Optical biopsy mapping on endoscopic image mosaics with a marker-free probe

Gastric cancer is the second leading cause of cancer-related deaths worldwide. Early diagnosis significantly increases the chances of survival; therefore, improved assisted exploration and screening techniques are necessary. Previously, we made use of an augmented multi-spectral endoscope by inserting an optical probe into the instrumentation channel. However, the limited field of view and the lack of markings left by optical biopsies on the tissue complicate the navigation and revisit of the suspect areas probed in-vivo. In this contribution two innovative tools are introduced to significantly increase the traceability and monitoring of patients in clinical practice: (i) video mosaicing to build a more comprehensive and panoramic view of large gastric areas; (ii) optical biopsy targeting and registration with the endoscopic images. The proposed optical flow-based mosaicing technique selects images that minimize texture discontinuities and is robust despite the lack of texture and illumination variations. The optical biopsy targeting is based on automatic tracking of a free-marker probe in the endoscopic view using deep learning to dynamically estimate its pose during exploration. The accuracy of pose estimation is sufficient to ensure a precise overlapping of the standard white-light color image and the hyperspectral probe image, assuming that the small target area of the organ is almost flat. This allows the mapping of all spatio-temporally tracked biopsy sites onto the panoramic mosaic. Experimental validations are carried out from videos acquired on patients in hospital. The proposed technique is purely software-based and therefore easily integrable into clinical practice. It is also generic and compatible to any imaging modality that connects to a fiberscope.

Deep learning model can improve the diagnosis rate of endoscopic chronic atrophic gastritis: a prospective cohort study

BACKGROUND AND AIMS

Chronic atrophic gastritis (CAG) is a precancerous form of gastric cancer. However, with pathological diagnosis as the gold standard, the sensitivity of endoscopic diagnosis of atrophy is only 42%. We developed a deep learning (DL)-based real-time video monitoring diagnostic model for endoscopic CAG and conducted a prospective cohort study to verify whether this diagnostic model could improve the diagnosis rate of endoscopic CAG compared with that of endoscopists.

METHODS

A U-NET network was used to build a real-time video monitoring diagnostic model for endoscopic CAG based on DL. We enrolled 431 patients who underwent gastroscopy from October 1, 2020, to December 1, 2020. To keep the baseline data of enrolled patient uniform and control for confounding factors, we applied a paired design and included the same patients in both the DL and the endoscopist group.

RESULTS

The DL model improved the diagnosis rate of endoscopic CAG compared with that of endoscopists. Compared with diagnoses by endoscopists, the proportions of moderate and severe CAG in the atrophy patients diagnosed by the DL model were significantly larger, the proportion of "type O" CAG was significantly larger, the number of atrophy sites found was significantly increased, and the number of biopsies was significantly decreased. Compared with diagnoses by endoscopists, in the atrophic lesions diagnosed by the DL model, the proportions of severe atrophy and severe intestinal metaplasia were significantly increased.

CONCLUSIONS

Our study suggested the DL model could improve the diagnosis rate of endoscopic CAG compared with that of endoscopists.

TRIAL REGISTRATION

ChiCTR2100044458, 18/03/2020.

Ischemic injury of the upper gastrointestinal tract after out-of-hospital cardiac arrest: a prospective, multicenter study

Background

The consequences of cardiac arrest (CA) on the gastro-intestinal tract are poorly understood. We measured the incidence of ischemic injury in the upper gastro-intestinal tract after Out-of-hospital CA (OHCA) and determined the risk factors for and consequences of gastrointestinal ischemic injury according to its severity.

Methods

Prospective, non-controlled, multicenter study in nine ICUs in France and Belgium conducted from November 1, 2014 to November 30, 2018. Included patients underwent an esophago-gastro-duodenoscopy 2 to 4 d after OHCA if still intubated and the presence of ischemic lesions of the upper gastro-intestinal tract was determined by a gastroenterologist. Lesions were a priori defined as severe if there was ulceration or necrosis and moderate if there was mucosal edema or erythema. We compared clinical and cardiac arrest characteristics of three groups of patients (no, moderate, and severe lesions) and identified variables associated with gastrointestinal ischemic injury using multivariate regression analysis. We also compared the outcomes (organ failure during ICU stay and neurological status at hospital discharge) of the three groups of patients.

Results

Among the 214 patients included in the analysis, 121 (57%, 95% CI 50–63%) had an upper gastrointestinal ischemic lesion, most frequently on the fundus. Ischemic lesions were severe in 55/121 (45%) patients. In multivariate regression, higher adrenaline dose during cardiopulmonary resuscitation (OR 1.25 per mg (1.08–1.46)) was independently associated with increased odds of severe upper gastrointestinal ischemic lesions; previous proton pump inhibitor use (OR 0.40 (0.14–1.00)) and serum bicarbonate on day 1 (OR 0.89 (0.81–0.97)) were associated with lower odds of ischemic lesions. Patients with severe lesions had a higher SOFA score during the ICU stay and worse neurological outcome at hospital discharge.

