Tools for polyp histology prediction

Although removal of adenomatous polyps has been shown to decrease the risk of colon cancer, distal hyperplastic polyps are thought to not have malignant potential. Most polyps detected during colonoscopy are diminutive (≤ 5 mm) and rarely harbor advanced histology, such as high-grade dysplasia or cancer. Therefore, predicting histology in real-time during colonoscopy can potentially decrease the enormous expenditure that ensues from universal histopathologic evaluation of polyps, and several novel imaging technologies have been developed and tested over the past decade for this purpose. Of these different technologies, electronic chromoendoscopy seems to strike a fair balance between accuracy, feasibility, and cost.

Endoscopy versus early surgery for the management of chronic pancreatitis: a systematic review and meta-analysis

BACKGROUND AND AIM

Endoscopic stone removal and stenting of pancreatic strictures are the initial treatment for treating chronic pancreatitis-related pain. Surgery is considered when endoscopic interventions fail to improve symptoms. In this meta-analysis, we have compared early surgery versus endoscopic interventions.

METHODS

The study was performed as per the PRISMA statement. The literature search was conducted on online databases to identify studies that compared endoscopy and surgery for the management of chronic pancreatitis symptoms. Primary outcomes of interest were pain relief, complications, and exocrine/endocrine insufficiency. Secondary outcomes were mean length of stay and mean number of procedures. Pooled odds ratio (OR) was calculated using random-effects model with 95% confidence interval (CI).

RESULTS

Of a total of 9880 articles that were screened, three randomized controlled trials and two retrospective studies with 602 patients (71.4% males) were found to be eligible. Endoscopic interventions were performed in 317 patients and 285 patients underwent early surgery. Early surgery provided significantly better pain relief compared to endoscopy (OR 0.46; 95%CI 0.27-0.80; p = 0.01; I2 = 17.65%) and required less number of procedures (Mean difference 1.66; 95%CI 0.9-2.43; p = 0.00; I2 = 96.46%). There was no significant difference in procedure-related complication (OR 0.91; 95%CI 0.51-1.61; p = 0.74; I2 = 38.8%), endocrine (OR 1.18; 95%CI 0.63-2.20; p = 0.61; I2 = 28.24%), or exocrine insufficiency (OR 1.78; 95%CI 0.66-4.79; p = 0.25; I2 = 30.97%) or the length of stay (Mean difference 1.21; 95%CI -7.12 to 4.70; p = 0.69).

CONCLUSION

Compared to endoscopy, early surgery appears to be better in controlling chronic pancreatitis-related pain, with no significant difference in procedure-related complications. However, larger randomized controlled trials are needed to ascertain their efficacy.

Safety and feasibility of esophageal self- expandable metal stent placement without the aid of fluoroscopy

Self-expandable metal stents (SEMSs) are used for the management of certain esophageal conditions such as strictures, perforations, and fistulae. These can be placed using fluoroscopic control, endoscopic control, or a combination of both. We evaluated our institutional experience of placing a SEMS using only endoscopy without the aid of fluoroscopy to determine safety and feasibility using this technique. A retrospective review was performed to identify all patients who underwent esophageal SEMS from January 2010 to June 2015. Placement of SEMS was accomplished under direct endoscopic visualization without the aid of fluoroscopy. Esophageal lesion was initially identified during endoscopy and a fully covered SEMS was passed over the guide wire and deployed under direct vision. Misplacement of the SEMS during the procedure that required replacement with another new SEMS was considered as a failed procedure. Other periprocedural complications caused by placement of SEMS were noted. A total of 172 patients underwent 280 procedures for SEMS placement. Mean age was 66 years. The most common indication for SEMS placement was stricture in 248 (88%) procedures. Periprocedure SEMS misplacement occurred in 12 (4%) patients. However, only 8 (3%) patients needed to have a new SEMS placed during the same procedure. A total of 64 (23%) patients had migration of SEMS. There were no other periprocedure complications leading to adverse events. Self-expandable metal stent can be placed accurately and safely under direct endoscopic visualization without the aid of fluoroscopy.

Accuracy of Endoscopic Ultrasound-guided Fine Needle Aspiration in Diagnosing Solid Pseudopapillary Tumor

Background:

Solid pseudopapillary tumors are rare pancreatic tumors. Accurate preoperative diagnosis helps in planning of the surgery.

