Balloon catheter-assisted endoscopic resection for papillary adenoma of non-exposed protruded type (with video)

Papillary adenomas, known precursors to papillary adenocarcinoma, warrant close monitoring due to their malignant potential. Historically, surgical resection represented the mainstay of treatment for papillary adenomas with intraductal extension. However, recent advancements in endoscopic techniques have facilitated the adoption of endoscopic papillectomy as a minimally invasive alternative in carefully selected cases. We report a case of an 82-year-old woman with a diagnosis of papillary adenoma exhibiting intraductal extension. This was managed with a novel endoscopic technique, balloon catheter-assisted endoscopic resection. Due to the obscured intraductal component of the papillary mass, a balloon occlusion catheter was deployed within the common bile duct and used as traction to facilitate endoscopic visualization of the mass. Endoscopic resection via papillectomy was subsequently performed. Histopathological examination of the resected specimen revealed a villous adenoma with high-grade dysplasia. Serial endoscopic ultrasound examinations with targeted papillary biopsies were performed to monitor for disease recurrence.

Clinical assessment of computed tomography for detecting ingested blister packs: A single-center retrospective study

Objectives

Blister pack (BP) ingestion poses serious risks, such as gastrointestinal perforation, and accurate localization by computed tomography (CT) is a common practice. However, while it has been reported in vitro that CT visibility varies with the material type of BPs, there have been no reports on this variability in clinical settings. In this study, we investigated the CT detection rates of different BPs in clinical settings.

Methods

This single-center retrospective study from 2010 to 2022 included patients who underwent endoscopic foreign body removal for BP ingestion. The patients were categorized into two groups for BP components, the polypropylene (PP) and the polyvinyl chloride (PVC)/polyvinylidene chloride (PVDC) groups. The primary outcome was the comparison of CT detection rates between the groups. We also evaluated whether the BPs contained tablets and analyzed their locations.

Results

This study included 61 patients (15 in the PP group and 46 in the PVC/PVDC group). Detection rates were 97.8% for the PVC/PVDC group compared to 53.3% for the PP group, a significant difference (p < 0.01). No cases of BPs composed solely of PP were detected by CT. Blister packs were most commonly found in the upper thoracic esophagus.

Conclusions

Even in a clinical setting, the detection rates of PVC and PVDC were higher than that of PP alone. Identifying PP without tablets has proven challenging in clinical. Considering the risk of perforation, these findings suggest that esophagogastroduodenoscopy may be necessary, even if CT detection is negative.

Endoscopic findings and outcomes of gastric mucosal changes relating to potassium-competitive acid blocker and proton pump inhibitor therapy

Gastric mucosal changes associated with long-term potassium-competitive acid blocker and proton pump inhibitor (PPI) therapy may raise concern. In contrast to that for PPIs, the evidence concerning the safety of long-term potassium-competitive acid blocker use is scant. Vonoprazan (VPZ) is a representative potassium-competitive acid blocker released in Japan in 2015. In order to shed some comparative light regarding the outcomes of gastric mucosal lesions associated with a long-term acid blockade, we have reviewed six representative gastric mucosal lesions: fundic gland polyps, gastric hyperplastic polyps, multiple white and flat elevated lesions, cobblestone-like gastric mucosal changes, gastric black spots, and stardust gastric mucosal changes. For these mucosal lesions, we have evaluated the association with the type of acid blockade, patient gender, Helicobacter pylori infection status, the degree of gastric atrophy, and serum gastrin levels. There is no concrete evidence to support a significant relationship between VPZ/PPI use and the development of neuroendocrine tumors. Current data also shows that the risk of gastric mucosal changes is similar for long-term VPZ and PPI use. Serum hypergastrinemia is not correlated with the development of some gastric mucosal lesions. Therefore, serum gastrin level is unhelpful for risk estimation and for decision-making relating to the cessation of these drugs in routine clinical practice. Given the confounding potential neoplastic risk relating to H. pylori infection, this should be eradicated before VPZ/PPI therapy is commenced. The evidence to date does not support the cessation of clinically appropriate VPZ/PPI therapy solely because of the presence of these associated gastric mucosal lesions.

Technical review of endoscopic ultrasound-guided drainage/anastomosis and trans-endosonographically created route procedures for the treatment of pancreatic diseases

Endoscopic ultrasound (EUS)-guided pancreatic duct drainage includes two procedures: EUS-guided drainage/anastomosis (EUS-D/A) and trans-papillary drainage with EUS-assisted pancreatic rendezvous. EUS-guided pancreatogastrostomy is the most common EUS-D/A procedure and is recommended as a salvage procedure in cases in which endoscopic retrograde cholangiopancreatography fails or is difficult. However, initial EUS-D/A is performed in patients with surgically altered anatomy at our institution. It is one of the most difficult interventional EUS procedures and has a high incidence of adverse events. The technical difficulties differ according to etiology, and the incidence of adverse events varies between initial EUS-D/A and subsequent trans-endosonographically/EUS-guided created route procedures. Hence, it is important to meticulously prepare a procedure based on the patient's condition and the available devices. The technical difficulties in EUS-D/A include: (1) determination of the puncture point, (2) selection of a puncture needle and guidewire, (3) guidewire manipulation, and (4) dilation of the puncture route and stenting. Proper technical procedures are important to increase the success rate and reduce the incidence and severity of adverse events. The complexity of EUS-D/A is also contingent on the severity of pancreatic fibrosis and stricture. In post-pancreatectomy cases, determination of the puncture site is important for success because of the remnant pancreas. Trans-endosonographically/EUS-guided created route procedures following initial EUS-D/A are also important for achieving the treatment goal. This article focuses on effective strategies for initial EUS-D/A, based on the etiology and condition of the pancreas. We mainly discuss EUS-D/A, including its indications, techniques, and success-enhancing strategies.

Impact of advanced endoscopy training on colonoscopy quality and efficiency

Objectives

Few reports have detailed improvements in the quality of colonoscopies with continuous training post-fellowship completion. We examined the changes in colonoscopy performance among trainees during our advanced endoscopy training program.

Methods

Screening or surveillance colonoscopies performed by 11 trainees who participated in our 3-year advanced endoscopy training program between April 2015 and March 2020 were retrospectively analyzed. Quality and efficiency metrics of colonoscopies were evaluated annually.

Results

Altogether, 297, 385, and 438 colonoscopies were enrolled in the first, second, and third training years, respectively. The mean insertion times were 8.6, 7.6, and 6.9 min in the first, second, and third training years, respectively, with significant improvement from the first to second year (p = 0.03) and from the first to third year (p < 0.01). The adenoma detection rate, proximal adenoma detection rate, and mean number of adenomas per patient exhibited a tendency to improve annually; however, the difference was not significant. Polypectomy efficiency was 10.5%, 11.2%, and 13.0%, with significant improvements from the first to third year (p < 0.01) and from the second to third year (p = 0.02). Insertion time and polypectomy efficiency showed significant improvements, especially among trainees experienced with <500 colonoscopies.

Conclusions

Through our advanced endoscopy training program, there has been an improvement in the quality and efficiency of colonoscopy for trainees who have completed their fellowships, particularly those with <500 colonoscopies.

Lumen-apposing metal stents provide early and late clinical benefits for the management of benign gastrointestinal strictures: Is there a role for definitive therapy?

Objectives

This study aimed to characterize the clinical outcomes, safety, and efficacy of lumen-apposing metal stents (LAMS) in treating benign gastrointestinal strictures.

Methods

A single-center retrospective review of all patients who underwent LAMS placement for benign strictures from June 2017 to July 2023. Primary outcomes were technical success, early clinical success, late clinical success (LCS), and sustained post-LAMS clinical success (SPLCS). Secondary outcomes included stent dwell time, stenosis changes, adverse events, reintervention rates, and symptomatology evaluation.

Results

Thirty-five patients underwent placement of 42 LAMS (74% female, mean age: 54.2 ± 11.7 years). Anastomotic strictures accounted for 64% of cases (N = 27, 45% at the gastrojejunal anastomosis). The median STD was 91.0 days (interquartile range [IQR]: 55.0-132.0). Technical success was obtained in all cases. Early clinical successand LCS were achieved in 80% of cases overall. SPLCS was achieved in 45% (n = 15) of cases. The overall reintervention rate was 63%, with a median time to reintervention being 50.5 days (IQR: 24-105). adverse events occurred in 28% (n = 12) overall, with a 24% migration rate (n = 10). Follow-up was completed in 83% of cases with a median duration of 629 days (range: 192.0-1297.0). Overall symptom improvement occurred in 79% (n = 27) during indwelling LAMS versus 58% and 56% at 30- and 60-days post-removal, respectively.

