Investigation of the actual implementation of "post-sedation discharge briteria" and "time-out" immediately before procedure in endoscopy: A nationwide survey study in Japan

OBJECTIVES

Post-sedation discharge criteria for outpatient endoscopy and time-out procedures immediately before endoscopic examinations are important for ensuring patient safety. This study used a web-based questionnaire to survey the implementation status and current situation of these practices in Japan in 2024.

METHODS

A self-administered questionnaire was conducted from December 2023 to January 2024 using Google Forms. Participants were primarily from facilities involved in endoscopy study groups and readers of an endoscopy-specific e-newsletter. Additionally, medical staff from endoscopic centers across Japan were invited to participate in collaboration with the Japan Gastroenterological Endoscopy Technicians Society.

RESULTS

A total of 1,495 valid responses (medical staff: 1197 [80%]; doctors: 298) were collected from 1168 facilities, after excluding duplicate responses. Among the participating facilities, 58% were general hospitals, 21% were clinics or health check-up centers, and 9% were university hospitals or national cancer centers. Post-sedation discharge criteria were implemented in 58% of facilities for esophagogastroduodenoscopy and 56% for colonoscopy, with the post-sedation recovery score used as the criterion in about half of these cases. Time-out procedures were implemented in 57% of the facilities for both esophagogastroduodenoscopy and colonoscopy. Items confirmed during time-out in more than half of the facilities included: patient's name, details of antithrombotic drugs, content of examination, drug allergies, underlying disease, date of birth, consent form, age, procedure start time, and patient's identification number.

CONCLUSION

The implementation rate of post-sedation discharge criteria and time-out procedures was found to be close to 60%, reflecting the real-world situation in Japan in 2024.

Optimal timing of precut sphincterotomy to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in difficult biliary cannulation: A retrospective study

Objectives

Precut sphincterotomy is often performed when bile duct cannulation is difficult; however, the former has a higher risk of complications than conventional methods. Early precut reduces the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). This study aimed to determine the appropriate timing for precut sphincterotomy to minimize the incidence of PEP.

Methods

This retrospective study analyzed 320 patients who underwent precut sphincterotomy during their first endoscopic retrograde cholangiopancreatography at a single center. The optimal precut timing was identified using receiver operating characteristic analysis. Patients were divided into an optimized precut group (≤12 min, n = 198) and a delayed group (>12 min, n = 122). The incidence and risk factors of PEP were evaluated using multivariate analyses.

Results

Receiver operating characteristic analysis identified 12.5 min as the optimal cutoff for transitioning to precut sphincterotomy (area under the curve, 0.613; sensitivity, 61.5%; specificity, 63.9%). The incidence of PEP was significantly lower in the optimized precut group than in the delayed precut group (5.1% vs. 13.1%, p = 0.02). Multivariate analysis identified delayed precut timing (odds ratio [OR], 3.134; p = 0.04) and the absence of endoscopic pancreatic stenting (OR, 0.284; p = 0.01) as independent risk factors for PEP.

Conclusion

Precut sphincterotomy within 12.5 min of a cannulation attempt reduces the risk of PEP while maintaining procedural safety. Additionally, endoscopic pancreatic stenting can reduce PEP, even in precut scenarios.

Updated evidence on epidemiology, diagnosis, and treatment for colonic diverticular bleeding

Since 2020, multiple large-scale studies (CODE BLUE-J) in Japan have accelerated the accumulation of evidence on colonic diverticular bleeding (CDB). This review summarizes the latest findings regarding CDB epidemiology and endoscopic hemostasis. Recent data show that CDB has become the most common cause of lower gastrointestinal bleeding in Japan, driven by an aging population and the increased use of antithrombotic medications. Although 70%-90% of patients achieve spontaneous hemostasis, rebleeding occurs in up to 35% of cases within 1 year. Despite an overall mortality rate of < 1%, patients with CDB can present with hypovolemic shock and may require urgent intervention. There are no effective pharmacological treatments for controlling CDB. Therefore, endoscopic therapy plays a crucial role in its management. Based on available evidence, both clipping and endoscopic band ligation are considered effective initial treatments. Recent studies indicate that direct clipping reduces early rebleeding compared with indirect clipping, while endoscopic band ligation achieves lower rebleeding rates (13%-15%) than clipping. The choice between direct clipping and endoscopic band ligation depends on the diverticulum location and the presence of active bleeding. Newer techniques, such as over-the-scope clip and self-assembling peptide application, have shown potential, but require further study. The detection of the bleeding source remains challenging because accurate identification is essential for successful hemostasis. Additional research is needed to refine the endoscopic diagnostic and therapeutic techniques, prevent rebleeding, and improve patient outcomes.

Tumour necrosis factor inhibitors in Ulcerative colitis: real-world data on Therapeutic drug monitoring and evaluation of current treatment targets (STRIDE II)

BACKGROUND

The benefit of therapeutic drug monitoring (TDM) and implementation of recommendations from the Selection of Therapeutic Targets in Inflammatory Bowel Disease (IBD, STRIDE) are discussed in the IBD community. We report real-world data in ulcerative colitis patients receiving first-line tumour necrosis factor inhibitor (TNFi) treatment followed by TDM, and assess how implementation of the STRIDE II recommendations might affect clinical practice.

METHODS

Adult, biologically naïve UC patients starting TNFi between 2014 and 2021 at Oslo University Hospital were included in a medical chart review study, and data were collected at three and twelve months after the start of treatment. Target serum drug levels were defined as ≥7.5 mg/L for adalimumab and ≥5 mg/L for infliximab.

RESULTS

Of 141 included patients, 36% were in clinical and biochemical (combined) remission after twelve months. Among 102 treatment persistent patients, 54% were in combined remission after twelve months. Target drug level at three months was associated with clinical remission at twelve months (OR = 2.97, 95% CI [1.24-7.12]) and biochemical remission at twelve months (OR = 2.64, 95% CI [1.03-6.77]). In total, 56% of recorded dosage adjustments were related only to serum drug levels.

CONCLUSIONS

Combined remission rates at twelve months for treatment persistent patients suggest that 46% should have been considered for a change of treatment according to the STRIDE II recommendations. A majority of dosage adjustments were made proactively. Target drug level at three months was associated with remission at twelve months and supports the use of proactive TDM.

Structural or functional abnormality of sphincter of Oddi: an important factor for the recurrence of choledocholithiasis after endoscopic treatment

A high recurrence rate is undesirable after treatment of common bile duct (CBD) stones. A major risk factor identified for recurrence is that invasive techniques, including surgical or endoscopic treatments, will impair the biliary tract system either by direct incision of the CBD or by cutting or dilating the ampulla of Vater. During endoscopic treatment, two main assisted methods for lithotomy, sphincterotomy and papillary balloon dilation, can result in different degrees of damage to the structure and function of the sphincter of Oddi (SO), contributing to slowing of biliary excretion, cholestasis, biliary bacterial infection, and promotion of bile duct stone recurrence. In this review, the relationship between endoscopic lithotomy and structural impairment or functional abnormality of the SO will be summarized, and their relationship with the recurrence of CBD stones will also be analyzed. Further improvement of these endoscopic methods or exploration of some novel methods, such as endoscopic endoclip papilloplasty, temporary insertion of a self-expandable metal stent, and combined application of peroral cholangioscopy, may aid in providing more appropriate treatment for patients with choledocholithiasis, repair or protect the function and structure of SO, reduce or prevent the recurrence of bile duct stones, and improve patient outcomes.

Therapeutic Potential of Upadacitinib in Adolescents with Idiopathic Chronic Panuveitis Who Lost Response to Adalimumab

PURPOSE

This report highlights the administration of upadacitinib in four adolescents with idiopathic chronic refractory panuveitis who showed an inadequate response to systemic glucocorticoids, immunosuppressive agents, and anti-TNF biologic therapy.

METHODS

We present four cases: two 13-year-old boys, one 15-year-old boy, and one 14-year-old girl, each with a history of idiopathic panuveitis that persisted for 4, 8, 4, and 5 years, respectively.