Conclusions

More than half of the patients successfully resuscitated from OHCA had upper gastrointestinal tract ischemic injury. Presence of ischemic lesions was independently associated with the amount of adrenaline used during resuscitation. Patients with severe lesions had higher organ failure scores during the ICU stay and a worse prognosis.

Clinical Trial RegistrationNCT02349074.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03939-9.

Deep learning for gastroscopic images: computer-aided techniques for clinicians

Gastric disease is a major health problem worldwide. Gastroscopy is the main method and the gold standard used to screen and diagnose many gastric diseases. However, several factors, such as the experience and fatigue of endoscopists, limit its performance. With recent advancements in deep learning, an increasing number of studies have used this technology to provide on-site assistance during real-time gastroscopy. This review summarizes the latest publications on deep learning applications in overcoming disease-related and nondisease-related gastroscopy challenges. The former aims to help endoscopists find lesions and characterize them when they appear in the view shed of the gastroscope. The purpose of the latter is to avoid missing lesions due to poor-quality frames, incomplete inspection coverage of gastroscopy, etc., thus improving the quality of gastroscopy. This study aims to provide technical guidance and a comprehensive perspective for physicians to understand deep learning technology in gastroscopy. Some key issues to be handled before the clinical application of deep learning technology and the future direction of disease-related and nondisease-related applications of deep learning to gastroscopy are discussed herein.

Incidence and Mortality in Upper Gastrointestinal Cancer After Negative Endoscopy for Gastroesophageal Reflux Disease

BACKGROUND AND AIMS

Gastroesophageal reflux disease (GERD) is associated with an increased risk of cancer of the upper gastrointestinal tract. This study aimed to assess whether and to what extent a negative upper endoscopy in patients with GERD is associated with decreased incidence and mortality in upper gastrointestinal cancer (ie, esophageal, gastric, or duodenal cancer).

METHODS

We conducted a population-based cohort study of all patients with newly diagnosed GERD between July 1, 1979 and December 31, 2018 in Denmark, Finland, Norway, and Sweden. The exposure, negative upper endoscopy, was examined as a time-varying exposure, where participants contributed unexposed person-time from GERD diagnosis until screened and exposed person-time from the negative upper endoscopy. The incidence and mortality in upper gastrointestinal cancer were assessed using parametric flexible models, providing adjusted hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

Among 1,062,740 patients with GERD (median age 58 years; 52% were women) followed for a mean of 7.0 person-years, 5324 (0.5%) developed upper gastrointestinal cancer and 4465 (0.4%) died from such cancer. Patients who had a negative upper endoscopy had a 55% decreased risk of upper gastrointestinal cancer compared with those who did not undergo endoscopy (HR, 0.45; 95% CI, 0.43-0.48), a decrease that was more pronounced during more recent years (HR, 0.34; 95% CI, 0.30-0.38 from 2008 onward), and was otherwise stable across sex and age groups. The corresponding reduction in upper gastrointestinal mortality among patients with upper endoscopy was 61% (adjusted HR, 0.39; 95% CI, 0.37-0.42). The risk reduction after a negative upper endoscopy in incidence and mortality lasted for 5 and at least 10 years, respectively.

CONCLUSIONS

Negative upper endoscopy is associated with strong and long-lasting decreases in incidence and mortality in upper gastrointestinal cancer in patients with GERD.

Fifteen Years after Sleeve Gastrectomy: Gastroscopies, Manometries, and 24-h pH-Metries in a Long-Term Follow-Up: A Multicenter Study

INTRODUCTION

Sleeve gastrectomy (SG) is the most common bariatric operation with over 340,000 procedures per year. There are only few studies presenting follow-up results >10 years in the literature today. The aim of this study was the objective evaluation of long-term outcomes of at least 15 years after SG in non-converted patients.

METHODS

This study (multicenter cross-sectional; university-hospital based) includes all non-converted patients with primary SG before December 2005 at participating bariatric centers. The following methods were used: gastroscopy, esophageal manometry, 24-h pH-metry, and Gastrointestinal Quality of Life Index (GIQLI).

RESULTS

After removing converted patients, patients with bariatric procedures before SG, and deceased patients from the cohort, 20 of 53 participants have met the inclusion criteria. Of this group, 55% are suffering from symptomatic gastroesophageal reflux disease (GERD); 45% are without GERD. Esophagitis, hiatal hernias, Barrett's esophagus, and enlarged sleeves were found in 44%, 50%, 13%, and 69% of patients during gastroscopy. Mean lower esophageal sphincter pressure was normal at 20.2 ± 14.1 mm Hg during manometry. Reflux activity in 24 h, number of refluxes, and DeMeester score were increased at 12.9 ± 9.7%, 98.0 ± 80.8, and 55.3 ± 36.3 during 24-h pH-metry. Patients with GERD scored significantly lower in the GIQLI than patients without GERD: 107.6 ± 18.4 versus 127.6 ± 14.4 (p = 0.04).

DISCUSSION/CONCLUSION

Fifteen years after primary SG, objective testing has shown that GERD, esophagitis, and Barrett's esophagus are major issues for these patients. Surveillance endoscopies at 5-year intervals in all SG patients and 3-year intervals in patients with Barrett's esophagus are recommended.

