Safety and efficacy of lumen-apposing metal stents and double-pigtail plastic stents for endoscopic ultrasound-guided drainage of walled-off necrosis; a systematic review and meta-analysis

BACKGROUND

Patients with walled-off necrosis (WON) are still challenging to treat safely and effectively. Recently, double-pigtail plastic stents (DPS), bi-flanged metallic stents (BFMS), and lumen-apposing metal stents (LAMS) have been employed with endoscopic ultrasound-guided (EUS-guided) drainage. However, there is little solid evidence to support the effectiveness and safety of using stents. This study aims to compare the outcomes of the LAMS and the PS.

METHOD

Till July 2022, a thorough database search was done, and studies that met the criteria were chosen. By using the RevMan software, the technical and clinical success and other secondary outcomes were calculated. Subgroup analysis was performed between the LAMS and the BFMS.

RESULTS

Fifteen studies (two randomized controlled trials and thirteen observational) with 687 patients receiving metal stents and 771 patients receiving plastic stents were selected for final analysis. There was no significant risk of bias or publication bias. The odds ratios (OR) for technical and clinical success were 0.36 (95% confidence interval (95% CI) 0.08, 1.52) and 2.26 (95%CI 1.62, 3.15), respectively. The OR for overall adverse events was 0.74 (95% CI 0.41, 1.34). In subgroup analysis, the LAMS and the BFMS showed the same outcomes.

CONCLUSION

Compared to DPS, LAMS had better clinical outcomes and fewer side effects when treating patients with WON.

The Evolution of Sedation for Pediatric Gastrointestinal Endoscopy

Sedation for pediatric endoscopy has evolved from an endoscopist-administered component of procedures to an almost entirely anesthesiologist-supported endeavor. Nevertheless, there are no ideal endoscopist or anesthesiologist-administered sedation protocols, and wide practice variation exists in both models. Furthermore, sedation for pediatric endoscopy, whether administered by endoscopists or anesthesiologists, remains the highest risk to patient safety. This underscores the importance of both specialties identifying best sedation practices together that can safeguard patients while maximizing procedural efficiency and minimizing costs. In this review, the authors discuss specific levels of sedation for endoscopy and the risks and benefits of various regimens.

Advances in Endoscopy for Pediatric Inflammatory Bowel Disease

Endoscopic characterization of pediatric inflammatory bowel disease (IBD) has developed in accordance with advances in treatment and improved understanding of disease progression and complications. Reliable and consistent endoscopic reporting practices and tools continue to evolve. The roles of endoscopic ultrasonography, capsule endoscopy, and deep enteroscopy in the care of children and adolescents with IBD are beginning to be clarified. Opportunities for therapeutic intervention with endoscopy in pediatric IBD, including endoscopic balloon dilation and electroincision therapy, require further study. This review discusses the current utility of endoscopic assessment in Pediatric Inflammatory Bowel Disease, as well as emerging and evolving techniques to improve patient care.

Association between anatomic variations of extrahepatic and intrahepatic bile ducts: Do look up!

Biliary anatomic variations are usually asymptomatic, but they may cause problems in diagnostic investigations and interventional and surgical procedures, increasing both their technical difficulty and their postoperative complication rates. The aim of the present study was to evaluate the prevalence of anatomic variations in the intrahepatic biliary ducts (IHBD) in relation to demographical and clinical characteristics in a large study population requiring magnetic resonance cholangiopancreatography (MRCP) for various clinical conditions. The possible association between IHBD and extrahepatic biliary ducts (EHBD) variants was then explored. From January 2017 to May 2019, 1004 patients underwent MRCP. Demographical and clinical data were collected. IHBD and EHBD anatomy were recorded and the EHBD anatomy was classified using both qualitative and quantitative classifications. The presence of a type 3 EHBD variant (an abnormal proximal cystic duct [CD] insertion) in both qualitative and quantitative classifications and an intrapancreatic CD were associated with the presence of IHBD variants at univariate analysis (p = 0.008, p = 0.019, and p = 0.001, respectively). The presence of a posterior or medial insertion of the CD into the EHBD was a strong predictive factor of the presence of IHBD variants both at uni- and multivariate analysis (p = 0.002 and p = 0.003 for posterior insertion and p = 0.002 and p = 0.002 for medial insertion, respectively). The presence of gallstones on MRCP resulted in a strong predictor of the presence of an anatomical variant of the IHBD both at uni- and multivariate analysis (p = 0.027 and p = 0.046, respectively). In conclusion, the presence of a type 3 variant of the EHBD, an intrapancreatic CD and, especially, a posterior/medial CD insertion into the EHBD represent predictive factors of the concomitant presence of IHBD variants, thus radiologists must be vigilant when encountering these EHBD configurations and always remember to "look up" at the IHBD. Finally, the presence of an IHBD variant is a strong predictive factor of gallstones.

Short‐term outcomes of patients undergoing endoscopic submucosal dissection for colorectal lesions

Objectives

Endoscopic submucosal dissection (ESD) of colorectal lesions was invented in Japan, but postoperative management including hospital stay has not been reconsidered due to the Japanese insurance system. To explore appropriate postoperative management after colorectal ESD, we reviewed short‐term outcomes after ESD in non‐selected consecutive patients.

Methods

Patients who underwent colorectal ESD from April 2013 to September 2020 in one institution were reviewed. The primary outcome measure was the occurrence of adverse events stratified by the Clavien‐Dindo classification with five grades. A logistic regression model with the Firth procedure was applied to investigate predictors of severe (grade III or greater) adverse events.

Results

A total of 330 patients (female 40%, male 60%; median 72 years; IQR 65–80 years) with colorectal lesions (median 30 mm, IQR 23–40 mm; colon 77%, rectum 23%; serrated lesion 4%, adenoma 47%, mucosal cancer 30%, invasive cancer 18%) was evaluated. The en bloc resection rate was 97%. The median dissection time was 58 min (IQR: 38–86). Intraprocedural perforation occurred in 3%, all successfully treated by endoscopic clipping. No delayed perforations occurred. Postprocedural bleeding occurred in 3% on days 1–10 (median day 2); all were controlled endoscopically. Severe adverse events included only delayed bleeding. In analyzing severe adverse events in a multivariate logistic regression model with the Firth procedure, antithrombotic agent use (p = 0.016) and rectal lesions (p = 0.0010) were both significant predictors.

Conclusions

No serious adverse events occurred in this series. Four days of hospitalization may be too long for the majority of patients after ESD.

American Society for Gastrointestinal Endoscopy guideline on management of post-liver transplant biliary strictures: methodology and review of evidence

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for strategies to manage biliary strictures in liver transplant recipients. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the role of ERCP versus percutaneous transhepatic biliary drainage and covered self-expandable metal stents (cSEMSs) versus multiple plastic stents for therapy of strictures, use of MRCP for diagnosing post-transplant biliary strictures, and administration of antibiotics versus no antibiotics during ERCP. In patients with post-transplant biliary strictures, we suggest ERCP as the initial intervention and cSEMSs as the preferred stent. In patients with unclear diagnosis or intermediate probability of a stricture, we suggest MRCP as the diagnostic modality. We suggest that antibiotics should be administered during ERCP when biliary drainage cannot be assured.