Conclusions

LAMS for benign gastrointestinal strictures are associated with high technical and early clinical success/LCS rates, positive quality-of-life metrics, and a tolerable adverse event rate. Overall, recurrence of symptoms and high reintervention rates post-LAMS removal reinforce the difficulty in managing benign gastrointestinal strictures but also argue for LAMS as a definitive therapy in select cases.

Visibility of esophageal squamous cell carcinoma under iodine staining on texture and color enhancement imaging

Objective

Iodine staining on white light imaging (WLI) is the gold standard for detecting and demarcating esophageal squamous cell carcinoma (ESCC). We examined the effects of texture and color enhancement imaging (TXI) on improving the endoscopic visibility of ESCC under iodine staining.

Methods

Twenty ESCC lesions that underwent endoscopic submucosal dissection were retrospectively included. The color difference between ESCC and the surrounding mucosa (ΔEe) on WLI, TXI, and narrow-band imaging was assessed, and ΔEe under 1% iodine staining on WLI and TXI. Furthermore, the visibility grade determined by endoscopists was evaluated on each imaging.

Result

The median ΔEe was greater on TXI than on WLI (14.53 vs. 10.71, respectively; p < 0.005). Moreover, the median ΔEe on TXI under iodine staining was greater than the median ΔEe on TXI and narrow-band imaging (39.20 vs. 14.53 vs. 16.42, respectively; p < 0.005 for both). A positive correlation in ΔEe under iodine staining was found between TXI and WLI (correlation coefficient = 0.61, p < 0.01). Moreover, ΔEe under iodine staining on TXI in each lesion was greater than the corresponding ΔEe on WLI. The visibility grade assessed by endoscopists on TXI was also significantly greater than that on WLI under iodine staining (p < 0.01).

Conclusions

The visibility of ESCC after iodine staining was greater on TXI than on WLI.

Gender disparities and woman-specific trends in Barrett’s esophagus in the United States: An 11-year nationwide population-based study

BACKGROUND

Barrett's esophagus (BE) is a known premalignant precursor to esophageal adenocarcinoma (EAC). The prevalence rates continue to rise in the United States, but many patients who are at risk of EAC are not screened. Current practice guidelines include male gender as a predisposing factor for BE and EAC. The population-based clinical evidence regarding female gender remains limited.

AIM

To study comparative trends of gender disparities in patients with BE in the United States.

METHODS

A nationwide retrospective study was conducted using the 2009-2019 National Inpatient Sample (NIS) database. Patients with a primary or secondary diagnosis code of BE were identified. The major outcome of interest was determining the gender disparities in patients with BE. Trend analysis for respective outcomes for females was also reported to ascertain any time-based shifts.

RESULTS

We identified 1204190 patients with BE for the study period. Among the included patients, 717439 (59.6%) were men and 486751 (40.4%) were women. The mean age was higher in women than in men (67.1 ± 0.4 vs 66.6 ± 0.3 years, P < 0.001). The rate of BE per 100000 total NIS hospitalizations for males increased from 144.6 in 2009 to 213.4 in 2019 (P < 0.001). The rate for females increased from 96.8 in 2009 to 148.7 in 2019 (P < 0.001). There was a higher frequency of obesity among women compared to men (17.4% vs 12.6%, P < 0.001). Obesity prevalence among females increased from 12.3% in 2009 to 21.9% in 2019 (P < 0.001). A lower prevalence of smoking was noted in women than in men (20.8% vs 35.7%, P < 0.001). However, trend analysis showed an increasing prevalence of smoking among women, from 12.9% in 2009 to 30.7% in 2019 (P < 0.001). Additionally, there was a lower prevalence of alcohol abuse, Helicobacter pylori (H. pylori), and diabetes mellitus among females than males (P < 0.001). Trend analysis showed an increasing prevalence of alcohol use disorder and a decreasing prevalence of H. pylori and diabetes mellitus among women (P < 0.001).

CONCLUSION

The prevalence of BE among women has steadily increased from 2009 to 2019. The existing knowledge concerning BE development has historically focused on men, but our findings show that the risk in women is not insignificant.

Clinical treatment strategy and follow-up of lymphoepithelioma-like carcinoma: a retrospective study

Aim: To investigate the clinical features, diagnosis and treatment of lymphoepithelioma-like carcinoma (LELC).Materials & methods: The clinical data of 114 LELC patients were retrospectively analyzed.Results: Ninety-eight patients (86.0%) were Epstein-Barr virus-encoded small RNA (EBER) positive detected by situ hybridization. A 67.1% (51/76) patients had PD-L1 expression. The 5-year overall survival rate of EBER negative patients was 51.6% while the rate of positive patients was 84.8% (p = 0.015). The 5-year progression free survival rate of EBER negative patients was 40.2% while the rate of positive patients was 70.2% (p = 0.004).Conclusion: The progression of LELC is relatively slow and present a better prognosis. The occurrence of tumor is closely related to Epstein-Barr virus infection and PD-L1 is highly expressed in tumor cells.

Characteristics and prognosis of small bowel tumors: A retrospective study

BACKGROUND

Small bowel tumors (SBTs) are a heterogeneous group of difficult-to-diagnose tumors that account for 2%-5% of all gastrointestinal tumors. Single-balloon enteroscopy greatly enhances the diagnosis and treatment of SBTs. However, few epidemiological studies have been conducted in Taiwan to determine the clinical profile of SBTs.

AIM

To investigate the clinical characteristics, managements and prognosis of SBTs in a medical center in Taiwan.

METHODS

The study enrolled 51 patients aged 58.9 ± 8.8 years (range, 22-93) diagnosed with SBTs from November 2009 to July 2021. We retrospectively recorded clinical characteristics, indications, endoscopic findings, pathological results, management, and outcomes for further analysis.

RESULTS

A male preponderance was observed (56.8%). The most common indications were suspected small intestinal tumors (52.9%) and obscure gastrointestinal bleeding (39.2%). The most common tumor location was the ileum (41.2%). The performance of imaging studies (P = 0.004) and the types of findings (P = 0.005) differed significantly between malignant and benign SBTs. The most frequent imaging finding was a small intestinal mass (43.1%). The top three malignant tumor types were gastrointestinal stromal tumors (GISTs), adenocarcinomas, and lymphomas. Moreover, the proportions of benign and malignant tumors were 27.5% and 72.5%, respectively. The survival rates of patients with malignant tumors in the GIST and non-GIST groups differed significantly (P = 0.015). Kaplan–Meier survival analysis showed a significant difference in survival between patients in the malignant and benign groups (P = 0.04). All patients with lymphoma underwent chemotherapy (n = 7/8, 87.5%), whereas most patients with GISTs underwent surgery (n = 13/14, 92.8%).

CONCLUSION

Patients with GISTs have a significantly higher survival rate than those with other malignant SBTs. Therefore, a large-scale nationwide study is warranted to evaluate the population-based epidemiology of SBTs.

Is reoperation required for patients presenting with hepatic portal venous gas after gastrointestinal surgery: a review of the literature

BACKGROUND AND OBJECTIVE

Hepatic portal venous gas(HPVG) represents a rare radiographic phenomenon frequently linked to intestinal necrosis, historically deemed to need immediate surgical intervention. The pivotal query arises about the imperative of urgent surgery when a patient manifests HPVG after gastrointestinal surgery. This inquiry seeks to elucidate whether emergent surgical measures remain a requisite in such cases.

METHODS

The investigation into 14 cases of HPVG after gastrointestinal procedures was conducted through a comprehensive review of relevant literature. This methodological approach contributes to a nuanced understanding of HPVG occurrences following gastrointestinal surgery, informing clinical considerations and potential therapeutic strategies.

RESULTS

Among the 14 patients, 12 recovered and 2 died. 6 patients underwent surgical exploration, 4 with negative findings and recovered. 8 cases received conservative treatment, resulting in improvement for 5, and 1 initially treated conservatively, revealed perforation during later surgical exploration, leading to improvement, 1 case ended in mortality.

CONCLUSION

After gastrointestinal surgery, in Computed Tomography (CT) imaging, the coexistence of HPVG and gastrointestinal dilatation, without signs of peritoneal irritation on abdominal examination, may suggest HPVG due to acute gastrointestinal injury, intestinal gas, and displacement of gas-producing bacteria. These patients can be managed conservatively under close supervision. In cases where HPVG coexists with gastrointestinal dilatation and Pneumatosis intestinalis (PI) without signs of peritoneal irritation, conservative treatment may be continued under close supervision. However, if progressive exacerbation occurs despite close monitoring and the aforementioned treatments, timely surgical exploration is deemed necessary. When HPVG is combined with signs of peritoneal irritation, prompt laparotomy and exploration are preferred.

