Endoscopic management of acute cholecystitis in high-risk surgical patients: A comprehensive review article

Acute cholecystitis is frequently encountered in daily clinical practice, and early cholecystectomy is the standard therapy. In high-risk surgical patients, such as those with advanced age, deteriorated performance status, or underlying diseases, conservative treatment is typically preferred to manage acute cholecystitis. However, in patients with a disease that is refractory to conservative treatment, drainage procedures are necessary to control the infection. At present, there are three basic approaches for gallbladder drainage: percutaneous transhepatic gallbladder drainage, endoscopic transpapillary gallbladder drainage, and endoscopic ultrasound gallbladder drainage. Each of these methods has advantages and disadvantages. Therefore, the appropriate treatment method is determined on a case-by-case basis, and no consistent strategy for gallbladder drainage has been established. This review aimed to summarize the characteristics of each drainage method and compare the clinical outcomes of the three procedures for acute cholecystitis in high-risk surgical patients.

Endoscopic findings of gallbladder lesions evaluated with image-enhanced endoscopy: A preliminary study using resected gallbladders

The diagnosis of gallbladder (GB) lesions relies on imaging findings. Transpapillary cholangioscopy can potentially be used to diagnose GB lesions; however, the images obtained remain unclear. This study aimed to characterize the endoscopic findings of GB lesions. We examined the endoscopic features of GB lesions in 50 consecutive patients who underwent cholecystectomy. GB specimens were obtained immediately following cholecystectomy, opened on the side opposite the liver bed, and flushed with saline solution. Each lesion was assessed using a high-resolution endoscope equipped with white light and narrow-band imaging magnification. For elevated lesions, both the surface structure (classified as regular, irregular, or absent) and vascular structure (dilation, meandering, caliber change, non-uniformity, and loose vessel areas) were assessed. Twelve of the 50 patients had elevated lesions, including cholesterol polyp (n = 4), hyperplastic polyp (n = 1), xanthogranulomatous cholecystitis (n = 1), and GB carcinoma (n = 6). Advanced GB carcinoma, as opposed to T1 GB carcinoma, demonstrated a papillary surface with destructive areas and neovascularization on narrow-band imaging magnification. Endoscopic images of each GB lesion were characterized, and the differences between GB carcinomas and benign lesions were identified. This preliminary classification may contribute to innovative imaging diagnosis and targeted biopsy for diagnosing GB lesions under direct vision.

Prevention of Adverse Events in Endoscopic Ultrasound-Guided Biliary Drainage

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is used when biliary drainage using endoscopic retrograde cholangiopancreatography fails. Recently, it has been adopted as a primary biliary drainage method, and its indications have expanded. Since EUS-BD can cause adverse events (AEs), such as bile leakage and stent migration, which do not occur in endoscopic retrograde cholangiopancreatography, endoscopists need to be well-versed in its management and preventive techniques. EUS-BD includes several procedures, such as EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS), EUS-guided antegrade stenting (EUS-AS), and EUS-guided rendezvous (EUS-RV). A recent meta-analysis reported that the overall AE rate of EUS-BD was 13.7% (EUS-CDS, 11.9%; EUS-HGS, 15.5%; EUS-AS, 9.9%; and EUS-RV, 8.8%). Among various EUS-BD techniques, EUS-CDS and EUS-HGS are the most frequently reported. Tubular self-expandable metal stents have been traditionally used in EUS-CDS; however, lumen-apposing metal stents have recently gained popularity. A systematic review showed that the rates of early AEs were similar between self-expandable metal stents and lumen-apposing metal stents; however, stent maldeployment was more problematic with lumen-apposing metal stents. Although tubular self-expandable metal stents are used in EUS-HGS, stent maldeployment remains a serious issue, and available devices and technical tips for preventing this AE should be well understood. Furthermore, AEs, such as sepsis, cholangitis, and bleeding, can occur, and strategies to mitigate these risks are essential. In this narrative review, we discussed AEs related to EUS-BD with a focus on management options and strategies for prevention.

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.