RESULTS

Upadacitinib effectively reduced ocular inflammation in all four cases during the first month of treatment. Following upadacitinib treatment, adalimumab was discontinued or extended, and the immunosuppressive agents were gradually tapered. In two cases, it led to complete resolution of the anterior segment and vitreous inflammation and significant improvement in the posterior segment. However, two patients developed upper respiratory tract symptoms at the second and fifth months, respectively, both of which were associated with recurrence of ocular inflammation and required high-dose glucocorticoids for control. No other serious adverse events were documented in the four patients during the nine to ten months follow-up period.

CONCLUSIONS

These cases indicate that upadacitinib may be an effective treatment strategy for adolescents with idiopathic chronic refractory panuveitis. However, the potential risk of infections should be considered and monitored.

Predicting Outcomes in Hospitalized Patients With Acute Severe Ulcerative Colitis in a Prospective Multicenter Cohort

BACKGROUND AND AIMS

Acute severe ulcerative colitis (UC) (ASUC) requiring hospitalization affects up to 1 in 4 patients with UC. There is a paucity of prospective and multicenter clinical cohorts to study treatment trends and predictors of disease outcomes. Here, we conduct a US-based multicenter prospective clinical cohort of ASUC to study predictors of the need for medical rescue therapy and colectomy.

METHODS

A total of 94 patients hospitalized for ASUC were included across 5 academic centers from December 2018 to December 2021. Demographic, clinical, and laboratory data were collected throughout the hospitalization. Patients were followed up to 1-year post-hospitalization to identify predictors of the need for rescue therapy and colectomy.

RESULTS

A total of 21 (22.3%) patients required colectomy within 1 year of admission with 11 (12%) requiring colectomy during the index admission. On multivariate analyses, a BMI < 21.5 kg/m2 (OR = 6.16, P = .02), a simple clinical colitis activity index (SCCAI) greater than 8 (OR = 14.44, P = .01) and an albumin level at admission lower than 2.4 g/dL (OR = 10.61, P = .04) were significant predictors of inpatient colectomy after adjusting for sex, age, and duration of disease.

CONCLUSIONS

In a prospective, multicenter cohort of patients hospitalized with ASUC, BMI, SCCAI, and albumin at admission were important determinants of colectomy risk during the index hospitalization and within 1 year of admission. Colectomy rates remain high-22.3% in this cohort across 5 academic, tertiary care centers-underscoring the need to identify the highest-risk patients, establish novel treatment and care paradigms, and examine opportunities to standardize care.

Longitudinal computed tomography-based delta-radiomics of visceral adipose tissue predicts infliximab secondary loss of response in Crohn’s disease patients

BACKGROUND

Visceral adipose tissue (VAT) plays a role in the pathogenesis of Crohn's disease (CD) and is associated with treatment outcomes following infliximab (IFX) therapy. We developed and validated the first delta-radiomics model to quantify VAT heterogeneity as a predictive biomarker for IFX response in patients with CD.

AIM

To develop a longitudinal computed tomography (CT)-based delta-radiomics model of VAT for predicting secondary loss of response (SLR) in patients with CD.

METHODS

This retrospective study included 161 patients with CD who achieved clinical remission following IFX induction therapy between 2015 and 2023. All patients underwent CT enterography before IFX initiation and after completing induction therapy. VAT volume was delineated by two radiologists in consensus. Radiomics features were extracted from pre-treatment and post-induction CT images, and delta-radiomics features were calculated as follows: Delta features = Feature_-post - Feature_-pre. A radiomics model was constructed using logistic regression. Model performance was assessed using discrimination, calibration, and decision curve analyses.

RESULTS

Nine significant delta-radiomics features were used to develop the delta-radiomics model, yielding an area under the receiver operating characteristic curve (AUC) of 0.816 (95%CI: 0.737-0.896) in the training cohort and 0.750 (95%CI: 0.605-0.895) in the validation cohort. Multivariable logistic regression identified platelet count, Montreal behavior classification, and the VAT/subcutaneous adipose tissue volume ratio prior to treatment as independent risk factors for SLR. The combined model integrating clinical predictors and delta-radiomics features achieved superior predictive performance, with an AUC of 0.853 (95%CI: 0.786-0.921) in the training cohort and 0.812 (95%CI: 0.677-0.948) in the validation cohort.

CONCLUSION

We developed a predictive model based on longitudinal changes in VAT, demonstrating significant potential for identifying patients with CD at high risk of SLR to IFX therapy.

Rectal diclofenac versus indomethacin for prevention of post-ERCP pancreatitis (DIPPP): a multicentre, double-blind, randomised, controlled trial

BACKGROUND

Recent meta-analyses suggested diclofenac may be superior to indomethacin in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The aim of our study was to compare the efficacy of 100 mg rectal indomethacin versus diclofenac on PEP incidences.

DESIGN

This multicentre, double-blinded, randomised controlled trial was conducted in nine tertiary centres in China. Patients with low and high risk for PEP and native papilla were randomly allocated (1:1) to receive 100 mg diclofenac or 100 mg indomethacin rectally before ERCP. The primary outcome was the occurrence of PEP defined by the Cotton consensus. The intention-to-treat principle was conducted for the analysis.

RESULTS

The trial was terminated early for futility after the predetermined first interim analysis. Between June 2023 and May 2024, 1204 patients were randomised into the diclofenac group (n=600) or indomethacin group (n=604). Baseline characteristics were balanced. The primary outcome occurred in 53 patients (8.8%) of 600 patients allocated to the diclofenac group and 37 patients (6.1%) of 604 patients allocated to the indomethacin group (relative risk 1.44; 95% CI 0.96 to 2.16, p=0.074). PEP occurred in 35 (14.2%) of 247 high-risk patients in the diclofenac group and 26 (9.8%) of 266 high-risk patients in the indomethacin group (p=0.124). PEP incidences were also comparable in low-risk patients between the two groups (18/353 (5.1%) vs 11/338 (3.3%), p=0.227). Other ERCP-related complications did not differ between the two groups.

CONCLUSION

Pre-procedure 100 mg rectal diclofenac was not superior to the same dose of rectal indomethacin regarding preventing PEP. These findings supported current clinical practice guidelines of 100 mg indomethacin or diclofenac for PEP prophylaxis in patients without contraindications.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT05947461).

Green Endoscopy: A Review of Global Perspectives on Environmental Sustainability of Gastrointestinal Endoscopy

Endoscopic procedures are the cornerstone of intervention in gastroenterology-from evaluating common illnesses to non-surgically managing complex diseases. Expectedly, these procedures are linked to greenhouse gas (GHG) emissions globally and contribute significantly to the global climate change crisis. Professional gastroenterology societies globally raise awareness of this evolving crisis and suggest specific measures to appropriately measure the burden contributed by endoscopy units and mitigate the environmental impact of this common clinical practice. To the unsuspecting eye, the solution to this crisis is relatively simple: decrease the utilization of endoscopic procedures. However, the dependence of modern medicine on these procedures, both diagnostically and therapeutically, makes it significantly more challenging to reduce their utilization. Instead, a structured approach to systematically consider the specific indications for each procedure, minimize waste generation, promote recycling of waste products, and limit the number of repeat endoscopies until clinically necessary may be more pragmatic to reduce GHG emissions globally. In this narrative review, we discuss the perspectives of global gastroenterology societies on sustainable or "green" endoscopy and summarize their recommendations to aid the day-to-day gastroenterologist in making their contribution to environmental sustainability while providing optimal care to their patients.

Effects of infliximab infusion on clinical symptom scores and serum cytokines in patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic relapsing gastrointestinal disorder. Infliximab (INF) has shown good efficacy in IBD treatment, but its specific impact requires further exploration. This study aimed to assess the effects of intravenous INF on clinical symptom scores and serum cytokine levels in IBD patients.

METHODS

A retrospective review of 126 IBD patients treated with INF was conducted. Baseline data, Mayo scores, Crohn's Disease Activity Index (CDAI) scores at 6 and 12 months, and serum levels of TNF-α, IL-6, IL-10, and CRP were recorded. Correlations between disease activity scores and inflammatory markers were analyzed, and the relationship between baseline indicators and treatment efficacy was examined.