Upskilling Pediatric Ileocolonoscopy

Upskilling in ileocolonoscopy is an important aspect of pediatric endoscopic practice as it enables endoscopists to learn additional skills through education and training to improve outcomes. With the advent of technologies, endoscopy is continuously evolving. Many devices can be applied to improve endoscopy quality and ergonomics. In addition, techniques such as dynamic position change can be employed to increase procedural efficiency and completeness. Key to upskilling is enhancing endoscopists' cognitive, technical and nontechnical skills and the concept of "training the trainer" to ensure trainers have the requisite skills to teach endoscopy effectively. This chapter details aspects of upskilling pediatric ileocolonoscopy.

Aptamer-Functionalized Microbubbles Targeted to P-selectin for Ultrasound Molecular Imaging of Murine Bowel Inflammation

PURPOSE

Our objectives were to develop a targeted microbubble with an anti-P-selectin aptamer and assess its ability to detect bowel inflammation in two murine models of acute colitis.

PROCEDURES

Lipid-shelled microbubbles were prepared using mechanical agitation. A rapid copper-free click chemistry approach (azide-DBCO) was used to conjugate the fluorescent anti-P-selectin aptamer (Fluor-P-Ap) to the microbubble surface. Bowel inflammation was chemically induced using 2,4,6-trinitrobenzenesulfonic acid (TNBS) in both Balb/C and interleukin-10-deficient (IL-10 KO) mice. Mouse bowels were imaged using non-linear contrast mode following an i.v. bolus of 1 × 10⁸ microbubbles. Each mouse received a bolus of aptamer-functionalized and non-targeted microbubbles. Mouse phenotypes and the presence of P-selectin were validated using histology and immunostaining, respectively.

RESULTS

Microbubble labelling of Fluor-P-Ap was complete after 20 min at 37 ̊C. We estimate approximately 300,000 Fluor-P-Ap per microbubble and confirmed fluorescence using confocal microscopy. There was a significant increase in ultrasound molecular imaging signal from both Balb/C (p = 0.003) and IL-10 KO (p = 0.02) mice with inflamed bowels using aptamer-functionalized microbubbles in comparison to non-targeted microbubbles. There was no signal in healthy mice (p = 0.4051) using either microbubble.

CONCLUSIONS

We constructed an aptamer-functionalized microbubble specific for P-selectin using a clinically relevant azide-DBCO click reaction, which could detect bowel inflammation in vivo. Aptamers have potential as a next generation targeting agent for developing cost-efficient and clinically translatable targeted microbubbles.

Music in the acute preoperative nursing care - A mixed-method pilot study

AIM

The aim was to (1) examine the feasibility aspect of a music intervention, (2) examine the association between music and pain, relaxation and well-being and (3) explore patients' experience of listening to music while waiting for acute surgery.

DESIGN

The design was a mixed-method study.

METHODS

Participants were offered a music pillow for 30 min. Before and after the intervention, participants reported their pain, relaxation and well-being using a visual analogue scale ranging from 0 to10. The qualitative part was based on field observation followed by a semi-structured interview.

RESULTS

The quantitative part included 30 participants. The Wilcoxon signed-rank test showed a positive significant association between music and pain, relaxation and well-being (p < 0.001). The qualitative part included 15 participants. Two themes derived from the analysis: (1) feelings of physical and mental well-being and (2) a break from the acute preoperative context.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Pediatric Neurogastroenterology and Motility Disorders: What Role Does Endoscopy Play?

Although pediatric neurogastroenterology and motility (PNGM) disorders are prevalent, often debilitating, and remain challenging to diagnose and treat, this field has made remarkable progress in the last decade. Diagnostic and therapeutic gastrointestinal endoscopy emerged as a valuable tool in the management of PNGM disorders. Novel modalities such as functional lumen imaging probe, per-oral endoscopic myotomy, gastric-POEM, and electrocautery incisional therapy have changed the diagnostic and therapeutic landscape of PNGM. In this review, the authors highlight the emerging role of therapeutic and diagnostic endoscopy in esophageal, gastric, small bowel, colonic, and anorectal disorders and disorders of gut and brain axis interaction.

Pediatric Unsedated Transnasal Endoscopy

Unsedated transnasal endoscopy (TNE) is a feasible, safe, and cost-effective procedure for pediatric patients. TNE provides direct visualization of the esophagus and enables acquisition of biopsy samples while eliminating the risks associated with sedation and anesthesia. TNE should be considered in the evaluation and monitoring of disorders of the upper gastrointestinal tract, particularly in diseases such as eosinophilic esophagitis that often require repeated endoscopy. Setting up a TNE program requires a thorough business plan as well as training of staff and endoscopists.

Protocol design for randomized clinical trial to compare underwater cold snare polypectomy to conventional cold snare polypectomy for non-pedunculated colon polyps of size 5-10 mm (COLDWATER study)

BACKGROUND

Colorectal cancer is internationally the third leading cause of death from a malignant disease. The aim of screening colonoscopy in adults > 45 years of age is early diagnosis and treatment of precancerous polyps. Endoscopic polyp removal (polypectomy) can be achieved with various techniques depending on the size, morphology, and location of the polyp. According to current guidelines, small non-pedunculated polyps should be removed with a cold snare after the colorectal lumen has been insufflated with air (conventional cold snare polypectomy).In recent years, several studies have described the benefits of water aided colonoscopy, as well as the safety and efficacy of underwater cold snare polypectomy for large colon polyps. However, there are insufficient data on conventional and underwater techniques for small polyps, the most commonly diagnosed colorectal polyps.

METHODS

We have designed a prospective randomized double-blind clinical trial to compare the safety and efficacy of conventional and underwater cold snare polypectomy for non-pedunculated polyps 5-10 mm in size. A total of 398 polyps will be randomized. Randomization will be carried out using the random numbers method of Microsoft Excel 2016. The primary endpoint is the muscularis mucosa resection rate. Secondary endpoints are the depth and percentage of R0 excisions, complications, and the recurrence rate at follow-up endoscopy 6-12 months after polypectomy.

DISCUSSION

We hypothesize underwater polypectomy will result in a higher muscularis mucosa resection rate. The results of our study will provide useful data for the development of guidelines in polypectomy techniques for non-pedunculated polyps 5-10 mm in size.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT05273697.

Ex‐vivo investigation of radiofrequency ablation in pancreatic adenocarcinoma after neoadjuvant chemotherapy

Objective

Endoscopic ultrasound (US)‐guided radiofrequency ablation (RFA) has been investigated for pancreatic ductal adenocarcinoma (PDAC) but studies are limited and heterogeneous. Computed tomography (CT) scan features may predict RFA response after chemotherapy but their role is unexplored. The primary aim was to investigate the efficacy of ex‐vivo application of a dedicated RFA system at three power on surgically resected PDAC in patients who underwent neoadjuvant chemotherapy. The secondary aim was to explore the association between pre‐treatment CT‐based quantitative features and RFA response.

Methods

Fifteen ex‐vivo PDAC samples were treated by RFA under US control at three power groups (10, 30, and 50 W). Short axis necrosis diameter was measured by two expert blinded pathologists as the primary outcome. Two radiologists independently reviewed preoperative CT images.

Results

Eighty percent of specimens showed coagulative necrosis consisting of few millimeters: 5.7 ± 3.9 mm at 10 W, 3.7 ± 2.2 mm at 30 W, and 3.5 ± 2.4 mm at 50 W (p = 0.3), without a significant correlation between power setting and mean necrosis short axis (rho = –0.28; p = 0.30). Good agreement was seen between pathologists (k = 0.76; 95% confidence interval 0.55–0.98). Logistic regression analysis did not show associations between CT features and RFA response.