Aim:

This study was to evaluate accuracy of endoscopic ultrasound-guided fine needle aspiration and immunohistochemistry in diagnosing solid pseudopapillary tumors.

Materials and Methods:

A retrospective review was performed by reviewing medical records to identify patients treated for solid pseudopapillary tumors over a 5-year period. Patients who were noted to have pancreatic lesions by computer tomography abdomen underwent endoscopic ultrasound. Fine needle aspiration was obtained from each of these lesions and subjected to immunohistochemistry.

Results:

Five patients were identified. Endoscopic ultrasound was able to identify the pancreatic lesions in all five patients noted in computer tomography abdomen. Solid pseudopapillary tumors were diagnosed by immunohistochemistry. All five patients underwent surgery and the resected lesions confirmed solid pseudopapillary tumors in 80% patients.

Conclusion:

Endoscopic ultrasound-guided fine needle aspiration has a higher degree of accuracy in diagnosing solid pseudopapillary tumors.

Comparable Efficacy of Laser-Cut and Braided Self Expanding Metallic Biliary Stent: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

In patients with unresectable malignant biliary obstruction (MBO), endoscopic biliary drainage is the treatment of choice. Self-expanding metallic stents (SEMS) are mainly used for this purpose, and data is limited on the comparative outcomes of laser-cut versus braided SEMS. Herein, we performed the first systematic review and meta-analysis to study the effectiveness and safety of braided and laser-cut SEMS in MBO.

METHODS

Multiple databases, including Medline, Scopus, and Embase, were searched (in May 2022) using specific terms for studies evaluating the outcomes of braided and laser-cut SEMS in MBO. Outcomes of interest were technical and clinical success, recurrent biliary obstruction, and adverse events. Standard meta-analysis methods were employed using the random-effects model. I2% heterogeneity was used to assess the heterogeneity.

RESULTS

Seven studies were included in the final analysis. (Laser-cut: 271 patients, 46% females, mean age 70 years; and braided: 282 patients, 47% females, mean age 72 years). The pooled rate of technical success and clinical success with laser-cut SEMS was 99% (95% CI [95-99; I2 = 0%]), 86% [60-96; I2 = 74%], and 98% [96-99; I2 = 0%], 89% [74-95; I2 = 78%] with braided. The pooled rate of recurrent biliary obstruction with laser-cut SEMS was 26% [14-43; I2 = 88%] and 12% [5-27; I2 = 56%) with braided. Pooled total adverse events were 11% [5-21; I2 = 77%] in laser-cut and 12% [6-24; I2 = 63%] in braided.

CONCLUSION

Our meta-analysis demonstrates similar clinical outcomes with laser-cut and braided SEMS in MBO. Given the comparable performance, a cost-effectiveness analysis might help in choosing one type versus another in patients with MBO.

Methods to become a high performer in characterization of colorectal polyp histology

The recent advent of advanced imaging technologies has brought real time characterization of polyp histology to the forefront. This concept of optical diagnosis of diminutive polyp histology can bring about a huge paradigm shift in the management of these lesions. Instead of resecting and sending all the diminutive polyps to pathology, there is the potential to practice "resect and discard" for those predicted to be adenomas and "do not resect" strategy for the recto-sigmoid polyps predicted to be hyperplastic. However, one of the major steps before the clinical implementation of real-time histology can be a reality, will be training endoscopists with varying levels of experience in novel imaging technologies. The two major methods for training include didactic teaching and the computer based method. After the initial training, it is imperative that the endoscopists practice this skill during performance of routine colonoscopy to auto validate and assess their own competency. Both practice and reinforcement can help endoscopists become high performers in the characterization of polyp histology.

Improving Diagnostic Yield in Indeterminate Biliary Strictures

Indeterminate biliary strictures are defined as a narrowing of the bile duct that cannot be differentiated as malignant or benign after performing cross-sectional imaging and an ERCP. Identifying the etiology of a bile duct stricture is the single most important step in determining whether a complex and potentially morbid surgical resection is warranted. Due to this diagnostic and therapeutic dilemma, new technologies, laboratory tests, and procedures are emerging to solve this problem.