From static web to metaverse: reinventing medical education in the post-pandemic era

The World Wide Web and the advancement of computer technology in the 1960s and 1990s respectively set the ground for a substantial and simultaneous change in many facets of our life, including medicine, health care, and medical education. The traditional didactic approach has shifted towards more dynamic and interactive methods, leveraging technologies such as simulation tools, virtual reality, and online platforms. At the forefront is the remarkable evolution that has revolutionized how medical knowledge is accessed, disseminated, and integrated into pedagogical practices. The COVID-19 pandemic also led to rapid and large-scale adoption of e-learning and digital resources in medical education because of widespread lockdowns, social distancing measures, and the closure of medical schools and healthcare training programs. This review paper examines the evolution of medical education from the Flexnerian era to the modern digital age, closely examining the influence of the evolving WWW and its shift from Education 1.0 to Education 4.0. This evolution has been further accentuated by the transition from the static landscapes of Web 2D to the immersive realms of Web 3D, especially considering the growing notion of the metaverse. The application of the metaverse is an interconnected, virtual shared space that includes virtual reality (VR), augmented reality (AR), and mixed reality (MR) to create a fertile ground for simulation-based training, collaborative learning, and experiential skill acquisition for competency development. This review includes the multifaceted applications of the metaverse in medical education, outlining both its benefits and challenges. Through insightful case studies and examples, it highlights the innovative potential of the metaverse as a platform for immersive learning experiences. Moreover, the review addresses the role of emerging technologies in shaping the post-pandemic future of medical education, ultimately culminating in a series of recommendations tailored for medical institutions aiming to successfully capitalize on revolutionary changes.

Biofunctional coatings and drug-coated stents for restenosis therapy

Palliative therapy utilizing interventional stents, such as vascular stents, biliary stents, esophageal stents, and other stents, has been a prevalent clinical strategy for treating duct narrowing and partial blockage. However, stent restenosis after implantation usually significantly compromises therapeutic efficacy and patient safety. Clinically, vascular stent restenosis is primarily attributed to endothelial hyperplasia and coagulation, while the risk of biliary stent occlusion is heightened by bacterial adhesion and bile sludge accumulation. Similarly, granulation tissue hyperplasia leads to tracheal stent restenosis. To address these issues, surface modifications of stents are extensively adopted as effective strategies to reduce the probability of restenosis and extend their functional lifespan. Applying coatings is one of the technical routes involving a complex selection of materials, drug loading capacities, release rates, and other factors. This paper provides an extensive overview of state of the art drug-coated stents, addressing both challenges and future prospects in this domain. We aim to contribute positively to the ongoing development and potential clinical applications of drug-coated stents in interventional therapy.

Comparison of postoperative prognoses for resectable colorectal cancer with vs. without oncologic emergency using propensity score‑matched analyses: A single-center retrospective observational study

While oncological emergencies in colorectal cancer present distinct challenges, existing literature offers conflicting evidence regarding long-term outcomes. Therefore, the present study compared the postoperative prognoses between patients with and without oncological emergencies. A retrospective evaluation was conducted on patients who had undergone radical surgery for pathological stages II and III colorectal cancer at a single center between January 2012 and December 2020. Patients were classified into the non-emergency and oncological emergency groups. The status of oncologic emergency was divided into obstruction and perforation. The outcomes were compared using propensity score matching. The primary objective was to compare the postoperative prognoses between non-emergency and oncological emergency situations. The secondary objectives included comparing prognoses between obstruction and perforation, identifying the type of recurrence depending on the status of oncologic emergency, and assessing the effect of adjuvant chemotherapy for oncologic emergencies. This study included 524 patients. After propensity score matching, the prognoses of oncological emergencies were worse compared with those without any emergency, whereas those of obstruction and perforation did not significantly differ. Regarding the type of recurrence, peritoneal dissemination in obstruction and local recurrence in perforation was more common compared with that in non-emergency cases. Adjuvant chemotherapy improved the recurrence-free survival for cases with oncological emergencies. The prognoses in cases with oncological emergencies could be worse compared with those without any emergency, whereas obstruction and perforation outcomes can be comparable. The administration of adjuvant chemotherapy should be strongly considered for oncological emergencies.

Characterization of biliary and duodenal microbiota in patients with primary and recurrent choledocholithiasis

Purpose

To explore the biliary and duodenal microbiota features associated with the formation and recurrence of choledocholithiasis (CDL).

Methods

We prospectively recruited patients with primary (P-CDL, n = 29) and recurrent CDL (R-CDL, n = 27) for endoscopic retrograde cholangiopancreatography (ERCP). Duodenal mucosa (DM), bile and bile duct stones (BDS) samples were collected in P- and R-CDL patients. DM samples were also collected in 8 healthy controls (HC). The microbiota profile analysis was performed with 16S rRNA gene sequencing.

Results

Short-course antibiotic application before ERCP showed no significant effects in alpha and beta diversities of the biliary and duodenal microbiota in CDL. Alpha diversity showed no difference between DM and bile samples in CDL. The duodenal microbial richness and diversity was lower in both P- and R-CDL than HC. The biliary microbiota composition showed a high similarity between P- and R-CDL. Fusobacterium and Enterococcus were higher abundant in DM, bile, and BDS samples of R-CDL than P-CDL, as well as Escherichia and Klebsiella in bile samples of R-CDL. The enriched duodenal and biliary bacteria in CDL were closely associated with cholecystectomy, inflammation and liver dysfunction. The bile-associated microbiota of R-CDL expressed enhanced capacity of D-glucuronide and D-glucuronate degradation, implicating an elevated level of β-glucuronidase probably produced by enriched Escherichia and Klebsiella in bile.

Conclusions

The duodenal microbiota was in an imbalance in CDL. The duodenal microbiota was probably the main source of the biliary microbiota and was closely related to CDL formation and recurrence. Enterococcus, Fusobacterium, Escherichia and Klebsiella might contribute to CDL recurrence.

Clinical trials

The study was registered at the Chinese Clinical Trial Registry (https://www.chictr.org.cn/index.html, ChiCTR2000033940).

Supplementary Information

The online version contains supplementary material available at 10.1007/s13755-023-00267-2.

Biliary stents for active materials and surface modification: Recent advances and future perspectives

Demand for biliary stents has expanded with the increasing incidence of biliary disease. The implantation of plastic or self-expandable metal stents can be an effective treatment for biliary strictures. However, these stents are nondegradable and prone to restenosis. Surgical removal or replacement of the nondegradable stents is necessary in cases of disease resolution or restenosis. To overcome these shortcomings, improvements were made to the materials and surfaces used for the stents. First, this paper reviews the advantages and limitations of nondegradable stents. Second, emphasis is placed on biodegradable polymer and biodegradable metal stents, along with functional coatings. This also encompasses tissue engineering & 3D-printed stents were highlighted. Finally, the future perspectives of biliary stents, including pro-epithelialization coatings, multifunctional coated stents, biodegradable shape memory stents, and 4D bioprinting, were discussed.

Foregut tuberculosis: Too close but miles apart

The worldwide burden of tuberculosis (TB) has increased and it can involve virtually any organ of the body. Intestinal TB accounts for about 2% of the cases of TB worldwide. The ileocecal region is the most commonly affected site, and the foregut is rarely involved. The reported incidence is approximately 0.5%. Esophageal TB presents with dysphagia, weight loss, and hematemesis in rare cases. Gastroduodenal TB usually manifests with symptoms such as nausea, vomiting, weight loss, and sometimes with gastric outlet obstruction. Gastroscopy may reveal shallow ulcers in stomach and duodenal deformity when underlying TB is suspected, therefore histopathology plays pivotal role. On computed tomography, duodenal TB typically manifests as duodenal strictures predominantly, accompanied by extrinsic compression, and occasionally as intraluminal mass. But their diagnosis can easily be missed if proper biopsies are not taken and samples are not sent for GeneXpert testing, TB polymerase chain reaction investigation and histopathological analysis. Despite being in close proximity to the lungs, the esophagus and stomach are rare sites of TB. The reasons could be low gastric pH and acidity which does not let mycobacterium grow. But there are various case reports of TB involving the foregut. We have summarized the rare cases of foregut TB in different sections and highlighted the importance of esophagogastroduodenoscopy, histopathology and advanced techniques like endoscopic ultrasound in establishing the diagnosis.