Conclusions

RFA causes histologically evident damage with coagulative necrosis of a few millimeters in 80% of ex‐vivo PDAC samples after chemotherapy and no clinical or pre‐operative CT features can predict efficacy. Power settings do not correlate with the histological ablation area. These results are of relevance when employing RFA in vivo and planning clinical trials on its role in PDAC patients.

Incarceration of a colonoscope in an inguinal hernia: A report of two cases

We report two cases of the rare complication of a colonoscope incarcerated in an inguinal hernia. The first patient was a 73‐year‐old man in whom a colonoscope was incarcerated in a left inguinal hernia on attempted withdrawal. The incarcerated colonoscope was successfully reduced manually under fluoroscopic guidance. The hernia was subsequently repaired using an extraperitoneal approach followed by a successful colonoscopy. The second patient was a 74‐year‐old man in whom the colonoscope became incarcerated in a left inguinal hernia on insertion. Similar to the first case, the colonoscope was manually reduced under fluoroscopy and the entire colonoscopy was then uneventfully performed. An advanced sigmoid cancer was identified and treated with sigmoidectomy. The hernia resolved after this operation. When a colonoscope becomes incarcerated in an inguinal hernia, the manual reduction should be attempted. Subsequent colonoscopy can be safely performed under certain circumstances.

Factors that affect the development of acute hemorrhagic rectal ulcer syndrome and rebleeding

Objectives

Acute hemorrhagic rectal ulcer syndrome (AHRUS) causes massive bleeding and often recurrent rebleeding from rectal ulcers that form immediately above the dentate line. This study aimed to determine the clinical background and risk factors contributing to rebleeding in patients with AHRUS and the most appropriate method of hemostasis treatment.

Methods

This retrospective study included 93 patients diagnosed with AHRUS at Showa University Fujigaoka Hospital, Japan, between April 2009 and November 2018. Information on clinical background factors, endoscopic findings, and hemostasis was obtained from medical records. The relationship with episodes of rebleeding was analyzed by multivariate logistic regression analysis.

Results

The median age was 79 years, and 84 patients (90%) had a performance status of grade 2 or higher. The patients had multiple background factors, with a median number of 5 per patient. The background factors could be classified into two major factors: those related to arteriosclerosis and those related to delayed wound healing.

In the multivariate analysis, significantly more rebleeding occurred in patients with active bleeding during the initial endoscopy (odds ratio 4.88, 95% confidence interval 1.80–14.46, p = 0.003); significantly less rebleeding occurred in patients for whom hemostasis was first performed by clipping (odds ratio 0.30, 95% confidence interval 0.09–0.88, p = 0.035).

Conclusions

In bedridden older individuals with poor general health, multiple combinations of arteriosclerosis‐related factors and protracted wound healing factors can induce AHRUS. We strongly recommend performing hemostasis via the clipping method on suspected bleeding points, including active bleeding sites, in AHRUS.

Endoscopic management of patients with high-risk colorectal colitis-associated neoplasia: a Delphi study

BACKGROUND AND AIMS

Current guidelines recommend endoscopic resection of visible and endoscopically resectable colorectal colitis-associated neoplasia (CAN) in patients with inflammatory bowel disease (IBD). However, patients with high-risk CAN (HR-CAN) are often not amenable to conventional resection techniques, and a consensus approach for the endoscopic management of these lesions is presently lacking. This Delphi study aims to reach consensus among experts on the endoscopic management of these lesions.

METHODS

A 3-round modified Delphi process was conducted to reach consensus among worldwide IBD and/or endoscopy experts (n = 18) from 3 continents. Consensus was considered if ≥75% agreed or disagreed. Quality of evidence was assessed by the criteria of the Cochrane Collaboration group.

RESULTS

Consensus was reached on all statements (n = 14). Experts agreed on a definition for CAN and HR-CAN. Consensus was reached on the examination of the colon with enhanced endoscopic imaging before resection, the endoscopic resectability of an HR-CAN lesion, and endoscopic assessment and standard report of CAN lesions. In addition, experts agreed on type of resections of HR-CAN (< 20 mm, >20 mm, with or without good lifting), endoscopic success (technical success and outcomes), histologic assessment, and follow-up in HR-CAN.

CONCLUSIONS

This is the first step in developing international consensus-based recommendations for endoscopic management of CAN and HR-CAN. Although the quality of available evidence was considered low, consensus was reached on several aspects of the management of CAN and HR-CAN. The present work and proposed standardization might benefit future studies.

Efficacy and safety of endoscopic stent placement for afferent loop obstruction using a short double‐balloon endoscopy

Background

Methods

Results

Conclusions

Palliative stenting for malignant colorectal stenosis in the elderly

Objectives

Self‐expandable metal stents are widely used for the treatment of malignant colorectal stenosis (MCS). In elderly individuals with MCS, self‐expandable metal stents are often used as a palliative treatment, but prophylactic stent placement is not recommended. We investigated the efficacy and safety of self‐expandable metal stents for the elderly in a palliative setting, specifically in a prophylactic setting.

Methods

Elderly patients with MCS who received a palliative stent (the stent group) or palliative stoma (the stoma group) were retrospectively enrolled between April 2017 and June 2022, and the prognosis and complication rates were assessed. Additionally, patients in the stent group were divided into symptomatic and asymptomatic subgroups, and prognosis, stent patency, and complication rates were evaluated.

Results

During the study period, 31 patients with a mean age of 85.4 years and 12 patients with a mean age of 82.0 years were enrolled in the stent and stoma groups, respectively. While overall survival and complication rates were comparable, the length of hospital stay was significantly shorter in the stent group. Of the 31 patients in the stent group, 16 asymptomatic patients received prophylactic stenting, which was not associated with increased complication rates.

Conclusions

Palliative stents for MCS appear to be effective and safe even in the elderly, and thus, prophylactic stents can be considered for asymptomatic patients.

Endoscopic Management of Congenital Esophageal Defects and Associated Comorbidities

The endoscopist plays a critical role in the management of patients with congenital esophageal defects. This review focuses on esophageal atresia and congenital esophageal strictures and, in particular, the endoscopic management of comorbidities related to these conditions, including anastomotic strictures, tracheoesophageal fistulas, esophageal perforations, and esophagitis surveillance. Practical aspects of endoscopic techniques for stricture management are reviewed including dilation, intralesional steroid injection, stenting, and endoscopic incisional therapy. Endoscopic surveillance for mucosal pathology is essential in this population, as patients are at high risk of esophagitis and its late complications such as Barrett's esophagus.

The Effect of Reiki on Anxiety, Stress, and Comfort Levels Before Gastrointestinal Endoscopy: A Randomized Sham-Controlled Trial

PURPOSE

This study's aim is to determine the effect of Reiki when applied before upper gastrointestinal endoscopy on levels of anxiety, stress, and comfort.

DESIGN

This single-blind, a pretest and post-test design, randomized, sham-controlled study was held between February and July 2021.

METHODS

Patients who met the inclusion criteria were separated by randomization into three groups: Reiki, sham Reiki, and control. A total of 159 patients participated in the study. In the intervention groups (Reiki and sham Reiki), Reiki and sham Reiki were applied once for approximately 20 to 25 minutes before gastrointestinal endoscopy.