Advanced Endoscopic Imaging and Interventions in GERD: An Update and Future Directions

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases encountered in primary care and gastroenterology clinics. Most cases of GERD can be diagnosed based on clinical presentation and risk factors; however, some patients present with atypical symptoms, which can make diagnosis difficult. An esophagogastroduodenoscopy can be used to assist in diagnosis of GERD, though only half of these patients have visible endoscopic findings on standard white light endoscopy. This led to the development of new advanced endoscopic techniques that enhanced the diagnosis of GERD and related complications like squamous cell dysplasia, Barrett's esophagus, and early esophageal adenocarcinoma. This is conducted by improved detection of subtle irregularities in the mucosa and vascular structures through optical biopsies in real-time. Management of GERD includes lifestyle modifications, pharmacological therapy, endoscopic and surgical intervention. Minimally invasive endoscopic intervention can be an option in selected patients with small hiatal hernia and without complications of GERD. These endoscopic interventions include endoscopic fundoplication, endoscopic mucosal resection techniques, ablative techniques, creating mechanical barriers, and suturing and stapling devices. As these new advanced endoscopic techniques are emerging, data surrounding the indications, advantages and disadvantages of these techniques need a thorough understanding.

Predictors and outcomes of acute respiratory failure in hospitalised patients with acute pancreatitis

BACKGROUND AND AIM

Acute pancreatitis (AP) is associated with organ failures and systemic complications, most commonly acute respiratory failure (ARF) and acute kidney injury. So far, no studies have analysed the predictors and hospitalisation outcomes, of patients with AP who developed ARF. The aim of this study was to measure the prevalence of ARF in AP and to determine the clinical predictors for ARF and mortality in AP.

METHODS

This is a retrospective cohort study using the Nationwide Inpatient Sample database from the year 2005-2014. The study population consisted of all hospitalisations with a primary or secondary discharge diagnosis of AP, which is further stratified based on the presence of ARF. The outcome measures include in-hospital mortality, hospital length of stay and hospitalisation cost.

RESULTS

In our study, about 5.4% of patients with AP had a codiagnosis of ARF, with a mortality rate of 26.5%. The significant predictors for ARF include sepsis, pleural effusion, pneumonia and cardiogenic shock. Key variables that were associated with a higher risk of mortality include mechanical ventilation, age more than 65 years, sepsis and cancer (excluding pancreatic cancer). The presence of ARF increased hospital stay by 8.3 days and hospitalisation charges by US$103 460.

CONCLUSION

In this study, we demonstrate that ARF is a significant risk factor for increased hospital mortality, greater length of stay and higher hospitalisation charges in patients with AP. This underlines significantly higher resource utilisation in patients with a dual diagnosis of AP-ARF.

Current advances in the management of chronic pancreatitis

Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.

Efficacy of Rituximab in Autoimmune-Mediated IgG4 Pancreaticobiliary Disease: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

IgG4 pancreaticobilliary disease (IgG4-PBD) typically shows a rapid improvement with glucocorticoid treatment, yet most patients experience a recurrence. Rituximab (RTX) has emerged as a hopeful approach to prevent relapses in IgG4-PBD. Nevertheless, there is a lack of data on the efficacy and safety of RTX in IgG4-PBD. In this study, we aim to perform a systematic review and meta-analysis to study the pooled efficacy of RTX in this patient population.

METHODS

Multiple databases, including MEDLINE, SCOPUS, and Embase, were searched (in March 2024) using specific terms for studies evaluating the efficacy and safety of RTX in IgG4 pancreatic biliary disease. Outcomes of interest were relapse, remission, partial remission rates, and adverse events. Standard meta-analysis methods were used using the random-effects model. I2% heterogeneity was used to assess the heterogeneity.

RESULTS

Twelve studies were included in the study (257 patients). The pooled rate of complete remission was 68% (54% to 80%), I2 =53%, respectively. The pooled relapse rate was 23% (13% to 36%), I2=64%. The pooled rate of total adverse events was 21% (12% to 35%), I2=52%. The pooled partial remission rate is 16% (7% to 32%), I2=25%. The pooled rate of complete and partial remission was 81% (66% to 90%), I2=75%. The pooled infusion reaction and infection were 12% (7% to 18%), I2=0% and 14% (8% to 22%), I2=16%, respectively.

CONCLUSION

RTX therapy appears effective in inducing and maintaining remission of pancreaticobiliary disease with a low rate of side effects. RTX presents as a promising treatment option for patients grappling with recurrent or unresponsive IgG4-related ailments. In addition, RTX emerges as an attractive alternative for individuals intolerant to steroids or experiencing IgG4-related disease relapses. Future studies comparing RTX with other immunomodulators will offer deeper insights into relapse factors and elucidate the appropriateness of utilizing this maintenance treatment following the initial flare.