High Quality Barrett's Esophagus Examination and Endoscopic Eradication Therapy

A high-quality examination (HQE) for Barrett's esophagus (BE) involves a 10-step approach including advanced imaging with virtual chromoendoscopy, adherence to biopsy protocols, documentation of landmarks, and use of high-definition white light in order to maximize diagnostic yield. For dysplastic BE and BE-related neoplasia, multimodal endoscopic eradication therapy (EET) has become the cornerstone of treatment, proving to be both efficacious and safe in numerous studies. By implementing principles of an HQE and utilizing EET as indicated, clinicians can improve outcomes in BE and reduce progression of disease to esophageal adenocarcinoma.

Interplay between gut microbiota and exosome dynamics in sleep apnea

Sleep-disordered breathing (SDB) is characterized by recurrent reductions or interruptions in airflow during sleep, termed hypopneas and apneas, respectively. SDB impairs sleep quality and is linked to substantive health issues including cardiovascular and metabolic disorders, as well as cognitive decline. Recent evidence suggests a link between gut microbiota (GM) composition and sleep apnea. Indeed, GM, a community of microorganisms residing in the gut, has emerged as a potential player in various diseases, and several studies have identified associations between sleep apnea and GM diversity along with shifts in bacterial populations. Additionally, the concept of "leaky gut," a compromised intestinal barrier with potentially increased inflammation, has emerged as another key player in the potential bidirectional relationship between GM and sleep apnea. One of the potential effectors could be extracellular vesicles (EVs) underlying gut-brain communication pathways that are relevant to sleep regulation and function. Thus, therapeutic implications afforded by targeting the GM or exosomes for sleep apnea management have surfaced as promising areas of research. This review explores current understanding of the relationship between GM, exosomes and sleep apnea, highlighting key research dynamics and potential mechanisms. A comprehensive review of the literature was conducted, focusing on studies investigating GM composition, intestinal barrier function and gut-brain communication in relation to sleep apnea.

Management of Esophageal Strictures

In this article, we review current state-of-the art techniques for the endoscopic management of esophageal strictures including balloon dilation, bougie dilation, stents, and steroid injection. We discuss the approach to stricture management based on specific disease states including reflux, eosinophilic esophagitis, caustic injuries, malignancy, and dermatologic conditions.

Advancing hemostasis: A meta-analysis of novel vs conventional endoscopic therapies for non variceal upper gastrointestinal bleeding

BACKGROUND

Non variceal upper gastrointestinal bleeding (NVUGIB) is a life-threatening condition requiring prompt and effective hemostasis. Various endoscopic interventions, including novel hemostatic powders (HP), over-the-scope clips (OTSC), and traditional approaches, have been employed to manage upper gastrointestinal bleeding (UGIB). Despite advancements, comparative efficacy and safety of these modalities remain uncertain.

AIM

To evaluate the efficacy and safety of novel hemostatic interventions compared to conventional endoscopic techniques for managing UGIB.

METHODS

Cochrane, MEDLINE, PubMed and Scopus libraries were searched for randomized controlled trials (RCTs) published up to October 2024. Only RCTs comparing novel interventions, such as HP or OTSC, with conventional endoscopic treatments computed tomography (CT) were included. The primary outcome was the 30-day rebleeding rate. Secondary outcomes included initial hemostasis, short-term rebleeding rates, need for salvage therapy (surgical/angiographic), 30-day all-cause mortality, and bleeding-related mortality. We performed pairwise and network meta- analyses for all treatments.

RESULTS

Seventeen studies were included in this analysis. Regarding the 30-day rebleeding rate, OTSC and HP showed superior efficacy compared with CT [OTSC vs CT: Relative risk (RR): 0.47, 95% confidence interval (CI): 0.33-0.65; HP vs CT: RR: 0.73, 95%CI: 0.45-1.13], while OTSC and HP had comparable efficacy (RR: 0.56, 95%CI: 0.30-1.05). OTSC ranked the highest in the network ranking estimate for this outcome. For the secondary outcomes, OTSC demonstrated superior efficacy for the short-term rebleeding rate (OTSC vs CT: RR: 0.35, 95%CI: 0.14-0.74; HP vs CT: RR: 0.62, 95%CI: 0.28-1.35; OTSC vs HP: RR: 0.59, 95%CI: 0.17-1.67). Regarding the initial hemostasis rate, OTSC was slightly more effective than CT (OTSC vs CT: RR: 1.20, 95%CI: 1.06-1.57) and comparable to HP (OTSC vs HP: RR: 1.08, 95%CI: 0.89-1.40). There were no significant differences among treatments for all-cause mortality, bleeding-related mortality, or the necessity of surgical or angiographic salvage therapy. OTSC consistently ranked highest across most outcomes in the network ranking estimate.