Are we missing varices by implementing Baveno-VI recommendation of not screening patients with Compensated Advanced Chronic Liver Disease?

OBJECTIVES

This study aimed to validate Baveno-VI recommendations for variceal screening in cACLD in our region and proposed our own cutoff values.

METHODS

Prospective cross-sectional study was conducted on cACLD patients from August 2020 till April 2021. Patients segregated into Group-A, having Liver stiffness measurement (LSM) of ≥ 20 kPa and platelet of ≤ 150 × 109 cells/L; and Group-B having LSM of < 20 kPa and PLT of > 150 × 109 cells/L. Gastroscopic findings were segregated into three categories, VNT, Varices Not Needing Treatment (VNNT) and No Varix (NV). ROC plots were generated for LSM and Platelet for VNT for sensitivity, specificity, Negative and Positive Predictive Values were calculated.

RESULTS

A total of 134 patients of cACLD were included. Group-A had 72 (53.7%) patients and Group-B had 62 (46.3%) patients. Group-A had 6 (8.3%) NV; 18 (25.0%) VNNT and 48 (66.7%) VNT. Group-B had 26 (41.9%) NV, 24 (38.7%) VNNT and 12 (19.4%) VNT. The sensitivity of 66.7%, specificity of 80.6% and NPV of 67.56% was obtained. Thus 19.4% VNT were missed on following Baveno VI recommendations. ROC in our study suggested cutoff value of 11.5 kPa with sensitivity of 100% and 1-sepcifity pf 78% (AUROC = 0.865; p < .001) of LSM below which screening gastroscopy could be avoided. The positive and negative predicted values for 84.85% and 100% respectively. Cut off value of platelet count for VNNT came out to be ≥ 97.5 × 109 cells/L with AUROC 0.891 (p < .001), having sensitivity of 100 % and 1-specificity of 83.3%.

CONCLUSIONS

Substantial number of VNT in cACLD patients are missed by following Baveno-VI recommendations and these needs to be revised on regional basis.

One- or two-operator techniques for oesophago-gastro-duodenoscopy in unsedated patients: A comparative prospective randomized study

BACKGROUND

The standard oesophago-gastro-duodenoscopy procedure is performed with a single endoscopist (SE). Nurse-assisted (NA) oesophago-gastro-duodenoscopies have not yet been studied. We aimed to evaluate the efficacy of an NA endoscopy compared to an SE endoscopy.

METHODS

A prospective, single-center, randomized trial, in which 500 adult patients were divided into two groups. In the first group, patients underwent an endoscopy with an SE. In the second group, the endoscopy was performed with an NA. The ease of the procedure (scores 1-4; 1 difficult, 2 satisfactory, 3 easy, 4 veryeasy), evaluation of patient satisfaction (scores 1-4; 1 uncomfortable, 2 satisfactory, 3 comfortable, 4 verycomfortable), total time of the procedure and vocal cord observation were determined as quality indicators.

RESULTS

Mean patient satisfaction scores in groups 1 and 2 were 2.98±0.79 and 3.11±0.78, respectively (p=0.043), with uncomfortable ratings in 5.2% vs 4%, satisfactory in 16.8% vs 13.2%, comfortable in 53.2% vs 50.4%, and very comfortable in 24.8% vs 32.4% of patients in groups 1 and 2, respectively. Retching rates during the procedure were 54.4% and 45.2% (p=0.040) in groups 1 and 2, respectively. No differences were seen in vocal cord observation (54.4% vs 56.0%), total procedure time (2.35±1.56 vs 2.41±1.48min) and easy score (3.26±0.603 vs 3.25±0.64) in groups 1 and 2 for the procedures. Very easy, easy, satisfactory, and difficult ratings were given by 33.6% vs 34.8%, 60.4% vs 56.4%, 4.8% vs 7.6% and 1.2% vs 1.2% of groups 1 and 2, respectively.

CONCLUSIONS

Compared with the conventional method, the assisted endoscopic technique provides more comfort and less gag reflex without increasing the processing time or difficulty of performing the procedure.

Long-term clinical outcomes of lipiodol marking using standard gastroscopy for image-guided radiotherapy of upper gastrointestinal cancers

BACKGROUND

Image-guided radiotherapy (IGRT) has significantly improved the precision in which radiotherapy is delivered in cancer treatment. Typically, IGRT uses bony landmarks and key anatomical structures to locate the tumor. Recent studies have demonstrated the feasibility of peri-tumor fiducials in enabling even more accurate delineation of target and normal tissue. The use of gold coils as fiducials in gastrointestinal tumors has been extensively studied. However, placement requires expertise and specialized endoscopic ultrasound equipment. This article reports the long-term outcomes of using a standard gastroscopy to inject liquid fiducials for the treatment of oesophageal and gastric tumors with IGRT.

AIM

To assess the long-term outcomes of liquid fiducial-guided IGRT in a cohort of oesophageal and gastric cancer patients.