FINDINGS

When the Reiki group was compared to the sham Reiki and control groups following the intervention, the decrease in the levels of patient stress (P < .001) and anxiety (P < .001) and the increase in patient comfort (P < .001) were found to be statistically significant.

CONCLUSIONS

Reiki applied to patients before upper gastrointestinal endoscopy was effective in reducing stress and anxiety and in increasing comfort.

Efficacy and Safety of Radiofrequency Ablation Plus Stent Versus Stent-alone Treatments for Malignant Biliary Strictures: A Systematic Review and Meta-analysis

BACKGROUND/AIMS

Malignant biliary strictures (MBS) are very aggressive and cannot be diagnosed in the early stages due to their asymptomatic nature. Stenting the stricture area of the biliary tree is palliative treatment but has poor survival time. Radiofrequency ablation plus stent (RFA+S) have been recently used to improve the survival and stent patency time in patients with MBS. In this systematic review and meta-analysis, we tried to evaluate the efficacy and safety of radiofrequency ablation.

MATERIALS AND METHODS

Study search up to December 2021 was performed in different medical databases such as PubMed, Web of Science, and Cochrane library, etc. We selected eligible studies reporting survival time, stent patency time, and adverse events in patients with MBS. We compare the outcomes of RFA+S and stent-alone treatment groups.

RESULTS

A total of 15 studies (6 randomized controlled trials and 9 observational studies) with 1815 patients were included for meta-analysis of which 701 patients were in RFA+S group and 1114 patients in the stent-alone group. Pooled mean difference of survival time was 2.88 months (95% CI: 1.78-3.97) and pooled mean difference of stent patency time was 2.11 months (95% CI: 0.91-3.30) and clinical success risk ratio was 1.05 (95% CI: 1.01-1.09). Risk ratios for adverse events are given; Bleeding 0.84 (95% CI: 0.34-2.11), abdominal pain 1.06 (95% CI: 0.79-1.40), pancreatitis 0.93 (95% CI: 0.43-2.01), cholangitis 1.07 (95% CI: 0.72-1.59), and stent dysfunction 0.87 (95% CI: 0.70-1.07).

CONCLUSIONS

Radiofrequency ablation is involved in increased survival and stent patency time for MBS patients. With the help of better techniques, adverse events can be limited.

Endoscopic full‑thickness resection with clip‑ and snare‑assisted traction for gastric submucosal tumours in the fundus: A single‑centre case series

Exposed endoscopic full-thickness resection (Eo-EFTR) has been recognized as a feasible therapy for gastrointestinal submucosal tumours (SMTs) originating deep in the muscularis propria layer; however, Eo-EFTR is difficult to perform in a retroflexed fashion in the gastric fundus. As a supportive technique, clip- and snare-assisted traction may help expose the surgical field and shorten the operation time in endoscopic resection of difficult regions. However, the application of clip- and snare-assisted traction in Eo-EFTR of SMTs in the gastric fundus is limited. Between April 2018 and December 2021, Eo-EFTR with clip- and snare-assisted traction was performed in 20 patients with SMTs in the gastric fundus at The First Affiliated Hospital of Soochow University. The relevant clinical data were collected retrospectively for all of the patients and analysed. All 20 patients underwent Eo-EFTR successfully without conversion to open surgery or severe adverse events. The en bloc resection rate and R0 resection rate were both 100%. Two patients had abdominal pain and fever after the operation, and five patients had fever, which recovered with medical therapy. No complications, such as delayed bleeding or delayed perforation, were observed. The postoperative pathology indicated that 19 cases were gastrointestinal stromal tumours and one case was leiomyoma. During the follow-up, no residual tumour, local recurrence or distant metastasis was detected by endoscopy or abdominal computed tomography. In conclusion, Eo-EFTR with clip- and snare-assisted traction appears to be a relatively safe and effective treatment for gastric SMTs in the fundus. However, prospective studies on a larger sample size are required to verify the effect of the clip- and snare-assisted traction in Eo-EFTR.

Establishment of a modified Kyoto classification scoring model and its significance in the diagnosis of Helicobacter pylori current infection

BACKGROUND AND AIMS

We aimed to establish a modified model of the Kyoto classification score and verify its accuracy for predicting Helicobacter pylori (HP) infection during endoscopy.

METHODS

Patients who underwent gastroscopy from June 2020 to March 2021 were included in this study. Atrophy, intestinal metaplasia, hypertrophy of the gastric fold, nodularity, diffuse redness, sticky mucus, spotty redness, xanthoma, map-like redness, fundic gland polyp, and regular arrangement of collecting venules (RAC) were recorded according to the Kyoto classification of gastritis. The HP infection status of participants was determined by a ¹³C breath test, anti-HP antibody, and histopathologic hematoxylin and eosin staining. The modified Kyoto classification scoring model was established based on univariate analysis and logistic regression analysis. The modified scoring model was used to judge the status of HP infection in patients undergoing gastroscopy from July to September 2021 and to evaluate the accuracy of the prediction.

RESULTS

Of 667 participants in the derivation dataset, 326 cases had HP infection and 341 cases did not. Atrophy, hypertrophy of the gastric fold, nodularity, diffuse redness, sticky mucus, and spotty redness were associated with HP current infection. Thus, a new scoring model, termed the modified Kyoto classification scoring model, was constructed that included atrophy, hypertrophy of the gastric fold, nodularity, diffuse redness, sticky mucus, spotty redness, fundic gland polyp, and RAC as indicators. To test the model, 808 subjects, including 251 HP-positive patients, comprised the validation dataset.

CONCLUSIONS

The modified Kyoto classification scoring model improved the accuracy of endoscopic determination of HP current infection and has clinical application potential in the Chinese population.

Pregnancy-associated mucinous cystic neoplasms of the pancreas - A systematic review

INTRODUCTION

Mucinous cystic neoplasms (MCN) are mucin-producing epithelial cell tumors of pancreas. They consist of an ovarian-type stroma expressing estrogen and progesterone receptors. Pregnancy-associated MCNs are presumed to be larger in size and more aggressive without any concrete evidence.

OBJECTIVE

and Data Sources: Systematic review of published literature using PubMed and Google Scholar databases. Original articles including case reports and series published between 1970&2021 were included wherein MCN was diagnosed during pregnancy/within one-year post-partum. Thirty-three publications having 36 cases, adding one of our own patient were analyzed in this review.

RESULT

Median age at presentation was 32 years. Only three (9%) patients were asymptomatic. Mean size of MCN was 135 mm. Ten patients (27%) reported an increase in size during pregnancy. Most tumors involved body and tail of pancreas (60%). Distal pancreatectomy with splenectomy was the most common resection performed (57%). No foetal mortality was reported to date.

CONCLUSION

Pregnancy may cause a rapid increase in size of MCN. Decision-making is more complex and needs a fine balance between optimal oncological and obstetric outcomes.

Clinical Characteristics of Patients With Surgically Resected Pancreatic Cysts: A Retrospective Analysis of 136 Patients

OBJECTIVES

To retrospectively analyze the characteristics of pancreatic cysts with respect to histopathological diagnosis and various diagnostic imaging tools.

METHODS

The clinical features of 136 patients and characteristics of histopathologically diagnosed cysts were retrospectively assessed. The diagnostic accuracy of endoscopic ultrasound (EUS), computed tomography (CT), and magnetic resonance imaging (MRI) for pancreatic cysts was compared. Risk factors for high-grade dysplasia/invasive cancer in patients with intraductal papillary mucinous neoplasms (IPMNs) were also determined.