CONCLUSION

This meta-analysis highlights OTSC as the most effective intervention for reducing 30-day and short-term rebleeding rates in NVUGIB, surpassing both CT and HP, supporting OTSC as a preferred first-line treatment for NVUGIB, while HP and CT remain viable alternatives. Further studies are needed to explore long-term outcomes and cost-effectiveness.

Lumen Apposing Metal Stents for Gastrojejunal Anastomotic Stricture Following Metabolic Bariatric Surgery

BACKGROUND

The standard of care for gastrojejunal anastomotic stricture following metabolic bariatric bypass surgery is endoscopic balloon dilatation, with revisional surgery as a last line option. The use of lumen-apposing metal stents is expanding to include many gastrointestinal benign and malignant causes in selected cases. They may provide an additional treatment option for post-bypass strictures.

METHODS

A single centre, retrospective outcomes analysis was performed over a 3-year period of patients with gastrojejunal anastomotic stricture following metabolic bariatric surgery that was treated with a lumen-apposing metal stent. Primary outcomes assessed were clinical success and perforation. Multiple secondary outcomes were assessed regarding safety and endoscopy use.

RESULTS

Of 88 patients that had lumen-apposing metal stents placed, 20 satisfied selection criteria. Eleven patients (55%) had at least one balloon dilatation prior to stent placement. All patients achieved clinical success 20 (100%) with zero perforations. Technical success was achieved in 19 patients (95%). There were four (20%) recurrent strictures, two stent migrations (10%) (with no associated complication), and one in-stent food bolus obstruction (5%). One patient ultimately required surgical revision (5%). Three patients had endoscopy within 30 days of stent removal (15%), and five patients required unplanned endoscopy with the stent in situ (25%).

CONCLUSION

Lumen-apposing metal stents within our study show potential as another treatment option for gastrojejunal anastomotic stricture following gastric bypass.

Surgical management of achalasia

Achalasia is a chronic esophageal motility disorder comprised of ineffective esophageal peristalsis and incomplete relaxation of the lower esophageal sphincter. This disease had historically been managed through medical means as well as endoscopic dilations. However, surgical interventions are now considered standard of care, including minimally invasive Heller myotomy, which was popularized in 1990s, followed by per oral endoscopic myotomy in the 2010s. Both surgical approaches provide acceptable resolution of dysphagia symptoms. Classification of the achalasia as well as other patient-level factors may drive the clinical decision-making between the two approaches, as well as surgical training and surgeon preference.

Co-occurrence of Gastric Xanthoma and Numerous Large Hyperplastic Polyps as a Complication of Argon Plasma Coagulation in GAVE

Gastric antral vascular ectasia is a form of gastrointestinal bleeding commonly treated with argon plasma coagulation (APC). APC is a noncontact electrocoagulation technique that transmits energy through ionized argon gas, ultimately coagulating and cauterizing the bleeding vessels. We report a rare case describing an association between APC therapy for gastric antral vascular ectasia and the subsequent development of hyperplastic polyps and gastric xanthoma. This outcome underscores the need for further research into refined treatment strategies to prevent such complications and highlights the importance of recognizing this complication and understanding its risk factors.

Endoscopic band ligation versus argon plasma coagulation in the treatment of gastric antral vascular ectasia: systematic review and meta-analysis

BACKGROUND AND AIMS

Argon plasma coagulation (APC) is the established endoscopic treatment for gastric antral vascular ectasia (GAVE). Recently, the use of endoscopic band ligation (EBL) has gained recognition as an alternate approach. The objective of our study was to compare the efficacy and safety of APC versus EBL in the treatment of GAVE.

METHODS

Multiple databases were searched for articles on APC versus EBL for GAVE treatment. Preferred outcomes were subjected to systematic review and meta-analysis.