METHODS

A retrospective cohort study of consecutive adults with Oesophagogastric cancers referred for liquid fiducial placement before definitive/neo-adjuvant or palliative IGRT between 2013 and 2021 at a tertiary hospital in Melbourne, Australia was conducted. Up to four liquid fiducials were inserted per patient, each injection consisting of 0.2-0.5mL of a 1:1 mixture of iodized oil (Lipiodol; Aspen Pharmacare) and n-butyl 2-cyanoacrylate (Histoacryl^®; B. Braun). A 23-gauge injector (Cook Medical) was used for the injection. All procedures were performed by or under the supervision of a gastroenterologist. Liquid fiducial-based IGRT (LF-IGRT) consisted of computer-assisted direct matching of the fiducial region on cone-beam computerised tomography at the time of radiotherapy. Patients received standard-IGRT (S-IGRT) if fiducial visibility was insufficient, consisting of bone match as a surrogate for tumor position. Radiotherapy was delivered to 54Gy in 30 fractions for curative patients and up to 45Gy in 15 fractions for palliative treatments.

RESULTS

52 patients were referred for liquid fiducial placement within the study period. A total of 51 patients underwent liquid fiducial implantation. Of these a total of 31 patients received radiotherapy. Among these, the median age was 77.4 years with a range between 57.5 and 88.8, and 64.5% were male. Twenty-seven out of the 31 patients were able to have LF-IGRT while four had S-IGRT. There were no complications after endoscopic implantation of liquid fiducials in our cohort. The cohort overall survival (OS) post-radiotherapy was 19 mo (range 0 to 87 mo). Whilst the progression-free survival (PFS) post-radiotherapy was 13 mo (range 0 to 74 mo). For those treated with curative intent, the median OS was 22.0 mo (range 0 to 87 mo) with a PFS median of 14.0 mo (range 0 to 74 mo). Grade 3 complication rate post-radiotherapy was 29%.

CONCLUSION

LF-IGRT is feasible in 87.1% of patients undergoing liquid fiducial placement through standard gastroscopy injection technique. Our cohort has an overall survival of 19 mo and PFS of 13 mo. Further studies are warranted to determine the long-term outcomes of liquid-fiducial based IGRT.

Novel albumin, bilirubin and platelet criteria for the exclusion of high-risk varices in compensated advanced chronic liver disease: A validation study

BACKGROUND AND AIMS

Availability of transient elastography (TE) limits the application of Baveno-VI criteria. In a derivation study, the ABP criteria (Albumin >40 g/l, Bilirubin <22 μmol/l and Platelet >114,000/μl) had been shown to perform well in identifying compensated advanced chronic liver disease (cACLD) patients without high-risk varices (HRV). We aim to externally validate this novel ABP criteria for the exclusion of HRVs among cACLD patients.

METHODS

Data was retrospectively collected from consecutive cACLD patients with paired TE and esophagogastroduodenoscopy (EGD) performed between 2011 and 2017 in Changi General Hospital, Singapore. We estimate the discriminative ability of ABP criteria in validation cohort using AUROC and calibration-in-the-large. We subsequently compare the performance between ABP and Baveno-VI criteria in the validation cohort.

RESULTS

Among 314 patients included in our validation cohort, 32 (10.2%) had HRV on screening EGD. Application of ABP criteria within this validation cohort has increased discriminative ability than the derivation cohort. The AUROC of validation and derivation cohort were 0.68 (0.60-0.76) and 0.66 (0.60-0.76), respectively. The mean and standard error for calibration-in-the-large and calibration slope were -0.08 (0.22) and 0.93 (0.26) respectively. The ABP criteria had excellent performance in excluding HRV and will spare more screening EGDs than the Baveno-VI criteria (39.2% vs 27.4%, p < 0.001), without missing more HRVs.

CONCLUSION

We validated the performance of ABP criteria for the exclusion of HRVs in cACLD patients. ABP criteria is superior to Baveno-VI criteria by sparing more screening EGD without the need of TE.

Midazolam dose is associated with recurrence of paradoxical reactions during endoscopy

BACKGROUND

Midazolam is commonly used for sedation during gastrointestinal procedures. However, some patients experience paradoxical reactions characterized by excessive movement or excitement.

AIM

To investigate the rate of recurrence of paradoxical reactions to midazolam during an upper endoscopy.

METHODS

We retrospectively reviewed 122152 sedative endoscopies among a total of 58553 patients at the Seoul National University Hospital, Healthcare System Gangnam Center, from July 2013 to December 2018. Among them, 361 patients with a history of paradoxical reaction during sedative upper endoscopy were enrolled. The characteristics of patients in the recurrent and non-recurrent groups were compared via multivariable analysis using logistic regression.