RESULTS

The final analysis included 30 serous cystic neoplasms (SCNs) (21.6%), 13 mucinous cystic neoplasms (MCNs) (9.4%), 65 IPMNs (46.8%), and 13 solid pseudopapillary neoplasms (SPNs) (9.4%). The percentage of women with MCNs, SPNs, SCNs, and IPMNs was 100.0, 76.9, 73.3, and 47.7%, respectively (P < .001). The percentages of patients over 60 years of age with IPMNs, SCNs, MCNs, and SPNs were 73.9, 23.3, 0, and 0%, respectively (P < .001). The percentage of cysts located in the body and tail of the pancreas in MCNs, SCNs, SPNs, and IPMNs was 100, 70, 53.9, and 46.2%, respectively (P < .001). A unique honeycomb appearance was observed in 26.7% of SCNs. The overall diagnostic accuracy of EUS, CT, and MRI for pancreatic cysts was 82.6, 72.5, and 73.9%, respectively. Lesion size and presence of solid components were independent predictors of high-risk IPMNs.

CONCLUSIONS

Patient characteristics and cyst features can help to differentiate pancreatic cyst types and identify high-risk IPMNs. The diagnostic accuracy of EUS for pancreatic cysts is superior to that of CT and MRI.

Comparison of endoscopic submucosal resection with ligation and endoscopic submucosal dissection for small rectal neuroendocrine tumors: A multicenter retrospective study

Objectives

Endoscopic submucosal resection with band ligation (ESMR‐L) and endoscopic submucosal dissection (ESD) are both standard endoscopic resection methods for rectal neuroendocrine tumors (NETs) <10 mm in size. However, there is no definitive consensus on which is better. Here, we compared the efficacy of ESMR‐L and ESD for small rectal NETs.

Methods

This was a multicenter retrospective cohort study including 205 patients with rectal NETs who underwent ESMR‐L or ESD. Treatment outcomes were compared by univariate analysis, multivariate analysis, and inverse probability treatment weighting (IPTW) using propensity scores. Subgroup analysis evaluated the impact of the endoscopist's experience on the technical outcome.

Results

Eighty‐nine patients were treated by ESMR‐L and 116 by ESD. The R0 resection rate was not significantly different between the two (90% vs. 92%, p = 0.73). The procedure time of ESMR‐L was significantly shorter than for ESD (17 min vs. 52 min, p < 0.01) and the hospitalization period was also significantly shorter (3 days vs. 5 days, p < 0.01). These results were confirmed by multivariate analysis and also after IPTW adjustment. The procedure time of ESD was significantly prolonged by a less‐experienced endoscopist (49 min vs. 70 min, p = 0.02), but that of ESMR‐L was not affected (17 min vs. 17 min, p = 0.27).

Conclusions

For small rectal NETs, both ESMR‐L and ESD showed similar high complete resection rates. However, considering the shorter procedure time and shorter hospitalization period, ESMR‐L is the more efficient treatment method, especially for less‐experienced endoscopists.

CLELNet: A continual learning network for esophageal lesion analysis on endoscopic images

BACKGROUND AND OBJECTIVE

A deep learning-based intelligent diagnosis system can significantly reduce the burden of endoscopists in the daily analysis of esophageal lesions. Considering the need to add new tasks in the diagnosis system, a deep learning model that can train a series of tasks incrementally using endoscopic images is essential for identifying the types and regions of esophageal lesions.

METHOD

In this paper, we proposed a continual learning-based esophageal lesion network (CLELNet), in which a convolutional autoencoder was designed to extract representation features of endoscopic images among different esophageal lesions. The proposed CLELNet consists of shared layers and task-specific layers. Shared layers are used to extract common features among different lesions while task-specific layers can complete different tasks. The first two tasks trained by the CLELNet are the classification (task 1) and the segmentation (task 2). We collected a dataset of esophageal endoscopic images from Macau Kiang Wu Hospital for training and testing the CLELNet.

RESULTS

The experimental results showed that the classification accuracy of task 1 was 95.96%, and the Intersection Over Union and the Dice Similarity Coefficient of task 2 were 65.66% and 78.08%, respectively.

CONCLUSIONS

The proposed CLELNet can realize task-incremental learning without forgetting the previous tasks and thus become a useful computer-aided diagnosis system in esophageal lesions analysis.

Efficacy of a new traction method using ring-shaped thread for endoscopic submucosal dissection in the pharynx

BACKGROUND

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for pharyngeal cancers. However, pharyngeal ESD is sometimes technically challenging because of the narrow and complex space in which to work. Traction is important to complete the procedure efficiently. Here, we report the technical details and efficacy of a new traction method for pharyngeal ESD using ring-shaped thread and grasping forceps.

METHODS

We analyzed pharyngeal ESD performed between January 2016 and March 2021 at our Institute. We designated cases resected using ring-shaped threads "Group R" and those resected without ring-shaped threads as conventional "Group C", and compared the technical outcomes between them. Multivariate analysis and the inverse probability treatment weighting (IPTW) method using propensity scores were adjusted by confounding variables.

RESULTS

We analyzed 89 lesions from 68 patients, of which 46 were in Group R and 43 in Group C. Median procedure time and median dissection speed were significantly shorter in Group R than C (37 min vs. 55 min, and 16.0 mm²/min vs. 7.0 mm²/min, respectively, both P < 0.05). These results were confirmed by both multivariate analysis and after IPTW adjustment. All lesions were resected en bloc, and the complete resection rate was not significantly different between Group R and C (91.3% vs. 79.1%, P = 0.14). There were no treatment-related adverse events in either group.

CONCLUSIONS

The traction method using ring-shaped thread increases the efficiency of pharyngeal ESD. This simple new traction method should be a useful option for pharyngeal ESD.

Clinicopathological features of gastric adenocarcinoma of fundic gland type

BACKGROUND

Gastric adenocarcinoma of fundic gland type (GA-FG) is a newly discovered type of gastric cancer in recent years, and it is a form of well-differentiated malignancy unlike conventional intestinal and diffuse gastric cancers. It is expected that GA-FG will account for an increasing proportion of all gastric cancers, but the current lack of knowledge among endoscopists and clinicopathologists may lead to misdiagnosis.

AIM

To increase the diagnostic yield of GA-FG and reduce missed diagnosis and misdiagnosis, we conducted a systematic review of the endoscopic, clinical, and pathological features of GA-FG.

METHODS

The clinical, pathological, and endoscopic data of patients with GA-FG reported in the Chinese and English literature published between January 2007 and March 2022 were collected from PubMed and CNKI and retrospectively analyzed.

RESULTS

Data related to a total of 322 lesions in 320 patients with GA-FG were collected from 67 articles. Most of the lesions were located in the upper third of the stomach (81.6%), with an average lesion size of 9.66 mm (1 mm-85 mm), and approximately 76.88% of the lesions had an elevated gross morphology. Microvascular dilatation and disorganized or thickened microglandular structures were observed on the surface of the lesions by narrow band imaging. The main cell differentiation type accounted for approximately 74.84% of all lesions, which significantly expressed MUC6 and pepsinogen.