RESULTS

We analyzed 10 studies involving 476 subjects (47.47% men and mean age of 56.25 years). The number of sessions required for the obliteration of lesions was higher with APC. The pooled eradication rate of GAVE with EBL was 88.6% (95% CI, 79.9-81.5; I2 = 13.5%) and with APC was 57.9% (95% CI, 43.7-71; I2 = 59%; relative risk [RR], 1.52; 95% CI, 1.16-2.02; I2 = 72%; P < .001). EBL had a lower bleeding recurrence (6.6%; 95% CI, 3.4-12.5; I2 = 0%) compared with APC (39.7%, 95% CI, 26.9-54.15; I2 = 55%; RR, 0.21; 95% CI, 0.09-0.44; I2 = 0%; P < .001). GAVE recurrence with EBL was 7.3% (95% CI, 3.8-13.6; I2 = 0%) and with APC was 38.5% (95% CI, 24.4-54.9; I2 = 64%; RR, 0.22; 95% CI, 0.109-0.446; I2 = 0%; P < .01). Transfusion requirements and hospitalizations were lower with EBL compared with APC. Adverse events associated with EBL were 16.8% (95% CI, 6.6-36.7; I2 = 83%) compared with APC at 9.3% (95% CI, 5.6-15.1; I2 = 19%; RR, 2.11; 95% CI, 0.8-5.46; I2 = 58%; P = .1).

CONCLUSIONS

EBL demonstrated better eradication with fewer treatment sessions, recurrent bleeding, hospitalizations, and transfusion requirements as compared with APC. It is time that EBL be used as the first-line endoscopic treatment for GAVE.

Endoscopic ultrasonography-guided gastroenterostomy versus uncovered duodenal metal stenting for unresectable malignant gastric outlet obstruction (DRA-GOO): a multicentre randomised controlled trial

BACKGROUND

Endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) is a novel endoscopic method to palliate malignant gastric outlet obstruction. We aimed to assess whether the use of EUS-GE with a double balloon occluder for malignant gastric outlet obstruction could reduce the need for reintervention within 6 months compared with conventional duodenal stenting.

METHODS

The was an international, multicentre, randomised, controlled trial conducted at seven sites in Hong Kong, Belgium, Brazil, India, Italy, and Spain. Consecutive patients (aged ≥18 years) with malignant gastric outlet obstruction due to unresectable primary gastroduodenal or pancreatobiliary malignancies, a gastric outlet obstruction score (GOOS) of 0 (indicating an inability to intake food or liquids orally), and an Eastern Cooperative Oncology Group performance status score of 3 or lower were included and randomly allocated (1:1) to receive either EUS-GE or duodenal stenting. The primary outcome was the 6-month reintervention rate, defined as the percentage of patients requiring additional endoscopic intervention due to stent dysfunction (ie, restenosis of the stent due to tumour ingrowth, tumour overgrowth, or food residue; stent migration; or stent fracture) within 6 months, analysed in the intention-to-treat population. Prespecified secondary outcomes were technical success (successful placement of a stent), clinical success (1-point improvement in gastric outlet obstruction score [GOOS] within 3 days), adverse events within 30 days, death within 30 days, duration of stent patency, GOOS at 1 month, and quality-of-life scores. This study is registered with ClinicalTrials.gov (NCT03823690) and is completed.

FINDINGS

Between Dec 1, 2020, and Feb 28, 2022, 185 patients were screened and 97 (46 men and 51 women) were recruited and randomly allocated (48 to the EUS-GE group and 49 to the duodenal stent group). Mean age was 69·5 years (SD 12·6) in the EUS-GE group and 64·8 years (13·0) in the duodenal stent group. All randomly allocated patients completed follow-up and were analysed. Reintervention within 6 months was required in two (4%) patients in the EUS-GE group and 14 (29%) in the duodenal stent group [p=0·0020; risk ratio 0·15 [95% CI 0·04-0·61]). No significant difference in duration of stent patency was noted between groups. 1-month GOOS was significantly better in the EUS-GE group (mean 2·41 [SD 0·7]) than the duodenal stent group (1·91 [0·9], p=0·012). There were no statistically significant differences between the EUS-GE and duodenal stent groups in death within 30 days (ten [21%] vs six [12%] patients, respectively, p=0·286), technical success, clinical success, or quality-of-life scores at 1 month. Adverse events occurred 11 (23%) patients in the EUS-GE group and 12 (24%) in the duodenal stent group within 30 days (p=1·00); three cases of pneumonia (two in the EUS-GE group and one in the duodenal stent group) were considered to be procedure related.