Confocal Laser Endomicroscopy as a method for assessing endometriosis: A pilot study

OBJECTIVES

To validate probe-based Confocal Laser Endomicroscopy (pCLE) as a method in assessing endometriosis during conventional and robot-assisted laparoscopy.

STUDY DESIGN

Pilot study, including five women in Hospital Moriah, São Paulo, Brazil. During laparoscopic procedures, pCLE was used to assess endometriosis lesions, complemented by subsequent histological evaluations. 214 optical biopsies were performed. These assessments contributed to the development of a comparative atlas, which was used by surgeons to respond to a questionnaire to identify specific cellular structures related to endometriosis in selected confocal images.

RESULTS

The patients had an average age of 35, exhibiting predominant symptoms like dysmenorrhea and dyspareunia. Despite varied familiarity with pCLE, surgeons demonstrated positive acceptance of the method, with 63.1% recommending its use for intraoperative diagnosis. The technique was particularly noted for its ability to provide real-time, detailed images aiding the identification of endometriosis and associated structures like adipocytes and vascularization, with average evaluation scores exceeding 8 of 10.

CONCLUSIONS

This study underscores pCLE's potential as a transformative diagnostic tool in minimally invasive gynecological surgery. It highlights the feasibility and initial acceptance among surgeons, emphasizing the need for further improvements in device durability and cost-effectiveness. pCLE promises significant advancements in the diagnosis and management of endometriosis, suggesting a future direction for clinical applications and technological refinement.

Comparing oxygen therapies for hypoxemia prevention during gastrointestinal endoscopy under procedural sedation: A systematic review and network meta-analysis

STUDY OBJECTIVE

Hypoxemia is the most frequent adverse event observed during gastrointestinal endoscopy under procedural sedation. An optimum oxygen therapy has still not been conclusively determined.

DESIGN

A systematic review and network meta-analysis of randomized clinical trials.

SETTING

Digestive Endoscopy Center.

PATIENTS

Adults (≥18 years old and of both sexes) during gastrointestinal endoscopy under procedural sedation.

INTERVENTIONS

Pubmed, MEDLINE, Web of Science, Embase, and Clinicaltrials.gov. were searched until June 30, 2023. Randomized clinical trials (RCTs) comparing any oxygen therapy with another oxygen therapy or with placebo (nasal cannula, NC) were included.

MEASUREMENT

The primary outcome was the incidence of hypoxemia, defined as the pulse oxygen saturation (SpO2). Random-effects network meta-analyses were performed. Data are reported as odds ratios (OR), prediction intervals (PrI) and 95% CI. Bias risk was evaluated following the guidelines outlined by the Cochrane Collaboration. The quality of evidence was evaluated through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

MAIN RESULTS

We included 27 RCTs with a total of 7552 patients. Compared to the use of NC, non-invasive positive pressure ventilation (NIPPV) demonstrated superior efficacy in mitigating hypoxemia (NIPPV vs. NC, OR = 0.16, 95% CI: 0.08-0.31, 95% PrI: 0.06-0.41), followed by Wei nasal jet tube (WNJT) (WNJT vs. NC, OR = 0.17, 95% CI: 0.10-0.30, 95% PrI: 0.07-0.42). The efficacy for preventing hypoxemia was ranked as follows: NIPPV > WNJT > oropharynx/nasopharyngeal catheter > high-flow nasal oxygenation > nasal mask > NC.

CONCLUSIONS

During gastrointestinal endoscopy under procedural sedation, all other advanced oxygen therapies were found to be more efficacious than nasal cannula. NIPPV and WNJT appear to be the most efficacious oxygen therapy for preventing hypoxemia. Additionally, clinicians should make a choice regarding the most suitable oxygen therapy based on the risk population, type of endoscopy and adverse events.

Patients with cardinal symptoms of eosinophilic esophagitis. Prejudice affects clinical practice…

INTRODUCTION

Dysphagia and bolus impaction are the cardinal manifestations of eosinophilic esophagitis (EoE). Esophageal biopsy sampling is mandatory for EoE diagnosis, data though suggest that clinician do not always obtain biopsies from patients with cardinal EoE symptoms during upper gastrointestinal endoscopy even if no other entity than EoE can explain patients symptoms. We aimed to search for the esophageal biopsy procurement rate as also for factors that drive clinicians to obtain esophageal biopsies among patients with cardinal EoE symptoms.

METHODS

We retrospectively searched for patients with cardinal EoE symptoms submitted to upper gastrointestinal endoscopy between 1/2018 and 12/2023 in our department. Epidemiologic, clinical, endoscopic, and histological data were analyzed.

RESULTS

In total 163 patients with cardinal EoE symptoms (dysphagia: 63 and bolus impaction: 100) were included in the study (M/F: 100/63, mean age: 54 ± 22 years). Biopsy sampling was obtained in 77/163 (47.2%) patients and sampling rates did not differ between patients with bolus impaction or dysphagia (47/100, 47% vs 30/63, 47.6%, P  = 0.553). Higher rates of sampling were observed in males ( P  = 0.045), those younger than 65 years old ( P  < 0.001) and patients with endoscopic EoE signs ( P  = 0.004). Age and endoscopic findings compatible to EoE were independently correlated to biopsy sampling. EoE was diagnosed in 35/74 patients (47.3%); the majority of patients were male, with a bolus impaction episode, compatible endoscopic findings and all were younger than 65 years old.

CONCLUSION

Clinicians take esophageal biopsies in half of patients with cardinal EoE. Age and supportive endoscopic evidence drive clinicians' decision to obtain esophageal biopsies.

The additive diagnostic value of cytology in fine needle biopsy of pancreatic adenocarcinoma: A tertiary center experience

OBJECTIVE

Endoscopic ultrasound guide fine needle biopsy (EUS-FNB) is the main diagnostic tool for pancreatic adenocarcinoma. In most instances, only histology is obtained via FNB, without sending cytological slides. The aim of our study was to assess the additive diagnostic yield of cytology performed through FNB.

METHODS

We conducted a retrospective study of all patients with histological diagnosis of pancreatic adenocarcinoma who were diagnosed by EUS-FNB.

RESULTS

Overall, 80 patients were included in the study period. The overall concordance between cytology and histology all FNB needles was 78.2%. Notably, cytological assessment improved the diagnostic yield for malignancy by 12.8%. The overall kappa coefficient correlation between histology and cytology was .501, 95% CI 0.361-0.641. However, the kappa correlation for suspicious of malignancy and malignant was excellent of .872, 95% CI 0.733-1, suggesting that cytology is crucial when histology is inconclusive. Further analysis showed that the Acquire and Sharkcore needles outperformed the Procore needle in term of concordance between cytology and histology (kappa correlation of .527, 95% CI 0.331-0.724, .515, 95% CI 0.265-0.764, and .297, 95% CI -0.051-0.646), respectively.

CONCLUSION

Performing cytology specimen when using FNB improves the diagnostic yield in pancreatic adenocarcinoma.

Magnetic compression anastomosis gastrojejunostomy: feasibility and efficacy of a novel device in a swine model

BACKGROUND

Means of addressing technical challenges in forming gastrojejunostomy (GJ) anastomoses and maintaining their patency are sought.

OBJECTIVES

Evaluation of preclinical feasibility and healing efficacy of a novel linear magnetic compression anastomosis (MCA) device to form a patent GJ versus sutured jejunal enterotomy (JE) sites in swine.

SETTING

Single-center veterinary testing facility.

METHODS

Feasibility of 3 prototype sizes (4, 6, and 8 cm) of a metal MCA device (MCAD) to form a patent GJ was evaluated over 6 weeks. A distal magnet was laparoscopically inserted in the jejunum, a proximal magnet was placed gastroscopically in the stomach; magnets were aligned to gradually form an anastomosis, self-detached, and be expelled. At necropsy, MCAs were assessed for patency and compared with JE tissues to evaluate wound healing.

RESULTS

MCADs aligned at the GJ location without complications. In 5/6 MCAD pairs, dislodgement occurred between 7 and 26 days; expulsion 13-31 days; 1 MCAD pair was retained in the stomach. At necropsy, all pigs were healthy, gaining a mean 15.0 kg. Anastomoses were not adequately patent in 2/4 pigs receiving the 4-cm or 6-cm MCADs because their linear length was too small. But, anastomoses of both pigs receiving the 8-cm MCADs maintained full patency. Minimal inflammation and fibrosis were seen in MCA specimens versus sutured enterotomies.

