological features with conditions such as myositis ossificans and necessitates differentiation from malignancies like sarcomas. Advanced imaging revealed calcifications suggestive of HMO, but definitive diagnosis was achieved only through surgical resection and histopathological analysis, which confirmed the presence of ectopic bone formation. Although benign, HMO can result in severe complications, such as bowel perforation or obstruction. Therefore, awareness of HMO is crucial for clinicians to ensure timely and appropriate treatment.

Long-term outcomes of endoscopic submucosal dissection for gastric dysplasia and early neoplasia in a United Kingdom Caucasian population

BACKGROUND

Endoscopic submucosal dissection (ESD) is increasingly used to treat gastric dysplasia and early neoplasia in the West. Unlike Eastern countries, data for Caucasian patients in the United Kingdom is limited due to its limited implementation in a few tertiary centres.

AIM

To evaluate the outcomes of ESD on gastric dysplasia and neoplasia in Caucasian patients.

METHODS

Our ten-year retrospective study at a single tertiary centre included data spanning from May 2012 to July 2023. The efficacy of ESD on gastric dysplasia and early neoplasia was measured using parameters set out by the National Institute for Health and Care Excellence, which include en-bloc and curative resection (CR) rates, local recurrence and survival rates.

RESULTS

ESD was attempted on 111 lesions in 93 patients. 95.0% of completed procedures achieved endoscopic clearance. 74.3% were en-bloc resections and the rest were hybrid ESD with piecemeal resections. In all, 34.7% achieved histological CR. Overall, disease recurrence was 10.9% at latest follow-up (63 months, median follow-up). Importantly 100% of lesions in the CR group showed no disease recurrence at subsequent and latest follow-up. In the Indeterminate and Non-CR group, 18.8% of lesions showed disease recurrence at subsequent endoscopic follow-ups. ESD changed the histological staging of 44.5% of lesions. Immediate complications were observed in 9.9% of all ESD procedures. The median survival time was 69 months post-ESD. The mean age at death is 82.2 years old.

CONCLUSION

The study affirms the long-term efficacy and safety of ESD for gastric dysplasia and early neoplasia in Caucasian patients.

Discordance between endoscopic and histopathologic assessment in ileal Crohn's disease

BACKGROUND

Discordance between endoscopic and histologic assessments in Crohn's disease (CD) have been observed, however the prevalence and cause are unclear.

AIM

To assess if a protocolized approach to biopsy collection facilitates understanding of this discordance in patients with ileal CD.

METHODS

Patients with known ileal CD underwent colonoscopy with endoscopic disease activity assessment. Three protocolized biopsies were taken respectively from an ulcer edge, 7-mm, and 14-mm away from the ulcer edge in patients with discrete ileal ulcer(s). In patients with no ulcers as controls, the same 3-site biopsy protocol was applied in a randomly selected area of endoscopically-unremarkable terminal ileal mucosa. A blinded pathologist assessed mucosal inflammation in each biopsy using 3 validated histologic indices.

RESULTS

Twenty-four participants had visible ulcer(s) on endoscopy and 12 served as no-ulcer controls. Of biopsies taken from an ulcer edge, only 67% showed histologic evidence of active (neutrophilic) inflammation, and 33% showed histologic features of ulcer or erosion; all were from either large (n = 4) or very large (n = 4) ulcers. In the no-ulcer controls, no biopsies showed histologic features of ulcer or erosion, but 8% showed active inflammation.

CONCLUSION

A striking discordance exists between endoscopic and histologic assessments for mucosal inflammation in patients with active ileal CD, even in biopsies targeted at an ulcer edge, while a higher concordance is seen in patients with no endoscopic disease activity. It remains unclear how to incorporate histologic disease activity into the treatment paradigm. Further research is needed to optimize biopsy protocols and histologic assessments for CD.

Clinical impact of endoscopy in severely thrombocytopenic patients with hematologic malignancy experiencing gastrointestinal bleeding

BACKGROUND

Gastrointestinal bleeding (GIB) is a major cause of hospitalization worldwide. Patients with hematologic malignancies have a higher risk of GIB as a result of thrombocytopenia and platelet dysfunction. There is no consensus on the optimal platelet level that would be safe for endoscopic intervention, although a platelet level of > 50 × 109 / L was suggested based on expert opinion. There is a paucity of data on whether endoscopic intervention and the timing of endoscopy impacted the outcome of patients with hematologic malignancy and severe thrombocytopenia who experienced acute overt GIB.

AIM

To assess the safety of endoscopic intervention of inpatients with hematological malignancies and severe thrombocytopenia presenting with acute overt GIB.

METHODS

This is a single center retrospective study. The data was collected from the electronic health record from 2018 to 2020. Inpatients with hematologic malignancy who presented with acute overt GIB and platelet count ≤ 50 × 109/L were included in the study. Outcomes included mortality, transfusion requirements, length of stay, intensive care unit admission and recurrent bleeding. A subgroup analysis was performed to compare the outcomes of urgent endoscopy within 24 hours of GIB vs endoscopy > 24 hours.

RESULTS

A total of 76 patients were identified. The mean platelet count is 24.3 in the endoscopy arm and 14.6 in the conservative management arm. There was no statistically significant difference between patients who had endoscopy vs conservative management in 30-day (P = 0.13) or 1 year (P = 0.78) mortality, recurrent bleeding (P = 0.68), transfusion of red blood cells (P = 0.47), platelets (P = 0.31), or length of stay (P = 0.94). A subgroup analysis comparing urgent endoscopy within 24 hours compared with delayed endoscopy showed urgent endoscopy was not associated with improved 30-day or 1 year mortality (P = 0.11 and 0.46, respectively) compared to routine endoscopy, but was associated with decreased recurrent bleeding in 30 days (P = 0.01).

CONCLUSION

Medical supportive treatment without endoscopy could be considered as an alternative to endoscopic therapy for patients with hematologic malignancy complicated by severe thrombocytopenia and acute non-variceal GIB.

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.

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.

Endoscopic removal of an embedded chicken bone in the esophagus: A case report

BACKGROUND

Sharp foreign body ingestion can cause gastrointestinal tract mucosa injury and requires proper endoscopic removal. Typically, protective devices are used to reduce mucosal damage. This case presents an alternative approach for the endoscopic removal of a large, irregular, and sharp foreign body (chicken bone) when traditional protective devices are inadequate, thus contributing to the management of such ingestions.

CASE SUMMARY

A 57-year-old male presented with a history of swallowing an irregular and sharp-pointed chicken bone. Emergent endoscopy showed it was tightly embedded in the esophageal wall, with minor bleeding. The chicken bone was grasped and moved cautiously using a foreign forceps. It was loosened after repeated attempts but could not pass through the pharynx. Considering possible mucosal damage, it was carefully pushed into the stomach cavity and then wrapped in a condom. The chicken bone was retrieved uneventfully by grasping the open edge of the condom with foreign forceps. No additional damage was found, except for primary esophageal injuries caused by the embedded chicken bone. The patient was discharged on the following day. Our experience demonstrated that condoms can be an alternative as a protective device under such conditions.

CONCLUSION

Condoms can serve as an alternative when traditional protective devices are unsuitable. Because of its smooth and oily nature, it can provide mucosal protection and lubrication during endoscopic removal.