Risk of Metachronous Neoplasia with High-Risk Adenoma and Synchronous Sessile Serrated Adenoma: A Systematic Review and Meta-Analysis

Background: Sessile serrated adenomas are important precursors to colorectal cancers and account for 30% of colorectal cancers. The United States Multi-Society Task Force recommends that patients with sessile serrated adenomas undergo surveillance similar to tubular adenomas. However, the risk of metachronous neoplasia when the high-risk adenoma co-exists with sessile serrated adenomas is poorly defined. Objective: To examine the risk of metachronous neoplasia in the presence of high-risk adenoma and synchronous sessile serrated adenomas compared with isolated high-risk adenoma. Data sources: PubMed, Embase, Scopus, Cochrane Library. Study selection: A literature search for studies evaluating the risk of metachronous neoplasia in patients with high-risk adenoma alone and those with synchronous high-risk adenoma and sessile serrated adenomas during surveillance colonoscopy was conducted on online databases. Main outcome measures: The primary outcome of interest was the presence of metachronous neoplasia. Results: Of the 1164 records reviewed, six (four retrospective and two prospective) studies met inclusion criteria with 2490 patients (1607 males, mean age 59.98 ± 3.23 years). Average follow-up was 47.5 ± 12.5 months. There were 2068 patients with high-risk adenoma on index colonoscopy and 422 patients with high-risk adenoma and synchronous sessile serrated adenomas. Pooled estimates showed a significantly elevated risk for metachronous neoplasia in patients with high-risk adenoma and synchronous sessile serrated adenomas (pooled odds ratio 2.21; 95% confidence intervals 1.65-2.96; p < 0.01). There was low heterogeneity (I2 = 11%) among the studies. Sensitivity analysis of the prospective studies alone also showed elevated risk of metachronous neoplasm (pooled odds ratio 2.56; 95%, confidence intervals 1.05-6.23; p = 0.04). Limitations: Inclusion of a small number of retrospective studies. Conclusions: The presence of high-risk adenomas and synchronous sessile serrated adenomas is associated with an increased risk of metachronous neoplasia. Therefore, shorter surveillance intervals may be considered in patients with high-risk adenoma and synchronous sessile serrated adenomas compared to those with high-risk adenoma alone.

Endoscopic Advances in the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is one of the most common diseases that occurs secondary to failure of the antireflux barrier system, resulting in the frequent and abnormal reflux of gastric contents to the esophagus. GERD is diagnosed in routine clinical practice based on the classic symptoms of heartburn and regurgitation. However, a subset of patients with atypical symptoms can pose challenges in diagnosing GERD. An esophagogastroduodenoscopy (EGD) is the most common initial diagnostic test used in the assessment for GERD, although half of these patients will not have any positive endoscopic findings suggestive of GERD. The advanced endoscopic techniques have improved the diagnostic yield of GERD diagnosis and its complications, such as Barrett's esophagus and early esophageal adenocarcinoma. These newer endoscopic tools can better detect subtle irregularities in the mucosa and vascular structures. The management options for GERD include lifestyle modifications, pharmacological therapy, and endoscopic and surgical interventions. The latest addition to the armamentarium is the minimally invasive endoscopic interventions in carefully selected patients, including the electrical stimulation of the LES, Antireflux mucosectomy, Radiofrequency therapy, Transoral Incisionless Fundoplication, Endoscopic Full-Thickness plication (GERDx™), and suturing devices. With the emergence of these advanced endoscopic techniques, it is crucial to understand their selection criteria, advantages, and disadvantages.

Pancreatic Stones and Extracorporeal Shockwave Lithotripsy: A Review of the Literature

Pancreatic stones are sequelae of chronic pancreatitis, resulting in poor quality of life, frequent hospitalizations, and a significant economic burden. Extracorporeal shock wave lithotripsy (ESWL) can be used to treat pancreatic stones and is less invasive when compared to other modalities. In this review article, we have discussed the role of ESWL in the treatment of pancreatic stones and how it differs from other modalities. Databases were searched electronically for articles discussing the treatment of pancreatic ductal stones by ESWL or other modalities. Articles discussing or comparing treatment success rates were preferentially included. An inductive approach was used to identify articles related to the treatment of pancreatic stones with ESWL throughout the review process. Although laser lithotripsy and electrohydraulic lithotripsy appear to have higher success rates, the potential for ESWL to affect clinical outcomes is substantial, especially in individuals with a higher risk for invasive procedures. The decision to perform ESWL should be considered if the outcome will substantially alter the clinical management when performed by an experienced endoscopist. Further randomized controlled trials are needed to compare ESWL and peroral pancreatic lithotripsy methods.