INTERPRETATION

In patients with malignant gastric outlet obstruction, EUS-GE can reduce the frequency of reintervention and result in better patient-reported eating habits compared with duodenal stenting although there was no significant difference in duration of stent patency or overall survival between the two approaches. EUS-GE could be used preferentially over duodenal stending when expertise and required devices are available.

FUNDING

Research Grants Council (Hong Kong Special Administrative Region, China) and Sociedad Española de Endoscopia Digestiva.

Ultrasound-guided percutaneous biopsy for challenging perihilar focal liver lesions: diagnostic accuracy and safety assessment

PURPOSE

In cases of perihilar focal liver lesions, distinguishing between benign strictures and malignancies is critical to prevent unnecessary surgery. Although the use of contrast-enhanced CT or MRI in combination with clinical and laboratory findings can aid in diagnosis, histologic examination is often necessary. Histologic specimens can be obtained through various techniques, including ERCP-guided brush cytology or intraductal biopsy, cholangioscopy-directed biopsy or endoscopic ultrasound (EUS). However, these methods have been associated with suboptimal sensitivity and specificity, sometimes leading to inconclusive results. Therefore, ultrasound-guided percutaneous biopsy (US-guided PB) may play a crucial role, but data is lacking for perihilar lesions. The objective of our study was to assess the technical feasibility and safety of US-guided PB for perihilar lesions.

METHODS

We included 20 consecutive patients who underwent US-guided PB of perihilar liver lesions that were not suitable for surgery between June 2018 and October 2023.

RESULTS

All samples were obtained using a Menghini needle 20G and were adequate for histological examination, with a mean diameter of 12.3 mm (range 3-40 mm). Out of the 20 patients, 11 were diagnosed with malignancy while the remaining 9 had inflammatory or fibrotic tissue samples. No adverse events related to the procedure were reported.

CONCLUSION

US-guided PB of perihilar liver lesions is a valuable and safe diagnostic approach to consider for patients who are not suitable for surgery.

Gastric greater curvature plication combined with Nissen fundoplication compared to sleeve gastrectomy in patients with obesity and animal model

BACKGROUND

Gastric greater curvature plication combined with Nissen fundoplication (GGCP + Nissen) has been previously performed, but its efficacy remains uncertain.

METHODS

A single-center retrospective review was conducted on patients with obesity who underwent GGCP + Nissen or sleeve gastrectomy (SG) between January 2016 and December 2022. Both groups were matched for age, gender, and baseline BMI. In the animal experiments, GGCP + Nissen, SG, and sham procedures were performed on Goto-Kakizaki rats, a model of normal-weight rats with T2DM.

RESULTS

A total of 75 patients were included in this study, of whom 35 underwent GGCP + Nissen, and 40 underwent SG. Both groups were matched for age, gender, and baseline BMI. The percent total weight loss (%TWL) in the GGCP + Nissen and SG groups were 16.38 ± 3.69 and 25.05 ± 7.24 at 6 months (P < 0.05), 16.40 ± 4.96 and 26.85 ± 9.13 at 12 months (P < 0.05), and 12.46 ± 5.90 and 24.57 ± 8.61 at 24 months (P < 0.05), respectively. However, all 8 patients with preoperative reflux in the GGCP + Nissen group achieved complete resolution of symptoms postoperatively, whereas in the SG group, 10 patients developed new-onset reflux at 1 month, with 4 continuing to experience persistent symptoms at 24-month follow-up. In the animal experiments, both GGCP + Nissen and SG induced significant weight loss and improved glucose tolerance, with rats showing increased insulin sensitivity and secretion. However, the SG group performed better than the GGCP + Nissen group in terms of both weight loss and improvement of glucose tolerance.

CONCLUSIONS

GGCP + Nissen was inferior to SG both in weight loss and improvement of glucose tolerance, although GGCP + Nissen could lead a substantial weight loss and improve GERD efficiently.

Feasibility of Endoscopic Ultrasound-Guided Tissue Acquisition for < 20-mm Upper Gastrointestinal Subepithelial Lesions

BACKGROUND

There are few reports on the usefulness of endoscopic ultrasound-guided tissue acquisition (EUS-TA) for upper gastrointestinal subepithelial lesions (SELs) < 20 mm with on-site stereomicroscopic assessment.