CONCLUSION

The incidence of GA-FG is low. Endoscopic complete resection and surgical operation can achieve curative resection. The prognosis is good, but it tends to be misdiagnosed. The diagnosis should be combined with its clinicopathological characteristics to reduce the rate of misdiagnosis and missed diagnosis.

Comprehensive review on endoscopic ultrasound-guided tissue acquisition techniques for solid pancreatic tumor

Pancreatic ductal adenocarcinoma is speculated to become the second leading cause of cancer-related mortality by 2030, a high mortality rate considering the number of cases. Surgery and chemotherapy are the main treatment options, but they are burdensome for patients. A clear histological diagnosis is needed to determine a treatment plan, and endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is a suitable technique that does not worsen the cancer-specific prognosis even for lesions at risk of needle tract seeding. With the development of personalized medicine and precision treatment, there has been an increasing demand to increase cell counts and collect specimens while preserving tissue structure, leading to the development of the fine-needle biopsy (FNB) needle. EUS-FNB is rapidly replacing EUS-guided fine-needle aspiration (FNA) as the procedure of choice for EUS-TA of pancreatic cancer. However, EUS-FNA is sometimes necessary where the FNB needle cannot penetrate small hard lesions, so it is important clinicians are familiar with both. Given these recent dev-elopments, we present an up-to-date review of the role of EUS-TA in pancreatic cancer. Particularly, technical aspects, such as needle caliber, negative pressure, and puncture methods, for obtaining an adequate specimen in EUS-TA are discussed.

Case report: Per oral endoscopic myotomy (POEM) during pregnancy

Esophageal achalasia is the most frequent primary motor disorder of the esophagus, resulting in a peristalsis and failed relaxation of the lower esophageal sphincter (LES). Various treatments have been described. Endoscopic alternatives include botulinum toxin injection and pneumatic balloon dilation, but both tend to fail with time and usually repeated interventions are required. Laparoscopic Heller myotomy (LHM) has been considered the gold standard. The diagnosis of achalasia during pregnancy is extremely rare and optimal management remains unclear. Our aim was to report a successful per oral endoscopic myotomy (POEM) performed during pregnancy. A 40‐year‐old pregnant woman presented with esophageal achalasia during her first trimester. Her disease was diagnosed with high resolution esophageal manometry (HREM). Initially an expectant conduct was attempted, but dysphagia progressed during the first 6 weeks of follow‐up and an important weight loss was noticed. She underwent POEM at 15 weeks of gestation. After the procedure, she reported relief of both dysphagia and regurgitation, and her nutritional status improved. She delivered a healthy boy at term. During follow‐up, she remains without dysphagia, her upper GI endoscopy shows no esophagitis and her HREM reports a normal integrated relaxation pressure. In achalasia, as in other clinical conditions, therapeutic decisions during pregnancy should always consider both the welfare of the mother and the fetus. POEM is a purely endoscopic treatment and has been recognized as a safe procedure to treat achalasia, with postoperative clinical success comparable to LHM and potential benefits over it.

Perforated gastric ulcer after unhealthy decisions in a patient with an intragastric balloon, a hangover you will regret

BACKGROUND

Perforated gastric ulcers are life-threatening surgical emergencies that need early diagnosis and treatment to overcome severe complications. With the rise of obesity in recent years, intragastric balloons have arisen as a "safe" strategy; however, in medicine, no treatment is risk-free. Nausea, pain, vomiting, and more severe complications like perforation, ulceration, and death can occur.

CASE PRESENTATION

We present the case of a 28-year-old man with obesity; treatment with an intragastric balloon was initiated with good results at the beginning of his treatment. However, he neglected his treatment over time and made unhealthy choices, leading to a severe complication. However, thanks to prompt surgical treatment, he made a full recovery.

COMPLICATIONS

Gastric perforation following an intragastric balloon is a severe and potentially life-threatening complication that an experienced multidisciplinary team must treat promptly and, more importantly, prevent.

Surgical management of acute pancreatitis: Historical perspectives, challenges, and current management approaches

Acute pancreatitis (AP) is a serious condition presenting catastrophic consequences. In severe AP, the mortality rate is high, and some patients initially diagnosed with mild-to-moderate AP can progress to a life-threatening severe state. Treatment of AP has evolved over the years. Drainage was the first surgical procedure performed for AP; however, later, surgical approaches were replaced by more conservative approaches due to the availability of advanced medical care and improved understanding of the course of AP. Currently, surgery is used to manage several complications of AP, such as pseudocysts, pancreatic fistulas, and biliary tract obstruction. Patients who are unresponsive to conservative treatment or have complications are typically considered for surgical intervention. This review focuses on the surgical approaches (endoscopic, percutaneous, and open) that have been established in recent studies to treat this acute condition and summarizes the common management guidelines for AP, discussing the relevant indications, significance, and complications. It is evident that despite their reduced involvement, surgeons lead the multidisciplinary care of patients with AP; however, given the gaps in existing knowledge, more research is required to standardize surgical protocols for AP.

Risk factors of pancreatitis after endoscopic retrograde cholangiopancreatography in patients with biliary tract diseases

BACKGROUND

To investigate the risk factors of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in patients with biliary tract diseases.

METHODS

We retrospectively analyzed the clinical data of 480 patients who underwent ERCP for biliary tract diseases at the Affiliated Zhongshan Hospital of Dalian University from October 2011 to October 2016. The patients were divided into a study group (n = 75, with PEP) and a control group (n = 405, without PEP) based on whether they developed post-ERCP pancreatitis (PEP), and their clinical baseline data and intraoperative conditions were retrieved and compared. Then, factors associated with PEP were analyzed using logistic regression model, based on which a nomogram prediction model was constructed. The receiver operating characteristic (ROC) curve and calibration curve were used to evaluate the performance of the prediction model.

RESULTS

Significant differences in age, sex, history of pancreatitis, history of choledocholithiasis, pancreatic duct imaging, pancreatic sphincterotomy, difficult cannulation, multiple cannulation attempts and juxtapapillary duodenal diverticula were observed between the two groups. Multivariate logistic regression analysis showed that age less than 60 years (OR, 0.477; 95% CI, 0.26-0.855), female sex (OR, 2.162; 95% CI, 1.220-3.831), history of pancreatitis (OR, 2.567; 95% CI, 1.218-5.410), history of choledocholithiasis (OR, 2.062; 95% CI, 1.162-3.658), pancreatic sphincterotomy (OR, 2.387; 95% CI, 1.298-4.390), pancreatic duct imaging (OR, 4.429; 95% CI, 1.481-13.242), multiple cannulation attempts (OR, 2.327; 95% CI, 1.205-4.493), difficult cannulation (OR, 2.421; 95% CI, 1.143-5.128), and JPD (OR, 2.002; 95% CI, 1.125-3.564) were independent risk factors for PEP. The nomogram for predicting the occurrence of PEP demonstrated an area under the ROC curve (AUC) of 0.787, and the calibration curves of the model showed good consistency between the predicted and actual probability of PEP.

CONCLUSION

Our results showed that age less than 60 years, female sex, history of pancreatitis, history of choledocholithiasis, pancreatic sphincterotomy, pancreatic duct imaging, multiple cannulation attempts, difficult cannulation and juxtapapillary duodenal diverticula were independent risk factors for PEP. In addition, the established nomogram demonstrated promising clinical efficacy in predicting PEP risk in patients who underwent ERCP for biliary tract diseases.