CONCLUSIONS

A novel linear MCA device was feasible and effectively created a patent GJ anastomosis in swine with minimal inflammation and fibrosis. The MCAD may be appropriate for clinical evaluation.

Endoscopic Management of Iatrogenic Perforations

The evolution of sophisticated technology has brought about the rise of endoscopic strategies for managing iatrogenic esophageal perforation. This approach is reserved for stable patients with limited contamination. The most commonly performed procedures are reviewed, focusing on procedural steps and outcomes. Esophageal stenting remains the most widely implemented strategy with promising success rates. Clipping, endoluminal vacuum therapy, and suturing are also viable options. Patient selection and further study are paramount to establishing this less invasive strategy as a more standard approach.

The association between bilirubin concentrations and inflammatory bowel disease: Insights from a systematic review and meta-analysis

BACKGROUND

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), poses a significant challenge to health care systems because of its chronic nature and increasing global prevalence. Effective management of IBD requires accurate diagnostic tools and biomarkers. This systematic review and meta-analysis aimed to evaluate the relationship between bilirubin concentrations and IBD activity and outcomes.

METHODS

A comprehensive search of electronic databases identified 11 studies that included 2606 subjects with IBD and 3607 healthy controls.

RESULTS

Bilirubin concentrations were significantly lower in subjects with IBD when compared to controls (SMD = -0.96, 95% CI -1.21 to -0.70; p < .001). Although substantial heterogeneity was observed, sensitivity analysis confirmed the robustness of the results. Publication bias was detected, but subgroup analyses did not significantly alter the results. Meta-regression showed that age was a significant factor influencing the association between bilirubin concentrations and IBD. Subgroup analyses showed a more pronounced reduction in bilirubin concentrations in subjects with CD than those with UC.

CONCLUSION

This study supports the potential utility of bilirubin as a biomarker in IBD, emphasizing the need for further research to validate its clinical significance.

Single incision laparoscopic surgery for hepatocellular carcinoma

Single incision laparoscopic liver resection (SILLR) is the most recent development in the laparoscopic approach to the liver. SILLR for hepatocellular carcinoma (HCC) has developed much more slowly than multiport LLR. So far, 195 patients completed SILLR for HCC. In this paper, we reviewed all published papers about SILLR for HCC and discussed the feasibility of the SILLR, peri and postoperative findings, tricks of patient selection and whether SILLR compromise the oncological principles.

AGA Clinical Practice Update on Esophageal Dysfunction Due to Disordered Immunity and Infection: Expert Review

METHODS

This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Since systematic reviews were not performed, these BPA statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations.

DESCRIPTION

Infectious and immune-mediated esophageal disorders are poorly understood and often under-diagnosed conditions that lead to esophageal dysfunction and health care costs due to repeated procedures and a lack of understanding of their etiology and pathogenesis. Without a high index of suspicion, these disorders may be overlooked. Esophageal dysfunction may arise from active, localized infection and immune-mediated disease (ie, candida, etc.) or from an organ-specific manifestation of a more diffuse immune-mediated disease or infection (ie, systemic sclerosis, connective tissue disease, neurologic disease). These conditions can sometimes lead to neuromuscular dysfunction and subsequent esophageal dysmotility. Awareness of local and systemic processes that lead to esophageal dysfunction will improve patient outcomes by focusing therapeutics and limiting unnecessary procedures. Therefore, the purpose of this AGA Clinical Practice Update Expert Review is to provide BPA on diagnostic considerations of immune-mediated disorders that should be considered when encountering patients with dysphagia, heartburn, and odynophagia. Best Practice Advice Statements: BEST PRACTICE ADVICE 1: Gastroenterologists should be aware of the esophageal manifestations of systemic immunologic and infectious diseases to reduce diagnostic delay. Clinicians should identify if there are risks for inflammatory or infectious possibilities for a patient's esophageal symptoms and investigate for these disorders as a potential cause of esophageal dysfunction. BEST PRACTICE ADVICE 2: Once esophageal infection is identified, clinicians should identify whether accompanying signs/symptoms suggest immunocompromise leading to a more systemic infection. Consultation with an infectious disease expert will aid in guiding appropriate treatment. BEST PRACTICE ADVICE 3: If symptoms do not improve after therapy for infectious esophagitis, evaluation for refractory infection or additional underlying sources of esophageal and immunologic dysfunction should be performed. BEST PRACTICE ADVICE 4: In individuals with eosinophilic esophagitis (EoE) who continue to experience symptoms of esophageal dysfunction despite histologic and endoscopic disease remission, clinicians should be aware that some patients with EoE may develop motility disorders. Further evaluation of esophageal motility may be warranted. BEST PRACTICE ADVICE 5: In individuals with histologic and endoscopic features of lymphocytic esophagitis, clinicians should consider treatment of lymphocytic-related inflammation with proton-pump inhibitor therapy or swallowed topical corticosteroids and as needed esophageal dilation. BEST PRACTICE ADVICE 6: In patients who present with esophageal symptoms in the setting of hypereosinophilia (absolute eosinophil count [AEC] >1500 cells/uL), consider further work-up of non-EoE eosinophilic gastrointestinal (GI) disease, hypereosinophilic syndrome, and eosinophilic granulomatosis with polyangiitis (EGPA). Consultation with allergy/immunology may help guide further diagnostic work-up and treatment. BEST PRACTICE ADVICE 7: In individuals with rheumatologic diseases of systemic sclerosis (SSc), mixed connective tissue disease (MCTD), systemic lupus erythematosus (SLE), or Sjogren's disease, clinicians should be aware that esophageal symptoms can occur due to involvement of the esophageal muscle layer, resulting in dysmotility and/or incompetence of the lower esophageal sphincter. The degree of dysfunction is often especially significant in those with SSc or MCTD. BEST PRACTICE ADVICE 8: In individuals with Crohn's disease, clinicians should be aware that a minority of individuals can develop esophageal involvement from inflammatory, stricturing, or fistulizing changes with granulomas seen histologically. Esophageal manifestations of Crohn's disease tend to occur in individuals with active intestinal disease. BEST PRACTICE ADVICE 9: In individuals with dermatologic diseases of lichen planus or bullous disorders, clinicians should be aware that dysphagia can occur due to endoscopically visible esophageal mucosal involvement. Esophageal lichen planus, in particular, can occur without skin involvement and can be difficult to define on esophageal histopathology. BEST PRACTICE ADVICE 10: Clinicians should consider infectious and inflammatory causes of secondary achalasia during initial evaluation. One should query for any history of recent COVID infections, risks for Chagas disease, and symptoms or signs of eosinophilic disease.

Has the cat got your tongue, or is something obstructing your throat? A review of imaging of ingested and aspirated foreign bodies in the paediatric population

Children frequently swallow or inhale foreign objects, a situation that can be life-threatening. Radiographic imaging plays a lead role in the early identification and location of inhaled or swallowed objects is essential. Promptly identifying and locating inhaled or swallowed objects are essential, as some items require immediate removal. For example, button batteries in the throat can cause grave harm; magnets can attract each other through the gut and cause perforations; and other objects can obstruct the airway or intestinal tract. Radiologists must understand how these objects appear in images to assist doctors in treating patients effectively. Recognising signs of inhaled objects on radiographs is also crucial, as symptoms may not always be clear, and many inhaled objects are not visible on radiographs. Radiographs are the primary means of checking for swallowed or inhaled objects, although other tests like fluoroscopy and computed tomography may be used in complex cases. Doctors working with children should be acquainted with the appearance of these common objects on images and their clinical importance.

Endoscopic diagnosis and management of adult inflammatory bowel disease: a consensus document from the American Society for Gastrointestinal Endoscopy IBD Endoscopy Consensus Panel

Endoscopy plays a key role in diagnosis, monitoring of disease activity, assessment of treatment response, dysplasia surveillance, postoperative evaluation, and interventional therapy for patients with inflammatory bowel disease (IBD). Clinical practice patterns in the endoscopic management of IBD vary. A panel of experts consisting of IBD specialists, endoscopists, and GI pathologists participated in virtual conferences and developed this modified Delphi-based consensus document to address endoscopic aspects of IBD management.

Feasibility, safety and efficacy of endoscopic single-operator cholangioscopy: a retrospective single-center study

Background

Endoscopic retrograde cholangiopancreaticography (ERCP) is the standard endoscopic procedure for the diagnosis and treatment of diseases of the pancreas and bile ducts. Cholangioscopy provides direct visualization of the bile ducts. It offers the possibility of more detailed diagnostic and therapeutic indications. Today, cholangioscopy is often performed as a single-operator (SOC) procedure.