RESULTS

Paradoxical reactions occurred in 0.86% (1054/122152) of endoscopies, and in 1.51% (888/58553) of patients. Among the 361 subjects with previous paradoxical reactions in sedative endoscopies, 111 (30.7%) experienced further paradoxical reactions. Univariable analysis revealed that the total midazolam dose used was higher in the recurrent group (6.74 ± 2.58 mg) than in the non-recurrent group (5.49 ± 2.04 mg; P < 0.0001). Patients were administered a lower dose of midazolam than previous doses: 1 mg less in the recurrent group and 2 mg less in the non-recurrent group. Multivariable analysis showed that the midazolam dose difference was an independent risk factor for recurrent paradoxical reaction (odds ratio: 1.213, 95%CI: 1.099-1.338, P = 0.0001).

CONCLUSION

The rate of recurrence of paradoxical reactions is significantly associated with midazolam dosage. The dose of midazolam administered to patients with previous paradoxical reactions should be less than that previously used.

Odynophagia in an Immunocompromised Patient

Our article presents a case of Herpes Simplex esophagitis in an immunocompromised patient who presented with severe odynophagia on a background of Metastatic Merkel Cell Carcinoma. Our patient's clinical history and examination findings initially suggest a likely fungal etiology for esophagitis, however as the case develops the diagnosis of Herpes Simplex esophagitis becomes more evident. Our case highlights common endoscopic and histological abnormalities seen in Herpes Simplex esophagitis. Our discussion elaborates on these abnormalities and reminds readers of the treatment for HSV esophagitis.

Risk stratification of patients with gastric lesions indefinite for dysplasia

BACKGROUND/AIMS

There are no definite guidelines for the management of gastric lesions diagnosed as indefinite for dysplasia (IND) by endoscopic forceps biopsy (EFB). Therefore, this study aimed to evaluate the clinical outcomes of gastric IND and predictive factors for gastric neoplasm.

METHODS

This study included 457 patients with a first diagnosis of gastric IND by EFB between January 2005 and December 2013. Patient characteristics and endoscopic and pathological data were reviewed and compared.

RESULTS

Of the 457 gastric IND patients, 128 (28%) were diagnosed with invasive carcinoma, 21 (4.6%) with high-grade dysplasia, 31 (6.8%) with low-grade dysplasia, and 277 (60.6%) as negative for dysplasia. Of lesions observed, 180 (39.4%) showed upgraded histology. Multivariate analysis revealed that surface erythema (odds ratio [OR], 2.804; 95% confidence interval [CI], 1.741 to 4.516), spontaneous bleeding (OR, 2.618; 95% CI, 1.298 to 5.279), lesion size ≥ 1 cm (OR, 5.762; 95% CI, 3.459 to 9.597), and depressed morphology (OR, 2.183; 95% CI, 1.155 to 4.124) were significant risk factors for high-grade dysplasia or adenocarcinoma. The ORs associated with 2 and ≥ 3 risk factors were 7.131 and 34.86, respectively.

CONCLUSION

Precautions should be taken in the management of gastric IND patients, especially when risk factors, including surface erythema, spontaneous bleeding, lesion size ≥ 1 cm, and depressed morphology are present. Considering the combined effect of the presence of multiple risk factors on the incidence of high-grade dysplasia or adenocarcinoma, endoscopic resection should be recommended if a gastric IND patient has at two or more of these factors.

Combined laparoscopic-endoscopic approach for gastric glomus tumor: A case report

BACKGROUND

Gastric glomus tumor (GGT) is rare submucosal mesenchymal tumor that lacks specific clinical manifestations and is usually treated mainly by traditional surgical resection. This paper presents a case of a GGT, exhibited both intraluminally and extraluminally growth that was removed by laparoscopy-gastroscopy cooperative surgery.

CASE SUMMARY

A 52-year-old male presented with epigastric discomfort accompanied by a sense of fullness for 3 mo. Upper gastrointestinal endoscopy identified a submucosal lump located in the gastric antrum. Endoscopic ultrasonography identified a 2.4 cm × 1.8 cm lump located in the gastric antrum. It originated from the muscularis propria and exhibited both intraluminally and extraluminally growth, with hypoechoicity on the periphery, hyperechoicity in the middle, and unclear boundaries. Computed tomography showed nodular thickening of 3.0 cm × 2.2 cm in the gastric wall of the gastric antrum, and after enhancement, the lesion exhibited obvious enhancement We suspected that it was a gastrointestinal stromal tumor (glomus tumor and schwannoma were not excluded) and planned to perform laparoscopy-gastroscopy cooperative surgery. Immunohistochemical staining after the operation revealed that spinal muscular atrophy (+), h-caldesmon (+), cluster of differentiation 34 (CD34) (+), 2% Ki-67-positive rate, CD56, melanoma antigen, CD117, discovered on GIST-1, leukocyte common antigen, caudal type homeobox 2, cytokeratin, and S-100 were all negative. The tumor was finally diagnosed as a GGT.

CONCLUSION

GGTs are rare submucosal tumors of the stomach and should be considered in the differential diagnosis of gastric submucosal tumors. Laparoscopy-gastroscopy cooperative surgery is less invasive and more precise and could be an effective method for the treatment of GGTs.