AIM

This study is aimed at investigating the usefulness of EUS-TA combined with on-site stereomicroscopic assessment using fine-needle biopsy (FNB) for SELs < 20 mm.

METHODS

Participants (n = 133) underwent EUS-TA combined with on-site stereomicroscopic assessment using a 22-gauge FNB needle for upper gastrointestinal SELs between January 2018 and January 2022. We conducted a comparative study of diagnostic results after dividing the participants into two groups on the basis of lesion size: < 20 and ≥ 20 mm.

RESULTS

There were 42 cases in the < 20-mm group and 91 cases in the ≥ 20-mm group. The diagnostic yield of EUS-TA in all cases was 97.7%, with values of 97.6% in the < 20-mm group and 97.8% in the ≥ 20-mm group and no significant difference between the groups. A total of 298 passes were made. The tissue sampling rate was 99.0%, and specimens with stereomicroscopically visible white cores (SVWCs) ≥ 4 mm were sampled at a rate of 87.2%. There was no significant difference in the sampling rate of specimens with SVWCs ≥ 4 mm between the groups. The diagnostic sensitivity in specimens with SVWC ≥ 4 mm was 98.5% (256/260 passes). Multivariate analysis showed that this factor significantly contributed to diagnosis (odds ratio 24.396, 95% confidence interval: 1.6596-4.7292, p < 0.001).

CONCLUSIONS

EUS-TA using a FNB needle combined with on-site stereomicroscopic assessment is a useful diagnostic method for < 20-mm SELs.

Direct comparison of simultaneous and sequential endoscopic metallic bilateral stenting in malignant hilar biliary obstruction

BACKGROUND

Endoscopic bilateral biliary drainage is a first line palliative treatment for unresectable malignant hilar biliary obstruction (MHBO) but remains technically challenging. The emergence of self-expandable metallic stents carried by an ultra-thin (6 Fr or smaller) delivery system now permits simultaneous bilateral stent placement. To date, only a few studies have compared this new method with conventional sequential bilateral stenting.

AIM

To evaluate a possible superiority of simultaneous “side by side” (SBS) biliary drainage in unresectable MHBO.

METHODS

We identified 135 patients who benefited from bilateral drainage using uncovered self-expandable metallic stents between 2010 and 2023. Among them, 62 benefited from simultaneous SBS bilateral drainage between 2017 and 2023, and 73 benefited from sequential bilateral drainage [38 using “stent in stent” (SIS) technique and 35 using SBS technique between 2010 and 2017].

RESULTS

Technical success was significantly increased in simultaneous drainage compared with sequential drainage (94% vs 75%, P = 0.008). However, simultaneous SBS drainage and sequential SIS drainage had a similar technical success (94% vs 95%). We observed no differences regarding clinical success, procedure duration and recurrent biliary obstruction rate. Stent patency was shorter in the SIS group compared with the simultaneous group (103 days vs 144 days). Early adverse events were more frequent in the sequential group (31% vs 21%, P = 0.205), with no differences regarding SIS or SBS technique. Technical failure was associated with a higher rate of infectious fatal adverse events (9.5% vs 1.7%, P = 0.02). Reintervention after recurrent biliary obstruction seems to be more successful after using SBS rather than SIS techniques (83% vs 75%, P = 0.53).

CONCLUSION

Simultaneous SBS metallic stent placement using an ultra-thin delivery system was technically easier and as efficient as sequential bilateral stenting in unresectable MHBO to achieve bilateral drainage. The SIS procedure remains a good option in unresectable MHBO.

2024 Update to SAGES guidelines for the use of peroral endoscopic myotomy (POEM) in the treatment of achalasia

BACKGROUND

Peroral Endoscopic Myotomy (POEM) is a safe treatment for esophageal achalasia with comparable safety to Heller myotomy plus fundoplication and pneumatic dilatation (PD). More data comparing POEM to Heller Myotomy plus fundoplication and pneumatic dilation are available since the previous Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guideline published on this topic in 2021.

OBJECTIVE

This guideline provides an update to the evidence-based guideline from SAGES published in 2021. It is intended to support clinicians, surgeons, and patients in decisions about the use of POEM for the treatment of achalasia.