Objectives

We were interested in the clinical efficacy of our SOC procedure in comparison with published studies, and performed this retrospective data analysis of all our consecutive patients from 2016 to 2022 to analyze the feasibility, safety, and efficacy of SOC.

Design and Methods

A retrospective single-center analysis of patients undergoing SOC at a tertiary center from 2016 to 2022 (N = 196) was performed. Demographic data, indication for SOC, exam-specific data, efficacy, and complications were included. Sensitivity and specificity for diagnosing indeterminate biliary strictures were calculated.

Results

The most common indications for SOC were indeterminate biliary strictures (n = 117; 60%), treatment of biliary stones (n = 45; 23%), and other indications (n = 34; 17%), for example, foreign body removal or intraoperative SOC. In 97% of the SOC (n = 191), the procedure was technically successful. The diagnostic or therapeutic goal was achieved in 91% of SOC (n = 173). In the subgroup where the SOC result was confirmed by subsequent surgery (n = 93), sensitivity was 86%, specificity 99%, and SOC treatment of stones was successful in 89%. Complications occurred in (20%; n = 37). The majority of these patients (n = 18; 10%) had minor bleeding requiring no intervention.

Conclusion

SOC is an effective and safe procedure that should be the standard of care when primary diagnostic and/or therapeutic ERCP has failed. The sensitivity and specificity for determining the dignity of biliary strictures and the efficacy for the treatment of difficult-to-treat stones are reproducibly very high.

Association between acute tobacco exposure and fractional exhaled nitric oxide in patients with chronic obstructive pulmonary disease: National health and Nutrition Examination Survey (NHANES) 2007-2012

BACKGROUND

Fractional exhaled nitric oxide (FeNO) is a marker of type 2 airway inflammation. Tobacco exposure can lower FeNO levels. However, the effect of acute tobacco exposure on FeNO in patients with chronic obstructive pulmonary disease (COPD) is unclear. This study aimed to investigate the relationship of acute tobacco exposure with FeNO and eosinophils in COPD patients.

METHODS

This retrospective cohort study included 445 patients with COPD based on the 2007-2012 National Health and Nutrition Examination Survey. Serum cotinine levels were examined to assess environmental tobacco smoke exposure. The patients were divided into five groups based on cotinine levels: Q1 (first quintile), Q2 (second quintile), Q3 (third quintile), Q4 (fourth quintile) and Q5 (fifth quintile). Logistic regression models and linear logistic regression models were used to evaluate the relationship between serum cotinine and FeNO and EOS levels.

RESULTS

Approximately 16.5 % (75/445) of the participants had elevated FeNO (>25 bbp). In the unadjusted model, COPD patients with the lowest quintile of serum cotinine levels (0.011-0.0185 ng/mL) had higher FeNO levels compared to those with the highest quintile (≥309 ng/mL) (odds ratios (OR), 5.86 [2.11-16.20]). These findings remained consistent even after adjusting for covariates of demographics, lifestyle, diabetes, coronary heart disease, tumours, hypertension, using oral or inhaled steroids within 2 days, asthma and respiratory symptoms within 7 days. Furthermore, a standard deviation increase of ln-transformed cotinine levels was associated with decreased FeNO levels (OR, 0.45 [0.33, 0.60]). No significant correlation was observed betweenserum cotinine and blood eosinophils. After high extents of tobacco exposure, no correlation was found between FeNO and eosinophils. Our findings indicate that high cotinine levels are associated with decreased FeNO in COPD patients but not with blood eosinophils. This reveals that smoking may affect FeNO levels in patients with COPD, whereas it does not appear to influence blood eosinophil levels.

The efficacy and safety of remimazolam tosilate compared with propofol for endoscopic retrograde cholangiopancreatography under monitored anesthesia care: A single-center randomized controlled clinical trial

Background

Although remimazolam tosilate is an ultra-short-acting benzodiazepine that causes less respiratory and circulatory depression than propofol, studies evaluating its efficacy and safety during endoscopic retrograde cholangiopancreatography (ERCP) are limited. This study aimed to compare the efficacy and safety of remimazolam and propofol for ERCP performed under monitored anesthesia care (MAC).

Methods

This study is a randomized controlled clinical trial featuring a noninferiority design. A total of 102 eligible patients undergoing ERCP under MAC were randomly assigned to either the remimazolam tosilate group (R group) or the propofol group (P group) in a 1:1 ratio. Patients in the R group were sedated with remimazolam tosilate, while those in the P group received propofol, both under MAC. The primary efficacy endpoint was the success rate of ERCP completion under MAC. Secondary outcomes included the time to loss of consciousness, sedative effects, and perioperative adverse events at various time points for patients in both groups.

Results

Baseline characteristics of both groups were similar. The successful completion rate for ERCP under MAC was 100 % in the R group and 96.1 % in the P group, resulting in a difference of 3.92 % (95 % CI: -2%, 10 %). This difference met the pre-established criterion of being greater than -8%. The total number of norepinephrine infusions, as well as the incidence of intravenous injection pain, post-induction hypotension, post-induction bradycardia, intraoperative hypotension, respiratory depression, and hypoxemia, were significantly lower in the R group compared to the P group. Conversely, the total number of phloroglucinol uses, body movements, and instances of rapid gastrointestinal peristalsis were significantly higher in the R group than in the P group.

Discussion

Remimazolam-based MAC for ERCP exhibited non-inferior efficacy compared to propofol-based MAC, while also resulting in fewer circulatory and respiratory adverse events during the procedures. Nevertheless, future studies with larger sample sizes are required to evaluate the utility of remimazolam in elderly patients.

Incidental diagnosis of gastric antral vascular ectasia in a case of chronic kidney disease from Nepal: a case report

INTRODUCTION

Gastric antral vascular ectasia is an uncommon clinical disease that affects elder people and is characterized by severe chronic upper gastrointestinal bleeding mainly affecting the gastric antrum. It is generally unusual among patients undergoing maintenance hemodialysis for chronic kidney disease.

CASE PRESENTATION

Here, we aim to present an uncommon case of incidental diagnosis of the gastric antral vascular ectasia and erosive gastritis in a 71-year-old Hindu male patient belonging to the Gurung ethnicity of Nepal undergoing maintenance hemodialysis due to chronic kidney disease. The patient presented with a history of melena and fatigue. On investigation, a low hemoglobin level of 7.3 gm% was used for blood transfusion. The patient was on regular hemodialysis after admission at our institution. Upper gastrointestinal bleeding was suspected after analyzing patient's history and investigations. Therefore, an upper gastrointestinal endoscopy was performed that showed linear ectatic punctuate lesions radiating from the body of the stomach to the antrum, and hence, an incidental diagnosis of the gastric antral vascular ectasia was made. Initial fluid resuscitation, iron therapy, and a triple regimen were administered. Proper management with argon plasma coagulation therapy was scheduled at another institution due to lack of respective facilities in our institution.

DISCUSSION

Gastric antral vascular ectasia is an unusual cause of upper gastrointestinal bleeding, primarily affecting the gastric antrum and pylorus with rare cases affecting the duodenum, jejunum, and gastric fundus. It is generally associated with other chronic disease conditions. Several hypotheses have been proposed for the pathogenesis of gastric antral vascular ectasia, especially its association with chronic kidney disease, as in our case, which is considered to be rare. Management varies from medical to endoscopic interventions to even surgery.

CONCLUSION

Prompt proper diagnosis and treatment for the gastric antral vascular ectasia should be sought, as it is frequently misdiagnosed or missed during upper gastrointestinal endoscopy. Our case report presents a case of gastric antral vascular ectasia in chronic kidney disease undergoing maintenance hemodialysis, which is quite uncommon, as literature has suggested the same point.

Rectus sheath nerve block for analgesia & incarcerated hernia reduction in the emergency department

BACKGROUND

Patients who present to the emergency department (ED) with incarcerated or strangulated ventral hernias are often in significant pain. Furthermore, even with procedural sedation, reduction itself also causes substantial pain. Hernias that cannot be reduced at the bedside with intravenous opioids or procedural sedation will require emergent surgery, which contributes to morbidity and mortality, especially in high-risk populations.

CASE REPORT

We present the case of a 94-year-old man with an incarcerated ventral hernia that was reduced in the ED with the aid of a rectus sheath block, ultimately avoiding the need for emergent surgical intervention.