Submucosal hematoma with a wide range of lesions, severe condition and atypical clinical symptoms: A case report

BACKGROUND

Submucosal hematoma (SH) is one of the rare causes of upper gastrointestinal bleeding. As a rare and critical disease in clinical practice, it should be paid more attention to by clinicians to avoid missed diagnosis and misdiagnosis. Most of the esophageal submucosal hematomas have clear causes, including retrosternal pain, dysphagia, etc. Here, we report a rare case of SH extending from the hypopharynx to the lower esophagus caused by oral administration of hirudin and panax notoginseng powder, with atypical clinical manifestation. Such a long submucosal hematoma has rarely been reported.

CASE SUMMARY

The patient was a 60-year-old male with a history of gastritis, hypertension, coronary heart disease, and coronary stent implantation. The patient developed chest tiredness and heartburn after taking 10 capsules of a homemade mixture of hirudin and notoginseng powder in the previous 2 d. He did not have hematemesis or black stool. Gastroscopy and chest computed tomography confirmed the diagnosis of SH, which ranged from the pharynx to the lower esophagus and was 35-40 cm in length. After the diagnosis was confirmed, we performed active conservative treatment on the patient, and the patient recovered well and remained asymptomatic during the 26-mo follow-up.

CONCLUSION

SH is rare, and cases with atypical clinical symptoms may lead to misdiagnosis and missed diagnosis. Ignorance of this disease can lead to serious clinical consequences. Conservative therapy is effective and the prognosis is good.

Prospective, randomized comparison of two supplemental oxygen methods during gastroscopy with propofol mono-sedation in obese patients. World J Clin Cases 2021;9:5479-5489. [PMID: 34307602 PMCID: PMC8281412 DOI: 10.12998/wjcc.v9.i20.5479]

BACKGROUND

Hypoxemia is a common complication in obese patients during gastroscopy with sedation. The Wei nasal jet tube (WNJT) is a new special nasopharyngeal airway with the ability to provide supraglottic jet ventilation and oxygen insufflation via its built-in wall channels. The aim of this study was to compare the efficacy and safety of the WNJT vs a nasal cannula for supplemental oxygen during gastroscopy with propofol mono-sedation in obese patients.

AIM

To compare the efficacy and safety of the WNJT vs a nasal cannula for supplemental oxygen during gastroscopy with propofol mono-sedation in obese patients.

METHODS

A total of 103 obese patients with a body mass index of 30 kg/m² or more undergoing elective gastroscopy under propofol mono-sedation were randomly assigned to receive supplemental oxygen at 5 L/min through either a WNJT (WNJT group, n = 51) or a nasal cannula (nasal cannula group, n = 52). The lowest pulse oxygen saturation (SpO₂) and mild and severe hypoxemia during gastroscopy were recorded. The primary outcome was the incidence of hypoxemia.

RESULTS

The lowest SpO₂ during gastroscopy with propofol mono-sedation was significantly increased in the WNJT group compared with the nasal cannula group. The incidence of mild hypoxemia and total incidence of hypoxemia were significantly lower in the WNJT group than in the nasal cannula group. Other than a higher incidence of epistaxis in the WNJT group, the occurrence of adverse events was similar between the devices. While neither device demonstrated a statistically significant difference in satisfaction among patients, the WNJT did result in improved satisfaction among anesthetists and physicians.

CONCLUSION

During gastroscopy with propofol mono-sedation in obese patients, the WNJT, when compared with a nasal cannula for supplemental oxygen, can significantly reduce the occurrence of hypoxemia and improve both arterial oxygenation and satisfaction among anesthetists and physicians. The use of the WNJT may, however, lead to epistaxis in a few patients. In view of this clinically acceptable risk-benefit ratio, the WNJT may be recommended as an alternative tool for supplemental oxygen for the prevention of hypoxemia during gastroscopy with propofol mono-sedation in obese patients.

Incidence and Mortality Related to Gastrointestinal Bleeding, and the Effect of Tranexamic Acid on Gastrointestinal Bleeding

Background

Gastrointestinal bleeding is a common and potentially life-threatening condition. The incidence of gastrointestinal bleeding has not decreased despite new prophylaxis and treatments. Ulcer is still one of the most common etiologies for upper gastrointestinal bleeding. It is routinely treated with proton pump inhibitors (PPIs) and endoscopic interventions, sometimes endovascular procedures, and rarely today, open surgery with suture to stop the bleeding. The fibrinolytic tranexamic acid (TXA) has a role in bleeding treatment, and is routinely used for example within trauma care, postpartum bleeding and orthopedic surgery. The aim of this study is to assess the incidence of gastrointestinal bleeding. A further aim was to investigate if TXA has any role in medical treatment of gastrointestinal bleeding today.

Methods

We performed a retrospective cohort study with a review of medical records, involving patients with clinical signs of gastrointestinal bleeding and endoscopically verified ulcers between the years of 2010 and 2016 at the University Hospital of Linkoping, Sweden. The cities of Motala and Linkoping have the primary acute admissions at this Hospital.