RESULTS

The panel agreed on 3 recommendations for adults with achalasia. A conditional recommendation for the use of POEM over PD was issued. Conditional recommendations included the option of using either POEM with appropriate use of proton pump inhibitors (PPIs) or HM with fundoplication to treat achalasia. POEM was favored over HM with fundoplication for achalasia subtype III. No new literature was found for children, and the previous recommendation from 2021 should be referred to for this population.

CONCLUSIONS

POEM is a safe and effective treatment for achalasia in adults. It demonstrates greater efficacy than PD, though there are specific situations where PD may be the more appropriate choice. POEM has previously been compared to Heller myotomy, but this comparison is less relevant to modern surgical practice. Shifting the paradigm, POEM plus appropriate use of PPIs should be compared to Heller plus fundoplication. This reflection of current practice allows for a conditional recommendation for either approach in the treatment of achalasia subtypes 1 and 2, and for a preference of POEM for subtype 3.

Cyanoacrylate injection assisted by endosonographic mini-probe in the management of gastric varices: a single-center, retrospective cohort study

BACKGROUND

Gastric varices (GV) pose the potential risk of massive bleeding. Endoscopic ultrasound (EUS) guided real-time delivery of adhesives and devices has emerged as a promising therapeutic modality for GV but was limited in its generalizability due to the unavailability and lack of expertise of linear echoendoscopy. Therefore, we utilized the more readily available EUS mini-probe (EMP) in assisting cyanoacrylate (CYA) injection in the management of GV.

METHODS

This is a retrospective cohort study from a single tertiary medical center. One hundred and thirty-three eligible patients were divided into three groups based on the treatment modalities including EMP-guided CYA injection via a dual-channel gastroscope (EMP-D group), EMP-guided injection via a single-channel gastroscope (EMP-S group) and direct endoscopic injection (DEI group). The clinical characteristics, procedural parameters, outcomes, adverse events and follow-up data were analyzed.

RESULTS

An overall statistical significance was achieved in the number of puncture site (p < 0.001), the number of instant blood return upon puncture (p = 0.001), cyanoacrylate dose (p = 0.004), late rebleeding rate (p = 0.018), post-injection ulcer (p = 0.005), and non-rebleeding interval (p = 0.026) among the three groups. Patients in EMP-D group exhibited a lower rate of post-injection ulcer than those in DEI group (p = 0.009). Procedural time of EMP-D was shorter than that of EMP-S (p < 0.001). Less amount of cyanoacrylate was needed per reinjection session in EMP-D than in DEI (p = 0.002).

CONCLUSIONS

EMP-guided cyanoacrylate injection exhibited superior effectiveness and safety to DEI, while use of the dual-channel gastroscope further enhanced the precision and efficiency.

Analysis of intra- and postoperative interventional endoscopic measures in 3000 bariatric surgical procedures over 15 years: a single center study

In addition to preoperative diagnostic gastroscopy, some bariatric surgery patients require one or more differentiated endoscopic interventions as part of postoperative complication management. The aim of this study is to analyze endoscopic interventions regarding indication, type of procedure, material used, and outcome. We prospectively collected and retrospectively analyzed data over a period of 15 years from 2006 to 2021 of all consecutive patients who underwent an interventional upper gastrointestinal endoscopy after bariatric surgery at our center. The primary study objective was the type and frequency of the treatment. Secondary study objectives included clinical outcomes and postinterventional complications. Of 3000 bariatric procedures, 145 (4.8%), among them 11.1% (n = 54) of 485 Roux-en-Y gastric bypasses, 7.1% (n = 20) of 282 redo operations, 5.7% (n = 20) of 351 revisional operations, 3.3% (n = 13) of 398 sleeve gastrectomies, and 1.9% (n = 26) of 1394 one-anastomosis gastric bypasses, received an interventional endoscopy for postoperative complication management. 79.3% (n = 115) were female, mean age was 42.4 (± 10.7) years, mean BMI was 43.5 (± 9.8) kg/m2. Complication after interventional endoscopy happened in 1.6%, revisional surgery was necessary in 0.5% (n = 3). Causes for endoscopic intervention were stenosis (52.4%), leakage/fistula (35.9%), intraluminal bleeding (13.1%), dumping syndrome (9.0%), and gallstones (1.4%). The performed interventions were balloon dilation (48.3%), stent therapy (33.1%), metallic clipping (12.4%), injection therapy (0.09%), bougienage (0.07%), vacuum therapy (0.06%), and pigtail therapy (0.04%). Endoscopic intervention is an effective and safe way of treating adverse events after bariatric surgery. Stenosis and leakage were the most frequent complications, with endoscopic balloon dilatation and stent therapy as the most frequent and successful treatment options. RYGB was the procedure with the most endoscopic interventional involvement. To better learn about outcomes of specific endoscopic techniques further studies preferably with larger multicenter samples are required.