Australian inflammatory bowel disease consensus statements for preconception, pregnancy and breast feeding

OBJECTIVE

Because pregnancy outcomes tend to be worse in women with inflammatory bowel disease (IBD) than in those without, we aimed to update consensus statements that guide the clinical management of pregnancy in patients with IBD.

DESIGN

A multidisciplinary working group was established to formulate these consensus statements. A modified RAND/UCLA appropriateness method was used, consisting of a literature review, online voting, discussion meeting and a second round of voting. The overall agreement among the delegates and appropriateness of the statement are reported.

RESULTS

Agreement was reached for 38/39 statements which provide guidance on management of pregnancy in patients with IBD. Most medications can and should be continued throughout pregnancy, except for methotrexate, allopurinol and new small molecules, such as tofacitinib. Due to limited data, no conclusion was reached on the use of tioguanine during pregnancy. Achieving and maintaining IBD remission before conception and throughout pregnancy is crucial to optimise maternofetal outcomes. This requires a multidisciplinary approach to engage patients, allay anxieties and maximise adherence tomedication. Intestinal ultrasound can be used for disease monitoring during pregnancy, and flexible sigmoidoscopy or MRI where clinically necessary.

CONCLUSION

These consensus statements provide up-to-date, comprehensive recommendations for the management of pregnancy in patients with IBD. This will enable a high standard of care for patients with IBD across all clinical settings.

Esophageal anthracosis occurred after treatment of esophageal tuberculosis secondary to mediastinal tuberculous lymphadenitis: a rare case report

BACKGROUND

Anthracosis is a disease generally considered to be in the lungs resulting from exposure to industrial dust in the workplace. Esophageal anthracosis is a fairly rare phenomenon and shows a strong correlation with tuberculosis. Moreover, esophageal involvement in tuberculosis is also rare. We here present an extremely rare case in which follow-up gastroesophageal endoscopy revealed a mass with a sunken, black area in the center and raised ring-like pattern in the surrounding mucosa resembling malignant melanoma. Uncovering the patient's tuberculosis history finally avoided a misdiagnosis or overtreatment.

CASE PRESENTATION

A 67-year-old male patient was admitted to the hospital due to "repeated chest pain for 1 month". Endoscopic ultrasonography and contrast-enhanced CT scans revealed a mass adjacent to the esophageal wall with unclear boundaries. Aspiration biopsy confirmed that esophageal tuberculosis was caused by nearby mediastinal tuberculous lymphadenitis. After a standard anti-tuberculosis treatment regimen, the patient achieved a favorable prognosis. The follow-up gastroesophageal endoscopy showed a sunken black lesion with elevated peripheral mucosa replacing the original tuberculous mass, which was thought to be anthracosis, a disease that rarely occurs in the esophagus.

CONCLUSION

The diagnosis of tuberculosis should be taken into consideration when a submucosal mass appears in the middle part of the esophagus. Endoscopic ultrasonography can effectively contribute to a definite diagnosis. Moreover, this is the first case of esophageal anthracosis observed only 1 year after the treatment of tuberculosis, indicating esophageal anthracosis can be a short-term disease. The traction of the reduction of tubercular mediastinal lymph nodes after anti-tuberculosis treatment may create a circumstance for pigmentation or dust deposition.

Factors affecting the quality of bowel preparation for colonoscopy in hard-to-prepare patients: Evidence from the literature

Adequate bowel cleansing is critical for a high-quality colonoscopy because it affects diagnostic accuracy and adenoma detection. Nevertheless, almost a quarter of procedures are still carried out with suboptimal preparation, resulting in longer procedure times, higher risk of complications, and higher likelihood of missing lesions. Current guidelines recommend high-volume or low-volume polyethylene glycol (PEG)/non-PEG-based split-dose regimens. In patients who have had insufficient bowel cleansing, the colonoscopy should be repeated the same day or the next day with additional bowel cleansing as a salvage option. A strategy that includes a prolonged low-fiber diet, a split preparation regimen, and a colonoscopy within 5 h of the end of preparation may increase cleansing success rates in the elderly. Furthermore, even though no specific product is specifically recommended in the other cases for difficult-to-prepare patients, clinical evidence suggests that 1-L PEG plus ascorbic acid preparation are associated with higher cleansing success in hospitalized and inflammatory bowel disease patients. Patients with severe renal insufficiency (creatinine clearance < 30 mL/min) should be prepared with isotonic high volume PEG solutions. Few data on cirrhotic patients are currently available, and no trials have been conducted in this population. An accurate characterization of procedural and patient variables may lead to a more personalized approach to bowel preparation, especially in patients undergoing resection of left colon lesions, where intestinal preparation has a poor outcome. The purpose of this review was to summarize the evidence on the risk factors influencing the quality of bowel cleansing in difficult-to-prepare patients, as well as strategies to improve colonoscopy preparation in these patients.

Management of colorectal high-grade dysplasia or cancer resected by cold snare polypectomy: a multicenter exploratory study

BACKGROUND

The clinical course and surveillance strategy for patients who undergo cold snare polypectomy (CSP) for high-grade dysplasia (HGD) or cancer is unclear. We investigated the management of colorectal HGDs and cancers following CSP.

METHODS

This Japanese nationwide multicenter exploratory study was retrospectively conducted on patients who had undergone CSP for colorectal HGDs or cancers and follow-up colonoscopy at least once from 2014 to 2020. We investigated the detection rate of CSP scars, local recurrence rate (LRR), risk factors for local recurrence, and follow-up strategy. This study was registered with the University Hospital Medical Information Network (UMIN) Clinical Trials Registry (UMIN000043670).

RESULTS

We included 155 patients with 156 lesions. CSP scars were identified in 22 (31.4%), 41 (54.7%), and 10 (90.9%) patients with curative, borderline, and non-curative resection, respectively. Among them, residual tumors were observed in one (4.5%), six (14.6%), and three (30.0%) cases, respectively. The total LRR was 13.7% (95% confidence interval: 6.8-23.8). R1 resection cases (either horizontal or vertical margins positive for tumors) were associated with local recurrence (p = 0.031). Salvage endoscopic and surgical resections were performed on 21 and 10 patients, respectively. Among them, the proportion of endoscopically suspected residual tumors was significantly higher (p < 0.001) in the residual tumor-positive group (100%) than in the residual tumor-negative group (28.6%).

CONCLUSIONS

LRR after CSP for HGDs or cancers was 13.7% based on scar-identified cases. Salvage endoscopic or surgical resection should be performed according to the curability of the lesion and endoscopic findings during colonoscopic surveillance.

One-year review of real-time artificial intelligence (AI)-aided endoscopy performance

BACKGROUND

Colonoscopies have long been the gold standard for detection of pre-malignant neoplastic lesions of the colon. Our previous study tried real-time artificial intelligence (AI)-aided colonoscopy over a three-month period and found significant improvements in collective and individual endoscopist's adenoma detection rates compared to baseline. As an expansion, this study evaluates the 1-year performance of AI-aided colonoscopy in the same institution.

METHODS

A prospective cohort study was conducted in a single institution in Singapore. The AI software used was GI Genius™ Intelligent Endoscopy Module, US-DG-2000309 © 2021 Medtronic. Between July 2021 and June 2022, polypectomy rates in non-AI-aided colonoscopies and AI-aided colonoscopies were calculated and compared. Some of the AI-aided colonoscopies were recorded and video reviewed. A "hit" was defined as a sustained detection of an area by the AI. If a polypectomy was performed for a "hit," its histology was reviewed. Additional calculations for polyp detection rate (PDR), adenoma detection rate (ADR), and adenoma detection per colonoscopy (ADPC) were performed. Cost analysis was performed to determine cost effectiveness of subscription to the AI program.