RESULTS

At 12 months, Mayo and CDAI scores, TNF-α, IL-6, and CRP levels were significantly reduced, while IL-10 levels increased. Disease activity scores positively correlated with TNF-α, IL-6, and IL-1β, and negatively with IL-10. Factors such as Crohn's disease subtype, age, high baseline CDAI or Mayo scores, elevated TNF-α, IL-6, CRP, and longer disease duration were associated with poorer outcomes (p < 0.05). Multivariate analysis identified disease type, high baseline disease activity, long disease duration, and elevated inflammatory markers as independent risk factors. Adverse reactions were infrequent, with no serious adverse events reported.

CONCLUSION

Intravenous INF effectively improves clinical symptoms and modulates inflammatory cytokines in IBD patients, with favorable safety and increasing efficacy over time. However, the limited sample size and lack of long-term data warrant further validation in larger, prospective multicenter studies.

IQ Survey Results on Current Industry Practices-Part 1: Immunogenicity Risk Assessment

An immunogenicity risk assessment (IRA) is a relatively new expectation of health authorities that is increasingly incorporated into the drug development process across the pharmaceutical/biotech industry. The guiding principle for an IRA includes a comprehensive evaluation of product- and patient-related factors that may influence the immunogenic potential of a biotherapeutic drug and a potential action plan. The Immunogenicity Working Group from the IQ Consortium (Clinical Pharmacology Leadership Group) has conducted a survey to understand the current practices for conducting IRAs and relevant aspects of bioanalysis. Survey results were provided by 19 IQ member companies participating in the Clinical Pharmacology Leadership Group (CPLG) and the Translational and ADME Sciences Leadership Group (TALG). Nearly all the respondents reported experience with monoclonal antibodies (mAb), with 10 other drug modalities including bioengineered protein therapeutics such as fusion and multi-domain proteins, peptides, oligonucleotides as well as gene and cell therapies. The survey results demonstrate that most companies have a defined IRA process, and there was a common understanding that the IRA may need to be revised as more information becomes available or the drug development strategy changes. Some differences found across the respondents are related to the time frame for implementation of IRA document, the types of preclinical data and computational methods used to assess risk, and how the IRA informs clinical plans and documentation practices. These results highlight that while there have been widespread insights gained with performing IRA for mAbs, more experience is needed to perform IRAs for the novel modalities.

Evaluating the risk of duodenoscope-associated colonization and duodenoscope-associated infection: a prospective observational study

BACKGROUND

The risk of duodenoscope-associated colonization (DAC) and infection (DAI) after endoscopic retrograde cholangiopancreatography (ERCP) with a contaminated duodenoscope remains unknown. Determining the incidence of these events is crucial for developing prevention strategies.

AIM

To assess the incidence of DAC and DAI.

METHODS

This prospective observational study included adult patients who underwent ERCP from January 2022 to December 2023. Duodenoscopes were sampled prior to each procedure. Contamination was defined as the presence of micro-organisms of gut or oral origin (MGO). Post ERCP, upon availability of culture results, patients exposed to contaminated duodenoscopes were asked to provide a stool sample and were followed for six months. Micro-organisms isolated from patient samples and clinical cultures were compared with those found in the duodenoscopes. Whole-genome sequencing (WGS) was used to confirm DAC or DAI.

FINDINGS

Among 341 ERCP patients, 73 (21.4%) procedures involved MGO-contaminated duodenoscopes. No duodenoscope-associated outbreaks occurred during the study. Stool samples were returned by 45 of the 73 patients (61.6%). Additionally, 80 MGOs from clinical cultures and 37 residual samples were stored. WGS was performed on eight duodenoscope-patient micro-organism pairs from six patients. No DAC or DAI cases were detected.

CONCLUSION

In a non-outbreak setting, supported by monthly routine microbiological surveillance and a quarantine protocol for duodenoscopes, the risk of DAC and DAI appears low. These findings suggest limited value in intensive patient surveillance for DACs/DAIs. Further research is warranted to confirm these results and address knowledge gaps regarding risk factors for DACs and DAIs.

A Predictive Model Based on Quantitative Fecal Immunochemical Test Can Stratify the Risk of Colorectal Cancer in an Organized Screening Program

BACKGROUND & AIMS

A significant number of post fecal immunochemical test (FIT) colonoscopies in European-organized colorectal cancer (CRC) screening programs are performed beyond the recommended 31-day threshold due to overburdened colonoscopy services. We aimed to develop a simple predictive model to stratify CRC risk of FIT+ patients.

METHODS

In a cohort of screenees undergoing colonoscopy following a positive (≥20 μg hemoglobin/g feces) OC-sensor FIT result between 2004 and 2019, we derived and validated logistic regression-based models including variables independently associated with CRC and advanced neoplasms. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported.

RESULTS

Overall, 40,276 patients (46% female; mean age, 66 ± 4 years) undergoing post FIT colonoscopy were included. Variables independently associated with CRC were age ≥70 years (OR, 1.20; 95% CI, 1.03-1.40), male sex (OR, 1.23; 95% CI, 1.11-1.37), fecal hemoglobin level (50-199 μg/g: OR, 2.84; 95% CI, 2.47-3.27; ≥200 μg/g: OR, 6.91; 95% CI, 5.99-7.98), and first round of FIT (OR, 1.53; 95% CI, 1.35-1.73). The discriminative ability of the model was good (area under the receiver operating characteristic, 0.75; 95% CI, 0.73-0.77) in the validation cohort. Applying the model would lead to over two-thirds decrease in delayed CRC diagnoses, considering various scenarios of timely colonoscopy scheduling after FIT+.

CONCLUSIONS

We derived and validated a predictive model for risk stratification of patients with positive FIT in a large CRC screening cohort. Applying our model in screening practice would allow policy makers to effectively prioritize FIT+ individuals based on the risk of CRC, substantially reducing the rate of delayed CRC diagnosis.

Streamlining Endoscopy Cleaning: The Impact of a New Detergent on Time and Water Use

Reprocessing reusable flexible endoscopes is resource-intensive and involves high water consumption. This study evaluated the impact of replacing a standard detergent with EndoPreZyme™, a novel detergent, at Blackpool Teaching Hospitals NHS Foundation Trust. We assessed manual cleaning times, water usage, costs, and technician experiences. A direct observational time system analysis was conducted over two one-week periods to record technician tasks before and after implementing EndoPreZyme™, allowing for the omission of the final rinse after manual cleaning. Technician surveys captured user experiences during the transition. The results showed that removing the final rinse after manual cleaning reduced water consumption by 25 litres per endoscope, resulting in an estimated saving of 725,000 L annually. The average manual cleaning time decreased from 13 min 10.2 s to 11 min 10.7 s-a reduction of 1 min 59.5 s per endoscope (15%). This efficiency gain translated to approximately 962.9 fewer technician hours being required annually for manual cleaning. Cost analysis revealed a slight per-endoscope cost reduction (GBP 4.88 vs. GBP 4.90). Technicians reported improved productivity, reduced workload, and an awareness of water conservation. These findings demonstrate that EndoPreZyme™ supports NHS sustainability goals by decreasing water usage and enhancing operational efficiency in healthcare delivery.

Differentiating IL-23 Inhibitors in Crohn's Disease

Interleukin-23 (IL-23), a member of the IL-12 family of cytokines, plays a critical role in intestinal homeostasis and inflammation and is strongly implicated in the pathogenesis of inflammatory bowel disease (IBD). Therapies targeting the p19 subunit of IL-23 have recently expanded the therapeutic options for IBD demonstrating efficacy and safety for the treatment of moderate to severe Crohn's disease (CD). Thus, in this review, we provide an overview of agents targeting the IL-23 pathway in CD, highlighting similarities and differences of specific IL-23 inhibitors. Furthermore, we summarize key phase 3 trials and head-to-head trials, focusing on design features and interpretation. Finally, we discuss the positioning of selective IL-23 agents for CD treatment along with areas of unmet clinical needs. However, real-world data will offer additional comparative effectiveness information, data for disease subtypes, and insights into the long-term outcomes of IL-23 inhibition. Looking ahead, ongoing phase 3 studies testing p19-specific selective IL-23 inhibitors are expected to expand the therapeutic options for patients with complex phenotypes, including those with extraintestinal manifestations (EIMs), fistulas, and strictures. Advances in molecular and cellular characterization, including the development of predictive molecular biomarkers, may help guide clinical decision-making, enabling more personalized treatment approaches. Precision medicine studies may further enhance our understanding of the molecular biology of IL-23, shedding light on how these agents work in complex CD and clarify their potential complementary or synergistic effects with other therapies.