IMPLICATIONS

Ultrasound can visualize and diagnose an incarcerated hernia, and a bilateral rectus sheath block can be performed in the ED to anesthetize the peritoneal wall, paralyze abdominal musculature, and achieve nearly painless hernia reduction.

Impact of different gastric acid suppressants on chronic unpredictable mild stress-induced cognitive impairment in rats: A possible involvement of gut dysbiosis

Recently, clinical evidence indicates that gastric acid suppressants are associated with an increased risk of the development of cognitive impairment and dementia, especially in elderly patients and those with mild cognitive impairment. Therefore, the aim of this research was to explore the impact of different gastric acid suppressants use, famotidine (Famo), esomeprazole (Esome) and vonoprazan (Vono) in the absence or the presence of chronic unpredictable mild stress (CUMS) on several memory tasks with examination of the role of gut dysbiosis. In the present study, rats received famotidine (3.7 mg/kg/day, p.o.) or esomeprazole (3.7 mg/kg/day, p.o.) or vonoprazan (1.85 mg/kg/day, p.o.) for 7 weeks with or without exposure to CUMS. Remarkably, CUMS with different acid suppressants caused a significant decrease in all memory tasks in late CUMS in the current investigation. CUMS with acid suppressants also revealed a marked alteration in the fecal Firmicutes/Bacteroidetes ratio compared to CUMS alone. This gut microbiome alteration was associated with an alteration in gut membrane integrity, as revealed by colonic histopathology and an elevation of systemic inflammatory markers. Besides, upregulation of hippocampal amyloid β and p-tau proteins and modification of brain histopathology were noticed. Our findings support the detrimental effect of gastric acid suppressants, especially proton pump inhibitors, on cognitive impairment in the presence of stress, with the possible involvement of gut dysbiosis.

Retrograde Colonic Intussusception After Colonoscopy without Organic Pathology: A Case Report

BACKGROUND Adult colonic intussusceptions are relatively rare and are mostly caused by organic structures that serve as lead points. However, the pathogenesis of adult intussusception is not fully understood, and no cases of retrograde colonic intussusception without pathological abnormalities or associations with colonoscopy have been reported. CASE REPORT A 74-year-old woman presented with abdominal distension and constipation. Abdominal computed tomography (CT) revealed marked dilatation of the right and sigmoid colon, initially suggesting volvulus of the sigmoid colon. Observation of the left colon revealed no abnormal findings on the colonoscopy. Due to the persistence of abdominal symptoms from right colon dilatation, another colonoscopy was performed, and a transanal drainage tube was inserted into the transverse colon. Enterography showed a steep contrast interruption in the descending colon, which was missed at this time. The patient's abdominal pain worsened 3 days after removal of the drainage tube. Retrograde intussusception of the sigmoid colon was discovered on abdominal CT, and a laparoscopic left hemicolectomy was performed. Pathological examination revealed multiple ulcers in the superimposed area, but no abnormal organic findings that could be considered as a lead point were found. In this case, the stretching technique and/or shear stress on the sigmoid colon by a second colonoscopy may have contributed to the development of this condition. CONCLUSIONS This is the first report of colonoscopy-associated retrograde colonic intussusception without organic abnormalities. Although much is unknown about the pathogenesis in this case, it may provide new insights into the pathogenesis of intussusception.

Analysis of the efficacy of Percutaneous Transhepatic Cholangiography Drainage (PTCD) and Endoscopic Retrograde Cholangiopancreatography (ERCP) in the treatment of Malignant Obstructive Jaundice (MOJ) in palliative drainage and preoperative biliary drainage: a single-center retrospective study

PURPOSE

This study aimed to assess the safety and efficacy of percutaneous transhepatic cholangiography drainage (PTCD) and endoscopic retrograde cholangiopancreatography (ERCP) in palliative drainage and preoperative biliary drainage for treating malignant obstructive jaundice (MOJ).

METHODS

A total of 520 patients with MOJ who underwent PTCD or ERCP were enrolled and classified into palliative drainage group and preoperative biliary drainage group. Baseline characteristics, liver function, blood routine, complications were compared among the groups.

RESULTS

The technical success rates for PTCD and ERCP in palliative group were 97.1% and 85.9%. In palliative drainage group, PTCD had higher levels of total bilirubin (TB) reduction (53.0 (30.0,97.0) vs. 36.8 (17.9,65.0), p < 0.001) and direct bilirubin (DB) reduction (42.0 (22.0,78.5) vs. 28.0 (12.0,50.8), p = 0.001) than ERCP. However, PTCD was associated with higher rates of drainage tube displacement (20 cases, 11.8%), while ERCP had a higher incidence of biliary infection (39 cases, 22.8%) and pancreatitis (7 cases, 4.1%). In preoperative drainage group, PTCD achieved a 50% reduction in total bilirubin faster than ERCP (7.1 days vs. 10.5 days). And the time from palliation of jaundice to surgery was 24.2 days in PTCD group and 35.7 days in ERCP group, a statistically significant difference (Student's t test, p = 0.017).

CONCLUSION

Both PTCD and ERCP could improve liver function for MOJ patients. PTCD seems to offer better outcomes in jaundice reduction and liver function improvement in palliative drainage, but requires careful postoperative management. In preoperative biliary drainage, PTCD may be a better preoperative bridge to improve liver function and control infection.

Glucagon-like peptide-1 receptor agonists significantly affect the quality of bowel preparation for colonoscopy

BACKGROUND

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) affect gastrointestinal motility, slowing gastric emptying and colonic transit. GLP-1RAs have an impact on gastric residue before endoscopy, but only limited data are available regarding its effect on the adequacy of colonic preparation. We investigated the association between GLP-1RA use and inadequate bowel preparation (IBP) for colonoscopy.

METHODS

We performed a multicenter retrospective study with GLP-1RA cases matched with controls (using propensity scores for age, sex, diabetes mellitus [DM], obesity, and co-morbidities). Data on demographics, medication use, procedural indications, and colonoscopy findings were collected. IBP ("poor preparation" on Aronchik scale or Boston Bowel preparation scale <5) was the primary outcome.

RESULTS

4876 patients treated with GLP-1RAs were included in the analysis and compared with 4876 controls selected from 333 648 patients without GLP-1RA use. Among the GLP-1RA patients, 10% (n = 487) had IBP compared with 197 (4%) of the control group (P<0.001). Subgroup analysis showed a higher rate of IBP among diabetic patients treated with GLP-1RA (284/2364 [12%]) than among diabetic patients without GLP-1RA treatment (118/2364 [5%]; P<0.001). Additionally, 203/2512 nondiabetic patients treated with GLP-1RAs had IBP (8%) compared with 79 of the nondiabetic non-GLP-1RA group (3%; P<0.001). On multivariate analysis, diabetes and GLP-1RA use were both found to be independent risk factors for IBP (odds ratio [OR] 1.4 and OR 2.7, respectively; both P<0.001).

CONCLUSION

Our findings highlight the necessity for special attention and tailored recommendations for both diabetic and nondiabetic patients treated with GLP-1RAs in terms of colonic preparation prior to colonoscopy.

Endoscopic or combined management of post-surgical biliary leaks: a two-center recent experience

BACKGROUND AND AIMS

Post-surgical biliary leaks (PSBL) are one of the most prevalent and significant adverse events emerging after liver or biliary tract surgeries. Endoscopic retrograde cholangiopancreatography (ERCP) alone or combined with another approach (Rendez Vous) as treatment of PSBL obtains optimal outcomes due to the possibility of modifying the resistances in the biliary tree.

METHODS

A retrospective double-center study was conducted in two tertiary centers. Consecutive patients who underwent at least one attempt of PSBL correction by ERCP or Rendez Vous procedure between January 2018 and August 2023 were included. The primary outcome was overall endoscopic clinical success. In contrast, the secondary outcomes were hospital stay exceeding five days and endoscopic clinical success with the first endoscopic procedure at the tertiary center. Both univariate and multivariate analyses were used to assess outcomes.

RESULTS

65 patients were included. Patients with one or multiple) leaks had more possibility to achieve the endoscopic clinical success compared to those affected by the association of leaks and stricture (96% vs 67%, p value 0.005). Leaks occurring in the main biliary duct had less probability (67%) to achieve the overall endoscopic clinical success compared to those in the end-to-end anastomosis (90%), in the resection plane or biliary stump (96%) or first or secondary order biliary branches (100%, p value 0.038). A leak-bridging stent positioning had more probability of achieving the endoscopic clinical success than a not leak-bridging stent (91% vs 53%, p value 0.005).