RESULTS

2433 AI-aided colonoscopies were performed between July 2021 and June 2022 and compared against 1770 non-AI-aided colonoscopies. AI-aided colonoscopies yielded significantly higher rates of polypectomies (33.6%) as compared with non-AI-aided colonoscopies (28.4%) (p < 0.001). Among the AI-aided colonoscopies, 1050 were reviewed and a final 843 were included for additional analysis. The polypectomy to "hit" ratio was 57.4%, PDR = 45.6%, ADR = 32.4%, and ADPC = 2.08. Histological review showed that 25 polyps (3.13%) were sessile-serrated adenomas. Cost analysis found that the increased polypectomy rates in AI-aided colonoscopes led to an increase in revenue, which covered the subscription cost with an excess of USD 20,000.

CONCLUSION

AI-aided colonoscopy is a cost effective means of improving colonoscopy quality and may help advance colorectal cancer screening in Singapore.

Patient Attitudes and Barriers to Endoscopy During the COVID-19 Pandemic

BACKGROUND

After COVID-19 restrictions on nonessential procedures were lifted and safety protocols established, utilization rates of endoscopic procedures remained reduced.

AIMS

This study assessed patient attitudes and barriers to scheduling endoscopy during the pandemic.

METHODS

A survey was administered to patients with ordered procedures at a hospital-based setting (7/21/2020-2/19/2021) collecting demographic data, body mass index, COVID-19 relevant comorbidities, level of procedural urgency (defined by recommended scheduling window), scheduling and attendance, concerns, and awareness of safety measures.

RESULTS

The average respondent was female (63.8%), age 57.6 ± 14, White (72.3%), married (76.7%), insured (99.3%), affluent English speakers (92.3%) and highly educated (at least college 90.2%). Most reported moderate to excellent COVID-19 knowledge (96.6%). Of 1039 procedures scheduled, emergent cases accounted for 5.1%, urgent 55.3% and elective 39.4%. Respondents identified appointment convenience (48.53%) as the most frequent factor impacting scheduling, also noting concern for results (28.4%). Age (p = .022), native language (p = .04), education (p = .007), self-reported COVID knowledge (p = .002), and a desire to be COVID tested pre-procedure (p = .023) were associated with arrival, more commonly in an ambulatory surgical center than hospital (p = .008). Diabetes mellitus (p = .004) and an immunocompromised state (p = .009) were adversely related to attendance. Attitudes towards safety protocols did not affect scheduling. Multivariate analysis demonstrated age, education and COVID knowledgeability were associated with procedure completion.

CONCLUSIONS

Safety protocols and urgency levels were not associated with procedure completion. Pre-pandemic barriers to endoscopy persisted as dominant factors amid pandemic concerns.

Comparison of Needle Knife versus Scissors Forceps for Colorectal Endoscopic Submucosal Dissection: A Prospective Randomized Study

Background and Aim: To evaluate the efficacy and safety of a grasping-type knife, called Clutch Cutter (CC), for colorectal endoscopic submucosal dissection (C-ESD). Methods: This was a randomized prospective study. Patients who underwent C-ESD for colorectal neoplasms >20 mm and <50 mm in size were enrolled, dividing into two groups: ESD using needle type of dual knife alone (D-group) and circumferential incision using dual knife followed by submucosal dissection using CC (CC-group). The primary outcome was the self-completion rate. The secondary outcomes were intraoperative complication rate, procedure time, and en bloc resection rate. Results: A total of 45 patients were allocated to the D-group and 43 to the CC-group were allocated. The self-completion rate was higher in the CC-group (87% [39/45] vs. 98% [42/43]). All of the six patients with an incomplete procedure in the D-group were completely resected with CC use. The intraoperative complication rate was not significant in either group (D vs. CC: 2% vs. 0%). The mean procedure time was significantly shorter in the D-group than that in the CC-group (62.0 vs. 81.1 min; p = 0.0036). The en bloc resection rate was 100% in the D-group and 98% in the CC-group. Conclusions: While dual knife use is superior to CC in terms of time efficiency, the use of CC may be a safe and efficacious option for achieving complete C-ESD.

Burden of gastrointestinal cancers in China from 1990 to 2019 and projection through 2029

Although gastrointestinal (GI) cancers pose a great challenge to public health, data are scant for understanding the burden of GI cancers in China. We aimed to provide an updated estimate of the burden of major GI cancers in China over three decades. According to the GLOBOCAN 2020 database, 1,922,362 GI cancer cases were newly diagnosed and 1,497,388 deaths occurred in China in 2020, with the highest incidence in colorectal cancer (555,480 new cases; 23.90/100,000 age-standardized incidence rate [ASIR]) and the highest mortality in liver cancer (391,150 deaths; 17.20/100,000 age-standardized mortality rate [ASMR]). The age-standardized rates (ASRs) in incidence, mortality, and disability-adjusted life year (DALY) rates for esophageal, gastric, and liver cancers have declined overall (1990-2019, average annual perventage change [AAPC] < 0%, p < 0.001) but have become flattened or reversed in recent years, alarmingly. The spectrum of GI cancers in China will continue transitioning in the next decade, characterized by rapid increases in colorectal and pancreatic cancers in addition to a high burden of esophageal, gastric, and liver cancers. High body-mass index was found to be the fastest-growing risk factor for GI cancers (estimated annual perventage change [EAPC]: 2.35%-3.20%, all p < 0.001), whereas smoking and alcohol consumption remained the top contributors to GI cancer-related deaths in men. In conclusion, GI cancers in China are challenging the healthcare system with a growing burden and a transitioning pattern. Comprehensive strategies are needed to reach the Healthy China 2030 target.

Endoscopic techniques for gastric neuroendocrine tumors: An update

Gastric neuroendocrine neoplasms (gNENs) are a rare type of gastric neoplasm, even if their frequency is increasing according to the latest epidemiologic revisions of the main registries worldwide. They are divided into three main subtypes, with different pathogeneses, biological behaviors, and clinical characteristics. GNEN heterogeneity poses challenges, therefore these neoplasms require different management strategies. Update the knowledge on the endoscopic treatment options to manage g-NENs. This manuscript is a narrative review of the literature. In recent years, many advances have been made not only in the knowledge of both the pathogenesis and the molecular profiling of gNENs but also in the endoscopic expertise towards innovative treatment options, which proved to be less aggressive without losing the capability of being radical. The endoscopic approach is increasingly applied in the field of gastrointestinal (GI) luminal neoplasms, and this is true not only for adenocarcinomas but also for gNENs. In particular, different techniques have been described for the endoscopic removal of suspected lesions, ranging from classical polypectomy (cold or hot snare) to endoscopic mucosal resection (both with “en bloc” or piecemeal technique), endoscopic submucosal dissection, and endoscopic full-thickness resection. GNENs comprise different subtypes of neoplasms with distinct management and prognosis. New endoscopic techniques offer a wide variety of approaches for GI localized neoplasms, which demonstrated to be appropriate and effective also in the case of gNENs. Correct evaluation of size, site, morphology, and clinical context allows the choice of tailored therapy in order to guarantee a definitive treatment.