Climate change and continued professional development (CPD): Is it time for all CPD diaries to include carbon footprint estimates?

The triple threat of changing climate, loss of biodiversity and pollution poses a significant challenge to our patients and the planet, and healthcare contributes to all three elements of the threat. The carbon footprint of continued professional development (CPD) is increasingly recognised, although a cognitive dissonance exists whereby climate change is acknowledged but air travel to conferences continues unabated. A CO2 allowance for CPD activities has been suggested previously. We suggest that CO2 footprint estimates could be incorporated into existing CPD diaries as a step towards visualising the environmental impact of CPD. Electronic CPD diaries are already widely used and typically contain dates and locations for CPD activities. It would be relatively easy and inexpensive to add an estimate of CO2 footprint to these diaries. Such an approach would initiate reflection, promote insight and help facilitate behavioural change. We call on institutions involved in CPD licensing, administration and documentation to trial this approach and share their experience.

Validation of British Society of Gastroenterology guidelines for acute lower GI bleeding from 8956 cases in Japan

BACKGROUND AND AIMS

We sought to validate the British Society of Gastroenterology (BSG) guidelines for acute lower GI bleeding (ALGIB).

METHODS

We analyzed 8956 patients with ALGIB in the Colonic Diverticular Bleeding Leaders Update Evidence From Multicenter Japanese Study (CODE BLUE-J) study and categorized them into 4 groups based on the BSG guidelines. Outcomes included 30-day rebleeding, 30-day mortality, blood transfusion, therapeutic intervention, and severe bleeding.

RESULTS

The severe bleeding rates significantly decreased from group I to group IV: 92.1%, 70.1%, 58.7%, and 38.4%. The rate of the need for blood transfusion and 30-day mortality also decreased from group I to group IV. Although outpatient follow-up was recommended in group IV, it had high rates of severe bleeding (38%) and 30-day rebleeding (11%). Notably, for colonic diverticular bleeding, the rate of 30-day rebleeding was 25.5%, even with an Oakland score of ≤8. We identified abdominal pain, diarrhea, and a high white blood cell count as independent factors that differentiate between nonsevere and severe bleeding cases in group IV. Using these factors, we found that the 30-day rebleeding rate in the nonsevere group was 3.6%, suggesting the feasibility of outpatient follow-up in this group. Furthermore, a novel group, Group X, which deviated from the existing 4 groups, had a high severe bleeding rate (70.9%) comparable to that of group II.

CONCLUSIONS

The BSG guidelines suggest a management approach that can clearly differentiate severity. However, caution is advised when using the Oakland score to triage patients for outpatient follow-up. Additionally, prompt intervention may be necessary for groups not covered by the guidelines.

Artificial intelligence-assisted endoscopic ultrasound diagnosis of esophageal subepithelial lesions

BACKGROUND

Endoscopic ultrasound (EUS) is one of the most accurate methods for determining the originating layer of subepithelial lesions (SELs). However, the accuracy is greatly influenced by the expertise and proficiency of the endoscopist. In this study, we aimed to develop an artificial intelligence (AI) model to identify the originating layer of SELs in the esophagus and evaluate its efficacy.

METHODS

A total of 1445 cases of esophageal SELs were used to develop the model. An AI model stemming from YOLOv8s-seg and MobileNetv2 was developed to detect esophageal lesions and identify the originating layer. Two seniors and two junior endoscopists independently diagnosed the same test set.

RESULTS

The precision, recall, mean average precision @ 0.5, and F1-score of the AI model were 92.2%, 73.6%, 0.832, and 81.9%, respectively. The overall accuracy of the originating layer recognition model was 55.2%. The F1-scores of the second, third, and fourth layers were 47.1%, 51.7%, and 66.1%, respectively. The accuracy of the AI system in differentiating layers 2 and 3 from four was 76.5% and was similar to that of senior endoscopists (74.9-79.8%, P = 0.585) but higher than that of junior endoscopists (65.6-66.7%, P = 0.045).

CONCLUSIONS

The EUS-AI model has shown high diagnostic potential for detecting esophageal SELs and identifying their originating layers. EUS-AI has the potential to enhance the diagnostic ability of junior endoscopists in clinical practice.

Effect of duodenal papilla morphology on biliary cannulation and complications in patients with common bile duct stones

BACKGROUND

The endoscopic appearance of the major duodenal papilla influences biliary cannulation and complications. This study aimed to investigate the role of major duodenal papillae in the endoscopic treatment of common bile duct (CBD) stones.

METHODS

This retrospective study was conducted at Bishan Hospital of Chongqing Medical University between January 2018 and August 2022. Patients with native papillae who underwent endoscopic treatment for CBD stones were recruited and divided into four groups according to Haraldsson's classification of papillae (types I-IV). Univariate and multivariate logistic regression analyses were used to identify risk factors for difficult cannulation and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

RESULTS

A total of 596 patients with CBD stones were enrolled. The proportion of patients with type I papilla was the highest (n = 231, 38.8%), followed by type III papilla (n = 175, 29.4%), type IV papilla (n = 101, 16.9%) and type II papilla (n = 89, 14.9%). Difficult cannulation occurred in 188 of 596 patients (31.5%), with most cases occurring in those with type III papilla (71/175, 40.6%, P = 0.020). Multivariate logistic analysis revealed that age [odds ratio (OR) = 1.034, 95% confidence interval (CI): 1.021-1.047, P < 0.001], type III papilla (OR = 2.255, 95% CI: 1.439-3.535, P < 0.001), gallbladder in situ (OR = 2.486, 95% CI: 1.346-4.590, P = 0.004), and CBD diameter < 10 mm (OR = 1.600, 95% CI: 1.049-2.441, P = 0.029) were risk factors for difficult cannulation. The total incidence of PEP was 10.9%. Compared with the other types of papillae, the rate of PEP was the highest in those with type I papilla (15.2%, P = 0.030). Multivariate analysis demonstrated that PEP was associated with difficult cannulation (OR = 1.811, 95% CI: 1.044-3.143, P = 0.035) and white blood cells (WBCs) < 10 × 109/L (OR = 2.199, 95% CI: 1.051-4.600, P = 0.036).

CONCLUSIONS

The endoscopic appearance of the major papilla is an important factor that influences both biliary cannulation and outcomes. Type III papilla is more frequently difficult to cannulate in the endoscopic treatment of CBD stones.

Pancreatic guidewire-assisted fistulotomy versus transpancreatic biliary sphincterotomy in difficult biliary cannulation with unintentional pancreatic duct cannulation: A randomized clinical trial

BACKGROUND AND AIMS

Difficult biliary cannulation with unintentional pancreatic duct cannulation is a challenging issue, even for experienced endoscopists. This prospective, randomized, single-center trial aims to evaluate the safety and efficacy of two advanced rescue cannulation methods in this context: transpancreatic biliary sphincterotomy and pancreatic guidewire-assisted fistulotomy.

METHODS

Patients with intact papilla who were planned to undergo bile duct cannulation were screened and those who experienced difficult cannulation with at least two inadvertent pancreatic duct cannulations following unsuccessful double guidewire technique attempts were randomly assigned one of two rescue cannulation techniques: pancreatic guidewire-assisted fistulotomy and transpancreatic biliary sphincterotomy. The primary outcome was the cannulation success rate and the secondary outcome was the frequency of cannulation-related adverse events (trial registration number: IRCT20230314057717N1).

RESULTS

Total 730 patients were screened and 194 were recruited according to the study protocol (97 in each group). Successful biliary cannulation was achieved in 93.8% (n = 91) of the pancreatic guidewire-assisted fistulotomy group and 81.4% (n = 79) of the transpancreatic biliary sphincterotomy group (p-value = 0.01). Multivariate analysis revealed that the transpancreatic biliary sphincterotomy technique and a normal common bile duct diameter were independently associated with unsuccessful cannulation. No significant differences were observed regarding pancreatitis and other adverse events between the two groups (p = 0.31).