Safety Parameters for the Use of Holmium:YAG Laser in the Treatment of Biliary Calculi: The Ex-Vivo Model

Background and Objectives: While studies have demonstrated the efficacy of cholangioscopy-guided Holmium-Yttrium aluminum garnet (Ho:YAG) laser lithotripsy for the treatment of refractory bile duct stones, data regarding the safety of the operating parameters for laser lithotripsy are lacking. The aim of this study was to determine safe, yet effective, energy settings for Ho:YAG laser in the ex-vivo model. Materials and Methods: This ex vivo experimental study utilized the Ho:YAG laser on porcine bile duct epithelium and human gallstones. Ho:YAG laser lithotripsy was applied in different power settings from 8 to 15 Watts (W) to six explanted porcine bile ducts. Settings that appeared safe were then utilized to fragment seventy-three human gallstones. Results: The median bile duct perforation times with the Ho:YAG laser between 8-15 W were: >60 s (8 W); 23 s (9 W); 29 s (10 W); 27 s (12 W); 12 s (14 W); and 8 s (15 W). Statistically significant differences in the median perforation times were noted between 8 W vs. 15 W, 9 W vs. 15 W, 10 W vs. 15 W, and 12 W vs. 15 W (p < 0.05). When using a 365 µm Ho:YAG laser probe at 8-12 W, the fragmentation rates on various size stones were: 100% (<1.5 cm); 80-100% (1.6-2.0 cm) and 0-32% (>2.0 cm). Optimal fragmentation was seen utilizing 12 W with high energy (2.4 J) and low frequency (5 Hz) settings. Using a larger 550 µm probe at these settings resulted in 100% fragmentation of stones larger than 2 cm. Conclusions: The Ho:YAG laser appears to be safe and effective in the treatment of large bile duct stones when used between 8-12 W in 5 s bursts in an ex vivo model utilizing porcine bile ducts and human gallstones.

Trainee Involvement and ERCP Complications: A Systematic Review and Meta-Analysis

BACKGROUND

Therapeutic endoscopy and gastroenterology fellows often participate in endoscopic retrograde cholangiopancreatography (ERCP) during their training period. However, it is generally feared that trainee involvement may increase ERCP-related complications, mainly because of the side-viewing nature of the endoscope and the higher risk of pancreatic duct cannulation. There is no concrete evidence to support this notion. This systematic review and meta-analysis aims to investigate the resultsof trainee participation on adverse events related to ERCP.

METHODS

PubMed, EMBASE, Google Scholar, SCOPUS, and Web of Science databases were searched from inception to 31 May 2023 for studies evaluating the ERCP outcomes defined as success rates, procedure time, failed attempts, and adverse events with and without trainee participation. A random effect model was used to perform the meta-analysis, and heterogeneity was assessed using the I2 statistics.

RESULTS

Seven studies were included in the final analysis, including 17,088 ERCPs. The pooled odds ratio (pOR) of success rate, incomplete/failed attempts in the trainee and no trainee groups were 0.466 (95% CI 0.13 to 1.66, I2 = 97.8%, p = 0.239) and 3.2 (95% CI 0.70 to 14.55), I2 = 98.5%, p = 0.134), respectively. The pOR of post-ERCP pancreatitis and bleeding in the trainee vs. no trainee groups was 0.97 (95% CI 0.76 to 1.23, I2 = 0%, p = 0.78) and 1.3 (95% CI 0.59 to 2.83, I2 = 49%, p = 0.54). The pOR of all adverse events in both groups was 1.028 (95% CI 0.917 to 1.152, I2 = 0%, p = 0.636). Surprisingly, the pooled std mean difference for the procedure time was 0.217 (95% - 0.093 to 0.05, I2 = 98.5%, p = 0.17).

CONCLUSION

This meta-analysis comprising of 17,088 ERCPs in seven studies demonstrated comparable ERCP outcomes related to trainee participation regarding success rates, procedure time, and adverse events. Trainees' involvement in ERCP within a proper teaching setting appears safe and does not compromise the overall procedure's success.