CONCLUSIONS

ERCP and Rendez Vous procedures are safe and effective for treating PSBL, regardless of the type of preceding surgery, even if technical or clinical success was not achieved on the first attempt. A stent should be placed, if feasible, leak-bridging to enhance treatment efficacy.

Incidence of post-operative nausea and vomiting after endoscopic bariatric and metabolic therapy procedures and the role of neurokinin-1 receptor antagonists: a retrospective cohort study

BACKGROUND

Both the transoral gastric reduction (TORe) and endoscopic sleeve gastroplasty (ESG) procedures are novel endoscopic bariatric and metabolic therapies (EBMT). Our practice has an aggressive approach to prophylaxis of postoperative nausea and vomiting (PONV) for EBMT cases, but there is divergence of practice regarding use of prophylactic neurokinin-1 receptor (NK-1) antagonists (aprepitant, fosaprepitant). Herein, we determined the incidence of PONV and its potential association with NK-1 antagonist administration following EBMT.

METHODS

We identified and reviewed medical records of patients who underwent EBMT between 2018 and 2023. Patients were divided into those administered or not administered an NK-1 antagonist. We analyzed rates of PONV, which was defined as rescue antiemetics during anesthesia recovery. A propensity score was calculated, and outcomes were assessed using generalized estimating equations with inverse probability of treatment weighting (IPTW).

RESULTS

We identified 404 patients undergoing EBMT (256 [63%] TORe, 148 [37%] ESG), and of these 253 patients developed PONV, (62.6% [95% CI: 57.9% to 67.3%]). NK-1 antagonists were administered to 119 (29.5%) patients. PONV was experienced by 42 (35%) and 211 (74%) of patients who were or were not administered an NK-1 antagonist, respectively (IPTW OR = 0.18, [95%CI: 0.10 to 0.31], P < 0.001).

CONCLUSIONS

EBMT has a high incidence of PONV during anesthesia recovery. Administration of a NK-1 antagonist as part of a multiagent PONV prophylaxis regimen dramatically reduces risk for this common adverse event.

Benign Tumors and Tumor-Like Conditions of Ampulla and Small Intestine: The PathologyOutlines.com Review

Small intestine and ampulla can be involved in a heterogeneous group of benign tumors and tumor-like diseases, potentially mimicking malignant neoplasms. In-depth knowledge of them is critical for practicing pathologists since they represent potential pitfalls in routine diagnostic activity. Such conditions include the following: (1) Brunner gland lesions, including Brunner gland hyperplasia and hamartoma; (2) polyps, such as adenoma, hyperplastic, hamartomatous, and inflammatory; (3) mesenchymal proliferations encompassing inflammatory fibroid polyp, inflammatory myofibroblastic tumor, leiomyomas, lipomas, and lipomatosis of the ileocecal valve; (4) fibrosis-associated diseases, such as idiopathic retroperitoneal fibrosis, reactive nodular fibrous pseudotumor, and sclerosing peritonitis; (5) disorders of lymphatic vessels, including lymphangiectasia and lymphangiomas; and (6) other rare conditions/miscellanea, such as enteritis cystica profunda, intussusception, ischemia, and pneumatosis cystoides intestinalis. This review, inspired by the content of the PathologyOutlines website (https://www.pathologyoutlines.com), aims to provide a reference point in this complex scenario, summarizing the essential histopathological features of all these entities for better addressing routine practice and differential diagnoses.

Obesity and cardiovascular disease: an ESC clinical consensus statement

The global prevalence of obesity has more than doubled over the past four decades, currently affecting more than a billion individuals. Beyond its recognition as a high-risk condition that is causally linked to many chronic illnesses, obesity has been declared a disease per se that results in impaired quality of life and reduced life expectancy. Notably, two-thirds of obesity-related excess mortality is attributable to cardiovascular disease. Despite the increasingly appreciated link between obesity and a broad range of cardiovascular disease manifestations including atherosclerotic disease, heart failure, thromboembolic disease, arrhythmias, and sudden cardiac death, obesity has been underrecognized and sub-optimally addressed compared with other modifiable cardiovascular risk factors. In the view of major repercussions of the obesity epidemic on public health, attention has focused on population-based and personalized approaches to prevent excess weight gain and maintain a healthy body weight from early childhood and throughout adult life, as well as on comprehensive weight loss interventions for persons with established obesity. This clinical consensus statement by the European Society of Cardiology discusses current evidence on the epidemiology and aetiology of obesity; the interplay between obesity, cardiovascular risk factors and cardiac conditions; the clinical management of patients with cardiac disease and obesity; and weight loss strategies including lifestyle changes, interventional procedures, and anti-obesity medications with particular focus on their impact on cardiometabolic risk and cardiac outcomes. The document aims to raise awareness on obesity as a major risk factor and provide guidance for implementing evidence-based practices for its prevention and optimal management within the context of primary and secondary cardiovascular disease prevention.

Diagnostic ability and adverse events of mucosal incision-assisted biopsy for gastric subepithelial tumors: Systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to evaluate the diagnostic ability and examine the efficacy of countermeasures to adverse events of mucosal incision-assisted biopsy (MIAB) for gastric subepithelial tumors (SETs).

METHODS

We performed a literature search and identified 533 relevant articles. Eleven articles, including 339 lesions, were ultimately used in the meta-analysis. The primary end-point was the pathological diagnostic rate of MIAB for gastric SETs, and the secondary end-point was the incidence of adverse events. The efficacy of acid secretion inhibitors in preventing postoperative bleeding and that of local injection before incision to prevent perforation were also examined.

RESULTS

Nine studies were conducted in Japan and two in South Korea, of which only two were prospective studies. The pooled pathological diagnostic rate of MIAB for gastric SETs was 87.8% (95% confidence interval [CI] 80.2-94.0; I2 = 68.7%). The adverse event rate of the pooled population was 0.2% (95% CI 0-1.4; I2 = 0%). The acid secretion inhibitors significantly reduced postoperative bleeding (odds ratio 0.06, 95% CI 0.01-0.66, P = 0.02). Perforation occurred in 0% and 2.6% of the local and nonlocal injection cohorts, respectively, and the pathological diagnostic rates were 50% and 66.7%, respectively.

CONCLUSIONS

MIAB is a reliable technique with a favorable diagnostic rate and few adverse events. Acid secretion inhibitors may effectively prevent postoperative bleeding; however, the efficacy of local injection remains unclear. This technique could be an option for tissue sampling in gastric SETs.

Tubular adenoma at the hepatico-jejunal anastomosis in familial adenomatous polyposis (FAP) following pancreaticoduodenectomy: challenges in adenoma surveillance and management

Upper gastrointestinal tumors, including ampullary adenomas, occur frequently in patients with familial adenomatous polyposis (FAP). Guidelines recommend upper gastrointestinal endoscopy in FAP for surveillance of gastric and duodenal adenomas. However, adenomas can rarely arise from biliary epithelium in patients with FAP. Here, we describe a case of tubular adenoma at the hepatico-jejunal anastomosis with intraductal extension in a patient with FAP and previous pancreaticoduodenectomy. This report illustrates a unique case and emphasizes the need for data on postoperative surveillance in patients with FAP, particularly following pancreaticoduodenectomy.

Role of Imaging in Screening for Hepatocellular Carcinoma

Primary liver cancer is among the most common cancers globally. It is the sixth-most common malignancy encountered and the third-most common cause of cancer-related death. Hepatocellular carcinoma (HCC) is the most common primary liver malignancy, accounting for about 90% of primary liver cancers. The majority of HCCs occur in patients with underlying cirrhosis, which results from chronic liver diseases such as fatty liver, hepatitis B and hepatitis C infections, and chronic alcohol use, which are the leading causes. The obesity pandemic has led to an increased prevalence of nonalcoholic fatty liver disease (NAFLD), which leads to nonalcoholic steatohepatitis and could progress to cirrhosis. As HCC is among the most common cancers and occurs in the setting of chronic liver disease in most patients, screening the population at risk could help in early diagnosis and management, leading to improved survival. Screening for HCC is performed using biochemical marker testing such as α-fetoprotein (AFP) and cross-sectional imaging. It is critical to emphasize that HCC could potentially occur in patients without cirrhosis (non-cirrhotic HCC), which can account for almost 20% of all HCCs. The lack of cirrhosis can cause a delay in surveillance, which could potentially lead to diagnosis at a later stage, worsening the prognosis for such patients. In this article, we discuss the diagnosis of cirrhosis in at-risk populations with details on the different modalities available for screening HCC in patients with cirrhosis, emphasizing the role of abdominal ultrasounds, the primary imaging modality in HCC screening.