CONCLUSIONS

In difficult biliary cannulation accompanied by inadvertent pancreatic duct cannulation, following unsuccessful double guidewire technique, pancreatic guidewire-assisted fistulotomy is superior to transpancreatic biliary sphincterotomy for biliary cannulation, with similar rates of adverse events.

Dome vs tapered tip sphincterotomes in endoscopic retrograde cholangiopancreatography: A pilot study on cannulation success and postprocedural pancreatitis

BACKGROUND

Despite advancements, endoscopic retrograde cholangiopancreatography (ERCP) poses challenges, including the risk of post-ERCP pancreatitis and difficulty of biliary cannulation.

AIM

To compare dome and tapered tip sphincterotomes, focusing on their efficacy in achieving successful biliary cannulation and reducing the incidence of post-ERCP pancreatitis.

METHODS

In this prospective, single-blind, randomized pilot study conducted at Inha University Hospital, 85 patients undergoing ERCP were equally divided into dome and tapered tip sphincterotome groups. The co-primary outcomes were the success rate of selective biliary cannulation and incidence of post-ERCP pancreatitis. The secondary outcomes included biliary cannulation time, number of unintended pancreatic duct access events, and total procedure time.

RESULTS

The success rates of selective biliary cannulation were 74.4% and 85.7% in the dome and tapered tip groups, respectively, with no significant difference (P = 0.20). Similarly, the incidence of post-ERCP pancreatitis did not differ significantly between the groups (5 cases in the tapered tip group vs 6 in the dome tip group, P = 0.72). However, difficult cannulation was significantly more common in the dome tip group than in the tapered tip group (P = 0.05). Selective biliary cannulation time emerged as a significant predictor of post-ERCP pancreatitis (multivariate odds ratio = 9.33, 95% confidence interval: 1.31-66.44, P = 0.03).

CONCLUSION

This study indicated that the sphincterotome tip type does not markedly affect biliary cannulation success or post-ERCP pancreatitis rates. However, cannulation duration is a key risk factor for post-ERCP pancreatitis. These findings provide preliminary insights that highlight the importance of refining ERCP practices, including sphincterotome selection, while underscoring the need for larger multicenter studies to improve procedure time and patient safety.

The Role and Appropriate Selection of Guidewires in Biliopancreatic Endoscopy

Guidewires are indispensable tools in biliopancreatic endoscopy, playing a critical role in facilitating access and enabling the advancement of various devices during interventions such as Endoscopic Retrograde Cholangiopancreatography (ERCP) and Endoscopic Ultrasound (EUS)-guided procedures. These devices are primarily used to achieve and maintain access to lumens, ensuring the success of complex therapeutic maneuvers. Guidewires vary widely in terms of material, structure, length, diameter, and tip shape, offering distinct advantages depending on the clinical context. Therefore, selecting the appropriate guidewire is crucial and must be tailored to the specific requirements of each procedure. This article provides a comprehensive review of the current landscape of guidewire use in biliopancreatic endoscopy, emphasizing their importance, characteristics, and best practices for selection to optimize patient outcomes. By reviewing existing guidelines and the literature, this paper aims to enhance the endoscopist's understanding of guidewire technology and its application in biliopancreatic endoscopy.

How to achieve the long-term goals of EUS training--survey on the performance of diagnostic EUS by newly trained endosonographers and analysis of the influencing factors

OBJECTIVES

This study endeavors to evaluate the integration of endoscopic ultrasonography (EUS) by trainees upon their return to the hospital and discern the influencing factors.

METHODS

A questionnaire survey was administered to trainees who completed EUS training at the Department of Gastroenterology, Nanjing Drum Tower Hospital from October 2016 to April 2022. The impact of various factors, including trainees' characteristics, working conditions, and EUS procedure numbers during training was analyzed.

RESULTS

65 valid questionnaires were categorized into two groups based on the median number of EUS procedures performed by trainees within one year post-training: a group with fewer EUS cases (< 30 cases) and a group with more EUS cases (≥ 30 cases). Significant differences were found in annual EUS procedures (P < 0.001), endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cases (P < 0.001), and complete scan rates (P = 0.007). Favorable conditions for trainees in performing EUS included higher-level hospitals (P = 0.001), more hospital beds (P = 0.015) and department beds (P = 0.033), greater annual endoscopy volume (P < 0.001), a longer prior duration of the use of EUS on the hospital (P = 0.003), higher departmental EUS volume (P < 0.001) and presence of established staff endosonographers (P < 0.001). Additionally, trainees in the group with more EUS cases had more guidance from experienced colleagues (P = 0.009). Multivariate logistic regression analysis highlighted annual endoscopy volume and EUS volume as independent influencing factors.

CONCLUSION

Tertiary hospitals with larger bed capacities and high endoscopy volumes foster optimal EUS skill development among trainees. Moreover, factors such as longer duration of EUS implementation, increased caseload and guidance from experienced colleagues all contribute to the professional growth of trainees.

CLINICAL TRIAL NUMBER

Not applicable.

Advancement of haemostatic self-assembling peptides in the treatment of gastrointestinal bleeding: What role for PuraStat®?

PuraStat® is a novel self-assembling peptide (SAP) used as a haemostatic agent in endoscopy, with widespread application in surgical settings. While the current evidence, though deserving further expansion, demonstrates a good haemostatic performance profile for this substance, there remains significant heterogeneity among studies, and an analysis of this SAP as monotherapy is not always available. The recent study by Bellester et al in the World Journal of Gastrointestinal Endoscopy provided an optimal effectiveness profile of this SAP in 45 patients treated for gastrointestinal (GI) bleeding, particularly highlighting data on its use as monotherapy in upper GI bleeding. This invited article outlines the current evidence on PuraStat® and offers a commentary on the recently published study.

The Role of Somatostatin in the Gastrointestinal Tract

The gastrointestinal (GI) tract is responsible for food digestion and host protection from harmful stimuli; however, its function as an endocrine organ is also well documented. Somatostatin (SST) was first discovered in the hypothalamus, but the GI tract is its main producer and target organ. SST is a potent inhibitor of many GI functions, including peristalsis, hormone secretion, and gastric acid production, while its anti-inflammatory effects contribute to the integrity of the intestinal barrier. These data make SST and its analogs useful agents in clinical practice. As our understanding of SST metabolism and function evolves, their use in a wide variety of medical conditions can improve patient care.

Synergies Among Clinicians, Academia, and Industry in the Age of Artificial Intelligence

In the rapidly evolving landscape of gastrointestinal health care, the integration of artificial intelligence (AI) presents unprecedented opportunities for enhancing patient outcomes, improving efficiency, and driving innovation. Effective collaboration among clinicians, academia, and industry is crucial to harness the full potential of AI technologies. Clinicians offer invaluable insights from real-world practice, ensuring that AI solutions address genuine clinical needs and improve patient care. Academia plays a pivotal role in advancing research, developing new methodologies, and training the next generation of professionals who will navigate this transformative field. Industry drives the commercialization of AI tools, providing the resources and infrastructure necessary for widespread adoption. Achieving these synergies is challenging. Issues including data privacy, regulatory hurdles, and interdisciplinary communication must be addressed to foster effective partnerships. By embracing collaborative models, including public-private partnerships, clinical trials, and innovation hubs, stakeholders can work together to overcome barriers and promote responsible AI integration in gastroenterology.

Endoscopic management of upper non-variceal and lower gastrointestinal bleeding: Where do we stand?