Results

We found in total 1,331 patients with gastrointestinal bleeding. The overall incidence for patients with gastrointestinal bleeding was 98.6 (98.6/100,000 inhabitants and year). For those with endoscopically verified ulcer (386 patients), the incidence for peptic ulcer was 28.6/100,000/year. In the group with endoscopically verified ulcer, 25 patients died, giving the 30-day mortality of 6.4%. TXA is still used for treatment of bleeding ulcers. We had two groups, those with and without TXA treatment. They were equal in age, gender and comorbidity. Clinically we saw no major differences in respect to hemodynamic stability. There were more patients with overt bleeding symptoms in the TXA group. We also saw more patients in need of intensive care in the TXA group.

Conclusions

The incidence of gastrointestinal bleeding has not significantly decreased during the last years. There was no significant positive effect of TXA in patients with upper gastrointestinal bleeding in this study. The difference between the two groups is probably more a question of whom we treat with TXA (e.g., the patients in worse condition or at higher risk) than a difference in drug effect. It is time to quit with TXA treatment in all patients with gastrointestinal bleeding, even those at intensive care unit (ICU).

Anesthetic strategy for obese patients during gastroscopy: deep sedation or conscious sedation? A prospective randomized controlled trial

OBJECTIVE

This paper aims to compare the incidence of SpO₂ values < 95% and < 90% of the obese patients between conscious sedation and deep sedation and whether conscious sedation was superior to the deep sedation for obese patients during diagnostic gastroscopy.

METHODS

Obese patients undergoing diagnostic gastroscopy were randomly assigned to two different intervention groups: group CS (conscious sedation) or group DS (deep sedation). Group CS patients were managed by conscious sedation [Modified Observer Assessment of Alertness/Sedation (MOAA/S) at 4-5] protocol, and group DS patients were managed by deep sedation (MOAA/S at ≤ 2) protocol. Propofol and sufentanil (0.1 and 0.05 mg/kg) were, respectively, infused for sedation and analgesia in CS and DS protocols. The primary endpoints were to compare the incidence of SpO₂ values < 95% and < 90% of the patients between the two groups. The incidence of successful sedation, satisfaction scores of patients and endoscopist were assessed as secondary endpoints.

RESULTS

115 obese patients (59 in group CS and 56 in group DS) were enrolled in this study. The incidences of SpO₂ < 95% and < 90% in group CS (42.4% and 6.8%) were significantly lower than those in group DS (69.6% and 19.6%, with P = 0.003 and 0.041, respectively). The incidence of successful sedation was similar between groups (86.4% vs 89.3%, P = 0.641). Patient satisfaction scores and endoscopist satisfaction scores were both similar between groups (P = 0.548 and 0.171).

CONCLUSION

Conscious sedation with propofol and sufentanil (0.1 mg/kg) reduced the incidence of hypoxic events without affecting gastroscopy procedure and satisfaction compared with the deep sedation for obese patients during diagnostic gastroscopy.

TRIAL REGISTRATION

ChiCTR-1900024894; registration date, July 31, 2019. http://www.chictr.org.cn .

Case Report: Phytobezoar Causing Gastric Outlet Obstruction as a Late Complication After Biliopancreatic Diversion with Duodenal Switch

Case report of a phytobezoar causing gastric outlet obstruction as a late complication after biliopancreatic diversion with duodenal switch, review of the literature and discussion of bezoars as a differential diagnosis in patients after bariatric surgery presenting with signs of intestinal obstruction.

A rare case of jejunogastric intussusception: A case report and review of the literature

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Jejunogastric intussusception following gastric bypass or reconstruction surgery is exceedingly rare with only 300 cases reported worldwide.

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Epigastric pain, hematemesis and a palpable, tender epigastric mass in patients with previous gastric bypass should raise suspicion for jejunogastric intussusception.

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Endoscopy is the gold-standard for diagnosis but should be avoided in critically ill patients who require immediate operative intervention.

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Definitive management with surgical reduction and repair reduces recurrence.

Introduction

Jejunogastric intussusception following gastrectomy or gastric bypass surgery is a rare complication that, if not identified early, can have catastrophic outcomes.

Presentation of case

In this case, a 59-year-old male with a previous Billroth II gastrojejunostomy presented with intussusception of the efferent loop of jejunum through his previous repair.

Discussion

As there has only been approximately 300 reported cases of this complication, it often does not rank high as a differential diagnosis. Early detection of jejunogastric intussusception by maintaining a high level of suspicion is critical in reducing morbidity and mortality associated with this complication. This can be achieved by following the appropriate steps to diagnosis and choosing the appropriate treatment modality.

Conclusion

Presentation of the case and a review of the literature is critical to make surgeons aware of this rare complication.

Validation of the Expanded Baveno-VI Criteria for Screening Gastroscopy in Asian Patients with Compensated Advanced Chronic Liver Disease

BACKGROUND

The expanded Baveno-VI criteria may further reduce the need for screening gastroscopy compared to Baveno-VI criteria.

AIM

We sought to validate the performance of these criteria in a cohort of compensated advanced chronic liver disease (cACLD) patients with predominantly hepatitis B infection.

METHODS

Consecutive cACLD patients from 2006 to 2012 with paired liver stiffness measurements and screening gastroscopy within 1 year were included. The expanded Baveno-VI criteria were applied to evaluate the sensitivity (SS), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) for the presence of high-risk varices (HRV).