Non-variceal upper gastrointestinal bleeding (GIB) remains a significant clinical challenge with a 30-day mortality of up to 11%. Peptic ulcers are the most common cause, followed by other conditions like Mallory-Weiss syndrome, Dieulafoy's lesions, and gastric neoplasms. Treatment strategies include acid-suppressive therapy, endoscopic interventions, and surgical or radiological procedures. Endoscopic techniques such as over-the-scope clips, coagulation graspers, and endoscopic ultrasound-guided treatments have significantly improved outcomes, reducing rebleeding rates and the need for surgery. Injectable therapies, mechanical hemostasis via clips, and thermal modalities (e.g., electrocoagulation, argon plasma coagulation) remain standard approaches for active bleeding. Newer hemostatic powders, such as TC-325, offer promising non-contact treatments, particularly in cases of refractory bleeding or malignancy. Doppler endoscopic probes aid in risk stratification by detecting residual arterial blood flow, improving the efficacy of endoscopic therapy and reducing rebleeding risks. For small bowel bleeding, endoscopic management with enteroscopy and thermal therapies remains key, though medical therapies are evolving. Lower GIB, which often involves conditions like diverticular disease and angioectasia, requires a comprehensive approach combining endoscopic, radiologic, and surgical interventions. Pharmacologic management focuses on balancing antithrombotic therapy with bleeding risks, with reversal agents playing a crucial role in life-threatening bleeding episodes. This review highlights advances in diagnostic tools and endoscopic therapies that have enhanced management outcomes for GIB across various etiologies.

Population Pharmacokinetic Model for the Use of Intravenous or Subcutaneous Infliximab in Patients with Inflammatory Bowel Disease: Real-World Data from a Prospective Cohort Study

Background/Aims

Infliximab treatment failure in patients with inflammatory bowel disease may result from sub-optimal infliximab trough level. An understanding of pharmacokinetics (PKs) is important to maintain an optimal trough level. PK studies of the switch to subcutaneous (SC) infliximab from intravenous (IV) infliximab using real-world data are lacking. We aimed to develop a population PK model of IV and SC infliximab to predict individual infliximab exposure during maintenance therapy.

Methods

We used data from prospectively collected data on IV and SC infliximab concentrations in patients with inflammatory bowel disease receiving maintenance treatment from February 2020 to December 2022 at Samsung Medical Center. Population PK analysis was conducted by using a two-compartment model with first-order absorption and first-order elimination. Goodness-of-fit plots and visual predictive check were used to evaluate the PK model.

Results

A total of 2,132 samples from 181 patients (149 Crohn's disease and 32 ulcerative colitis) were analyzed. We developed an infliximab population PK model using body mass index, albumin, C-reactive protein level, and the anti-drug antibody level and validated its predictive performance.

Conclusions

It may be possible to predict the infliximab trough level of both IV and SC infliximab in patients with inflammatory bowel disease during maintenance treatment by using our model in real-world practice.

The Incidence of Adverse Events in Adults Undergoing Procedural Sedation with Propofol Administered by Non-Anesthetists: A Systematic Review and Meta-Analysis

Background/Objectives: The administration of propofol without an anesthesiologist (NAAP) during endoscopic procedures is generally considered safe. However, the available data remain limited and fragmented due to legal constraints. This systematic review and meta-analysis aimed to evaluate the incidence of adverse events in adults undergoing procedural sedation with NAAP. Methods: A comprehensive search was conducted in three electronic databases (MEDLINE, EMBASE, and the Cochrane Library) for studies published between 2010 and 2023. Eligible studies included randomized controlled trials and observational studies that reported predefined adverse events in adult patients receiving NAAP for procedural sedation. The analysis encompassed various types of endoscopic procedures and sedation protocols, including both balanced sedation and propofol monotherapy. Clinical heterogeneity was assessed by comparing patient characteristics, sedation methods, and outcome measures across studies. A random effects model was used for the meta-analysis, with results presented as estimated incidence rates. Subgroup analyses were conducted based on the hypoxia severity, sedation approach, and procedure type. Results: The search yielded 2963 records, of which 73 studies met the inclusion criteria, covering a total of 967,238 procedural sedations. Hypoxia was the most frequently reported adverse event, occurring in 40‱ of cases, followed by hypotension (38‱) and bradycardia (9‱). Severe adverse events requiring emergency intervention were rare, with an incidence of 0.12‱. The subgroup analysis indicated a low occurrence (6‱) of severe desaturation (SpO2 < 80%) and no significant differences in adverse event rates between balanced propofol sedation and propofol-only sedation. However, advanced endoscopic procedures (EUS, ERCP, PEG, enteroscopy, EMR/ESD) were associated with a higher risk of hypoxia (10% vs. 26‱; p < 0.00001) and major complications (3.1‱ vs. 0.1‱; p = 0.015) compared to diagnostic procedures. Conclusions: NAAP-based procedural sedation appears to be generally safe. While the minor adverse event rates vary depending on the sedation regimen and procedure type, major complications remain exceptionally rare.

Immunogenicity and Efficacy of Subcutaneous Infliximab Monotherapy vs Combination Therapy in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Intravenous (IV) infliximab (IFX) combined with an immunomodulator (combination therapy) outperforms IV IFX monotherapy in terms of clinical, endoscopic, and immunogenicity outcomes in patients with inflammatory bowel disease (IBD). With the advent of subcutaneous (SC) IFX, which is associated with higher serum drug concentrations, it is essential to assess whether SC IFX monotherapy provides similar pharmacokinetic and clinical benefits as combination therapy.

METHODS

We conducted a systematic review and meta-analysis (until August 2024), of studies on patients with IBD treated with SC IFX. The primary outcome was anti-drug antibodies (ADAs) formation within 12 months (M) after starting SC IFX or after switching from IV to SC IFX. Secondary outcomes included treatment persistence, clinical efficacy, and biochemical parameters.

RESULTS

Twenty-four studies (n = 3172) were included. Among patients transitioning from IV IFX induction to SC IFX, immunogenicity was more prevalent with monotherapy than combination treatment (median, 68% vs 48%; odds ratio [OR], 3.29; 95% confidence interval [CI], 1.71-6.31; P < .001). Clinical response rates at 12M were comparable, with a trend favoring combination therapy (OR, 0.73; 95% CI, 0.50-1.06; P = .10). In patients switching from IV maintenance to SC IFX, relapse rates were low (median, 12% at 6M, 11% at week 50), with stable biochemical markers. Treatment persistence was high (93% at 6M, 92% at 12M). Among patients with quiescent disease at the time of switching, 1-year relapse rates were 9% to 11%, with baseline immunogenicity predicting treatment failure.

CONCLUSION

SC IFX monotherapy is associated with higher immunogenicity rates compared with combination therapy, particularly in new IFX starters. Although clinical response was comparable, a trend favoring combination therapy warrants further investigation.

Environmental footprint of a colonoscopy procedure: Life cycle assessment

Background and study aims

Gastroenterology is a specialty that has evolved rapidly over time, especially in terms of advancements in endoscopic procedures. However, these advancements also present challenges, given the substantial resource demands associated with endoscopy procedures. Numerous actions could be taken to develop a resilient healthcare system that consumes as few resources as possible, but recommendations are needed to prioritize which processes could be improved. We aimed to evaluate the environmental footprint of a colonoscopy procedure, and to identify the main contributing impact process categories.

Methods

A single-center observational study was conducted at a Dutch university hospital. No clinical patient data were collected, but the colonoscopy procedure was studied. Data were collected during 13 colonoscopies. Life cycle assessment (LCA) was used to calculate environmental impact.

Results

Damage to human health from one colonoscopy was 11.3·10 -5 disability-adjusted life-years, equivalent to 1 hour. A single colonoscopy resulted in emission of 56.4 kg of CO 2 -equivalent (CO 2 eq), equal to driving a car for 255 km or 55 days of emissions for an average European household. Transportation of patients and staff (76.5%) and disposables (13.5%) were the greatest contributors to damage to human health.

Conclusions

Among the 13 colonoscopies studied, the environmental impact was mainly attributable to transportation of patients and staff, and disposables. Therefore, raising awareness about the impact of transportation by car, and reducing resource consumption, particularly of disposable products, should be prioritized. Implementing alternatives to colonoscopy, such as intestinal ultrasound, could reduce the environmental footprint of the healthcare system.

Medicolegal aspects of digestive endoscopy: Results of a Chilean national survey

Background and study aims

Medical professional liability (MPL) is a significant concern for gastrointestinal physicians, yet there are limited data available from Latin America. We aimed to assess frequency of complaints and lawsuits related to digestive endoscopy among gastrointestinal endoscopists in Chile and to identify associated factors.

Methods

An online survey collected sociodemographic data, information about endoscopy unit characteristics, and MPL-related experiences. Invitations were sent to 525 gastrointestinal endoscopists in Chile between August and September 2022. Associations between categorical variables were analyzed using the Chi-square test.

Results

In total, 140 endoscopists participated (response rate: 26.7%). Mean age was 48.8 years; 68.6% were gastroenterologists, 70.7% were male, and 95% had MPL insurance. Written complaints were reported by 55% of participants, with an average of 1.5 complaints per year. The most common causes were procedure costs, adverse events (AEs), and sedation issues. Colonoscopy was the procedure most frequently associated with complaints (63.2%). Complaints related to AEs included perforation (48.7%), hemorrhage (23.7%), pancreatitis (21.1%), and death (13.2%). Factors associated with complaints included years of endoscopic practice ( P = 0.047), therapeutic procedures ( P < 0.001), and patient satisfaction assessments ( P = 0.048). Of respondents, 14.5% reported at least one lawsuit. Factors associated with lawsuits included age ( P = 0.0047), male gender ( P = 0.0033), Chilean nationality ( P = 0.0257), therapeutic procedures ( P = 0.004), and patient satisfaction assessments ( P = 0.002).

Conclusions

Gastrointestinal endoscopists are frequently exposed to complaints and lawsuits. Key factors include procedure costs, AEs, sedation practices, years of experience, type of endoscopic procedure, and communication. Proactive strategies to address these factors could mitigate medico-legal risks and improve patient outcomes.

A novel scheme for non-invasive drug delivery with a magnetically controlled drug delivering capsule endoscope

There is a lack of effective means for precise drug delivery of gastrointestinal diseases. Herein we report a novel magnetically controlled drug delivering capsule endoscope (MDCE) to achieve precision drug delivery for gastrointestinal diseases. MDCE integrates a drug delivery system into conventional capsule endoscope. It can carry 0.5 ml of liquid medication, which can be sprayed onto the target area using an electric pump upon detecting lesions by convolutional neural network (CNN)-model. Additionally, with the aid of an external magnet, the operator can adjust the posture and drug delivery direction of the capsule endoscope to enhance the accuracy of drug release. This adjustment process is monitored in real-time through the camera at the front of the capsule endoscope. To validate the clinical efficacy of the MDCE, we established porcine intestinal epithelial injury and bleeding models, and we demonstrated that MDCE could accurately deliver drugs under magnetic control through direct visualization. MDCE could significantly reduce injury area by delivering organoids to porcine injury sites after 7 days compared to the control group (48 mm2vs. 21 mm2, p = 0.018). MDCE could significantly reduce bleeding time by spraying norepinephrine to porcine intestinal bleeding site compared to the control group (731 s vs. 418 s, p = 0.007). These demonstrate that MDCE could actively accurately release drugs under magnetic control through direct visualization in a non-invasive manner. This opens a new chapter for the precision treatment of gastrointestinal diseases and provides a novel approach for oral drug administration for systemic diseases.

Endoscopic Resection Techniques for Widespread Precancerous Lesions and Early Carcinomas in the Rectum

Today, endoscopy plays a crucial role not only in the detection of precancerous and malignant colorectal lesions, but also in the treatment of even widespread adenomas and T1 early cancers. In addition to classic polypectomy and endoscopic mucosal resection (EMR) using a snare, in recent years, endoscopic submucosal dissection (ESD) has become increasingly important. Marking, submucosal injection, circumferential incision of the mucosa around the lesion, tunneling, and submucosal dissection using a short diathermic knife facilitate the 'en bloc' resection of lesions larger than 3 cm, difficult to resect in one piece using a snare. Lesions with high-grade dysplasia or mucosal carcinoma are other good candidates aside from widespread adenomata with a high risk of recurrence after piecemeal resection. ESD allows R0 resection rates of more than 90% in specialized centers. Lesions of 20 cm have been removed 'en bloc' by expert endoscopists. ESD provides an optimal histopathologic yield and has a risk of recurrence as low as 3%. Endoscopic full-thickness resection using a special device (eFTRD) is another addition to the resection armamentarium. It is especially suitable for circumscribed lesions up to 2 cm in the middle and upper rectum. Endoscopic intermuscular dissection (EID) is a recent modification of ESD primarily in the rectum, including the inner, circular muscular layer into the resection specimen. In this way, it allows a histopathologic analysis of the entire submucosa beyond the mucosal and upper submucosal layer such as in ESD. This is especially important for T1 cancers invading the submucosa without any other risk factors of invasion.

Clinical Outcomes After First-Line Anti- Tumor-Necrosis-Factor Treatment of Patients With Inflammatory Bowel Disease-A Prospective Multicenter Cohort Study

BACKGROUND AND AIMS

Existing findings on outcomes of anti-tumor-necrosis-factor (TNF) therapy in patients with inflammatory bowel diseases (IBD) are largely based on retrospective studies. We aimed to investigate real-world outcomes of anti-TNF therapy and predictors thereof in a prospective IBD cohort.

METHODS

In a Danish multicenter cohort of adult bio-naïve patients with IBD treated with anti-TNF, we assessed clinical response and remission to induction therapy using clinical disease activity scoring indices at Week 14. In patients who continued treatment beyond the induction period, we also assessed loss of response (LOR), drug withdrawal, and major IBD surgery during maintenance therapy.

RESULTS

This study included 774 patients (706 infliximab, 68 adalimumab) followed for a median duration of 125 weeks Clinical response was achieved in 209/331 (67.4%) of ulcerative colitis (UC) and 125/197 (74.0%) of Crohn's disease (CD) patients, while 143/331 (46.1%) UC and 81/197 (47.9%) CD patients achieved clinical remission. In 294 UC and 309 CD patients received maintenance therapy, while 86/294 (29.3%) UC and 78/309 (25.2%) CD patients experienced LOR. Active smoking and less severe disease activity predicted favorable outcomes in UC, while short disease duration, colonic disease, nonstricturing behavior, and concomitant immunomodulator therapy predicted favorable outcomes in CD.

CONCLUSIONS

Clinical response was achieved in 2 in 3 UC and 3 in 4 CD patients, meanwhile, one-third of UC and one-fourth of CD patients experienced LOR despite the short disease duration in this study. Several clinical features were associated with outcomes and may be useful predictors of anti-TNF treatment response.

Clinical Utility and Accuracy of Point-of-Care Testing for Anti-TNF Drug Monitoring and Loss of Response

BACKGROUND AND AIMS

Point-of-care tests (POCT) enable immediate measurement of anti-TNF blood concentrations. This study examined the association between loss of response (LOR) to infliximab (IFX) or adalimumab (ADL) and serum concentrations measured with POCT and enzyme-linked immunosorbent assay (ELISA) in inflammatory bowel disease (IBD) patients.

METHODS

Patients with IBD with stored IFX or ADL serum samples were recruited. POCT was conducted, agreement with ELISA was evaluated using Bland-Altman plots. The primary endpoint was LOR defined as change in therapy, IBD-related surgery, new actively draining fistula, and/or endoscopic deterioration. ROC curves and quartile analysis assessed the association between concentrations and LOR.

RESULTS

A total of 176 patients were included (92 IFX/84 ADL, 154 Crohn's disease, and 22 ulcerative colitis). Median follow-up time was 20 months (interquartile range 9-38). LOR occurred in 37/84 (44%) ADL users and 55/92 (60%) IFX users. Median serum concentrations were significantly lower in LOR patients compared with sustained response, measured by both techniques for ADL (POCT: 6.45 vs 13.48 µg/mL, P <.001; ELISA: 4.80 vs 8.80 µg/mL, P <.001) and IFX (POCT: 2.39 vs 6.50 µg/mL, P <.001; ELISA: 1.70 vs 4.40 µg/mL, P <.001). Quartile analysis revealed that higher serum concentrations were associated with maintained response. ROC curve analysis demonstrated good or excellent discrimination for POCT and ELISA in association with LOR (AUC IFX: POCT = 0.82, ELISA = 0.76; AUC ADL: POCT = 0.82, ELISA = 0.81; all P <.0001). An overestimation of serum concentrations with POCT was observed.