RESULTS

Among 165 cACLD patients included, 17 (10.3%) had HRV. The commonest etiology of cACLD was chronic hepatitis B (36.4%) followed by NAFLD (20.0%). Application of expanded Baveno-VI criteria avoided more screening gastroscopy (43.6%) as compared to the original Baveno-VI criteria (18.8%) without missing more HRV (1 with both criteria). The overall SS, SP, PPV and NPV of the expanded Baveno-VI criteria in predicting HRV were 94.1%, 48.0%, 17.2% and 98.6%, respectively.

CONCLUSION

Application of the expanded Baveno-VI criteria can safely avoid screening gastroscopy in 43.6% of cACLD patients with an excellent ability to exclude HRV.

Primary localized gastric amyloidosis: A scoping review of the literature from clinical presentations to prognosis

Localized gastric amyloidosis (LGA) is a rare disease characterized by abnormal extracellular deposition of amyloid protein restricted to the stomach and it is confirmed by positive results of Congo red staining. Over decades, only a few cases have been reported and studies or research focusing on it are few. Although LGA has a low incidence, patients may suffer a lot from it and require proper diagnosis and management. However, the pathology of LGA remains unknown and no overall review of LGA from its presentations to its prognosis has been published. Patients with LGA are often asymptomatic or manifest atypical symptoms, making it difficult to differentiate from other gastrointestinal diseases. Here, we report the case of a 70-year-old woman with LGA and provide an overview of case reports of LGA available to us. Based on that, we conclude current concepts of clinical manifestations, diagnosis, treatment, and prognosis of LGA, aiming at providing a detailed diagnostic procedure for clinicians and promoting the guidelines of LGA. In addition, a few advanced technologies applied in amyloidosis are also discussed in this review, aiming at providing clinicians with a reference of diagnostic process. With this review, we hope to raise awareness of LGA among the public and clinicians.

Quality in diagnostic upper gastrointestinal endoscopy for the detection and surveillance of gastric cancer precursor lesions: Position paper of AEG, SEED and SEAP

This position paper, sponsored by the Asociación Española de Gastroenterología [Spanish Association of Gastroenterology], the Sociedad Española de Endoscopia Digestiva [Spanish Gastrointestinal Endoscopy Society] and the Sociedad Española de Anatomía Patológica [Spanish Anatomical Pathology Society], aims to establish recommendations for performing an high quality upper gastrointestinal endoscopy for the screening of gastric cancer precursor lesions (GCPL) in low-incidence populations, such as the Spanish population. To establish the quality of the evidence and the levels of recommendation, we used the methodology based on the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). We obtained a consensus among experts using a Delphi method. The document evaluates different measures to improve the quality of upper gastrointestinal endoscopy in this setting and makes recommendations on how to evaluate and treat the identified lesions. We recommend that upper gastrointestinal endoscopy for surveillance of GCPL should be performed by endoscopists with adequate training, administering oral premedication and use of sedation. To improve the identification of GCPL, we recommend the use of high definition endoscopes and conventional or digital chromoendoscopy and, for biopsies, NBI should be used to target the most suspicious areas of intestinal metaplasia. Regarding the evaluation of visible lesions, the risk of submucosal invasion should be evaluated with magnifying endoscopes and endoscopic ultrasound should be reserved for those with suspected deep invasion. In lesions amenable to endoscopic resection, submucosal endoscopic dissection is considered the technique of choice.

Non-small-bowel lesions identification by capsule endoscopy: A single centre retrospective study

BACKGROUND

Capsule endoscopy has been considered the first-line approach for the investigation of obscure gastro-intestinal bleeding since its approval in 2001. Our study aims to evaluate the diagnostic yield of capsule endoscopy in the investigation of this condition. We also analyse the incidence of non-small-bowel lesions missed after conventional endoscopy and later detected by capsule endoscopy in patients with suspected obscure bleeding.

METHODS

A total of 290 patients with negative conventional endoscopy referred to our centre to undergo a capsule endoscopy examination for the investigation of obscure gastro-intestinal bleeding. We considered as non-small-bowel lesions those outside the tract between the second duodenal portion and the ileocecal valve. We also looked for actively bleeding lesions at the time of the exam.

RESULTS

Intestinal preparation was good, adequate or poor in 74.1%, 8.4%, and 17.5% of the tests, respectively. Caecum was reached in 92.4%. Capsule retention occurred in 0.7%. Mean small bowel transit time was 5hours and 13minutes. Diagnostic yield was 73.8%. An actively bleeding lesion was noticed in 39.3% of positive tests. Capsule endoscopy revealed clinically significant non-small-bowel lesions missed at gastroscopy or colonoscopy in 30.3% of patients, 43.2% of which were bleeding.

CONCLUSIONS

Capsule endoscopy has high diagnostic yield and safety in the investigation of obscure gastro-intestinal bleedings. Given the high percentage of non-small-bowel lesions detected, it may be appropriate to consider an endoscopic second look before performing a capsule endoscopy study.