CONCLUSIONS

Serum ADL and IFX POCT concentrations are comparable to ELISA and associated with LOR, indicating its clinical utility.

Ivermectin repurposing for COVID-19: pharmacological and bibliometric analysis

Since the onset of the COVID-19 pandemic in March 2020, researchers worldwide have sought effective drugs to prevent and manage SARS-CoV-2 and its spectrum of symptoms. Ivermectin, originally developed as an anthelmintic for controlling parasitic infections in humans and animals, has drawn attention based on the hypothesis that it inhibits viral replication. In Austria, ivermectin usage peaked in November 2021, following promotion by the right-wing Freedom Party of Austria (FPÖ) as an alternative treatment to vaccination, resonating strongly within anti-vaccine and skeptical communities. The topic is also very present in the United States of America due to the re-election of D. Trump as US President and the designation of R. Kennedy as the United States' Secretary of Health and Human Services. To critically examine the controversial use of ivermectin for COVID-19 and publication trends during the pandemic, this study analysed all publications listed in PubMed from 1 January 2020 to 31 December 2022 using the keywords 'ivermectin' and 'COVID-19', resulting in a dataset of 353 publications. These publications were assessed for scientific quality, methodological rigour and bias, with particular focus on the influence of social and political dynamics on publication practices, as well as the prevalence of preprints, citation trends and the role of funding sources. Our study shows that many highly cited studies on ivermectin display methodological weaknesses and data gaps, contributing to the propagation of hypotheses lacking substantial empirical support. This analysis underscores the necessity of rigorous quality control during crises and highlights the long-term risks posed to scientific databases and public health by methodologically deficient research.

Avoiding the complications of endoscopic retrograde cholangiopancreatography

PURPOSE OF REVIEW

To review the literature within the past 5 years on risk factors and prophylactic measures for avoiding the complications of endoscopic retrograde cholangiopancreatography (ERCP), including post-ERCP pancreatitis (PEP), post-ERCP cholangitis, bleeding, and perforation.

RECENT FINDINGS

Despite advances in endoscopic technique and numerous clinical trials, complications of ERCP still occur frequently, particularly PEP. Recent findings are concentrated in the PEP domain and include the following: the discovery of pancreatic steatosis as a potential novel risk factor, machine learning models to predict PEP, combination prophylactic strategies including rectal NSAIDs, aggressive intravenous fluid hydration and pancreatic duct stents, potential novel pharmacotherapies, and enhanced endoscopic techniques for difficult biliary cannulation.

SUMMARY

Endoscopists should be familiar with the complications of ERCP and prophylactic strategies. PEP carries a significant morbidity and economic burden, but its occurrence is par for the course when performing ERCP. Future studies should concentrate on elucidating further the pathophysiology of PEP and predicting cases that result in severe complications (severe if hospitalization was greater than 10 days along with the presence of pseudocyst, pancreatic necrosis, need for percutaneous drainage or surgery, or death).

Impact of endoscopic ultrasound-guided biliary drainage on the management of difficult biliary cannulation in patients with distal malignant biliary obstruction

Biliary drainage in patients with distal malignant biliary obstruction (DMBO) carries a higher risk of difficult biliary cannulation (DBC) during endoscopic retrograde cholangiopancreatography (ERCP). After the failure of standard cannulation, endoscopists may proceed with advanced cannulation techniques and/or with endoscopic ultrasound-guided biliary drainage (EUS-BD).This was a retrospective study of consecutive patients with DMBO and a dilated common bile duct (CBD; >12 mm) who underwent ERCP for endoscopic biliary drainage in four European centers. The rates of DBC, technical and clinical success, and procedure-related adverse events (AEs) were assessed. The predictive factors for AEs were also investigated through regression analysis. The EUS-BD approach was considered either as the first option after standard cannulation failure or as the final option after advanced cannulation failure.1016 patients with DMBO were included in the study, with 524 (51.6%) matching the definition of DBC. Clinical success was achieved in 956 patients (94.1%). Procedure-related AEs were experienced by 167 patients (16.4%). Patients with DBC had a higher risk of AEs (P=0.003); however, patients undergoing "early" EUS-BD showed a risk of AEs comparable with those managed with standard cannulation (P=0.38). An attempt at any advanced cannulation technique was independently associated with the occurrence of AEs (P=0.001).The risk of AEs is higher in patients with DMBO and DBC, this appears to be mainly related to the advanced cannulation techniques. In patients with a dilated CBD (>12 mm), "early" EUS-BD may minimize the risk of AEs.

Preventing oxygen desaturation during bronchoscopy in COPD patients using high-flow oxygen versus standard management: the randomised controlled PROSA 2 trial

BACKGROUND

Patients with COPD are at increased risk for developing additional respiratory comorbidities associated with smoking, and are thus prone to undergo flexible bronchoscopy. However, COPD patients have increased periprocedural complications risk and lower oxygen saturation during bronchoscopy.

METHODS

This was an investigator-initiated, single-centre, open-label randomised controlled trial designed to assess the benefits of high-flow nasal oxygen compared to conventional low-flow oxygen by nasal cannula during conscious sedation for bronchoscopy in patients with COPD. Low flow was supplied at a starting rate of 4 L·min-1 and gradually increased up to 12 L·min-1 to maintain peripheral oxygen saturation (S pO2 ) >90%. High flow delivered starting at a rate of 60 L·min-1 and an inspiratory oxygen fraction of 0.6 was increased up to 80 L·min-1 to preserve S pO2 >90%. The primary end-point was cumulative hypoxaemia time.

RESULTS

We randomised 600 COPD cases with a median (interquartile range (IQR)) age of 69.0 (62.0-76.0) years to either high flow (n=295) or low flow (n=305). The cumulative hypoxaemia time was 53% lower in the high-flow group (1.8% (95% CI 1.5-2.2%) versus 3.8% (95% CI 3.2-4.5%) of monitoring time; p<0.001). Additionally, the high-flow group experienced a median (IQR) of 3.0 (1.0-6.0) hypoxaemia events (S pO2 <90%) compared to 6.0 (3.0-10.0) in the low-flow group (p<0.001). The low-flow group had five-fold higher odds of experiencing hypoxaemia during bronchoscopy, (OR 5.1, 95% CI 3.2-8.2; p<0.001).

CONCLUSION

High flow is feasible, decreases cumulative hypoxaemia time and reduces hypoxaemia events during bronchoscopy in patients with COPD but does not impact patient comfort.

Patients with Gastrointestinal Bleeding and Atrial Fibrillation: Potential Ideal Target for Epicardial Appendage Occlusion

BACKGROUND

Gastrointestinal bleeding in patients with atrial fibrillation is an indication for left appendage occlusion. All endovascular devices mandate antithrombotic therapies: rebleeding risk remains an issue. To date, there are no reports on gastrointestinal rebleeding and stroke prevention by left appendage occlusion without any antithrombotic therapy in this category of patients.

METHODS

A total of 129 patients (male 85, mean age 76.6 ± 7.1, CHA2DS2Vasc 3.8 ± 1.5, HASBLED 3.3 ± 1.0; upper GI bleeding 10%, lower GI bleeding 86%, obscure occult 4.6%, on NOACS full dose 77.5%, NOACs reduced dose 13.1%, on anti-vitamin K 9.3%) with atrial fibrillation and history of repetitive gastrointestinal bleeding from ten centers underwent standalone thoracoscopic epicardial appendage closure without antithrombotic therapy for the entire follow up.

RESULTS

The observed bleeding rate was 0.91 events per year, equivalent to a relative risk of RR = 0.17 (p = 0.02) and a relative risk reduction (RRR) of 83%. The observed relative risk of stroke was 0.91 events per year, with a relative risk of RR = 0.19 (p = 0.03) and a relative risk reduction (RRR) of 81%.

CONCLUSION

Standalone epicardial appendage occlusion without antithrombotic therapy in patients with repetitive gastrointestinal bleeding is safe and promising when rebleeding and stroke risk reduction need to be optimized.