Endoscopic vacuum therapy for the management of nonvariceal upper gastrointestinal bleeding: a valuable resource for the endoscopist's toolbox

Endoscopic vacuum therapy (EVT) is a well-established method for managing gastrointestinal perforations. During the COVID pandemic, case reports demonstrated the effective use of EVT in controlling COVID-related diffuse duodenal bleeding. Owing to its unique mechanism of action, this approach may also be effective for other types of nonvariceal upper gastrointestinal bleeding (NVUGIB). This study aimed to assess EVT in the treatment of NVUGIB.This retrospective analysis of a prospectively collected database included patients who underwent EVT for the treatment of NVUGIB. The primary outcome was clinical success. Secondary outcomes included technical success and safety. Subgroup analysis comparing the outcomes for patients with and without COVID was conducted.19 patients underwent EVT for NVUGIB, with 57.9% having failed other therapies. Technical success occurred in all patients, and clinical success was achieved in 89.5%. There was no difference in the clinical success rates between patients with or without COVID (88% versus 91%, respectively). No procedure-related adverse events occurred. EVT appears to be safe and effective in the management of NVUGIB. This approach could be particularly useful in refractory or diffuse bleeding. Larger studies are warranted to validate these findings.

Efficacy and safety of endoscopic gastroplasty for treatment of obesity: An overview of comparative meta-analyses

BACKGROUND

There is a scarcity of evidence and systematic reviews on endoscopic gastroplasty (EG) compared to other management options for the treatment of obesity.

AIM

To assess the published meta-analyses through a systematic review approach and provide further insight into the current status of available evidence through a critical appraisal.

METHODS

PubMed/MEDLINE, Scopus, Embase and Cochrane Library were searched from inception to November 2022. The meta-analyses that compared the efficacy and safety of EG to other interventions were considered for this overview. The outcomes of interest were total body weight loss (TBWL), excessive weight loss, and average weight loss along with occurrence of adverse effects. Methodological quality, heterogeneity, and limitations were also reviewed.

RESULTS

A total of six meta-analyses out of 364 records were considered for this review with a major contribution from the United States. Overall methodological quality of included studies were moderate to good. EG treatments were significantly better in terms of TBWL, excessive weight loss, and average weight loss. However, there was no significant difference between endoscopic transoral outlet reduction and full-thickness suturing plus argon plasma mucosal coagulation. Lack of comparative studies and randomized trials, lack of long-term follow-up, reporting bias, selection bias, lack of control groups, and considerable level of heterogeneity were the major limitations in the available evidence.

CONCLUSION

Though EG was significantly effective for treatment of obesity, there is limited comparative evidence on this topic. High-quality well-controlled evidence is required to strengthen the current evidence base on EG treatment for obesity.

Perioperative management of patients taking glucagon-like peptide 1 receptor agonists: Society for Perioperative Assessment and Quality Improvement (SPAQI) multidisciplinary consensus statement

The perioperative management of patients using glucagon-like peptide 1 receptor agonists remains a topic of debate. While several multisociety statements have been published recently, the recommendations vary significantly in terms of medication management and preoperative fasting protocols for these patients. This document represents a multidisciplinary consensus statement led by the Society for Perioperative Assessment and Quality Improvement (SPAQI). It provides updated recommendations based on a modified Delphi process and supported by a systematic review of the current literature. The recommendations address management of the glucagon-like peptide 1 receptor agonists perioperatively, and preoperative fasting times for both solids and liquids. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42023438624).

Perioperative management of patients on GLP-1 receptor agonists: Risks, recommendations, and future directions-A narrative review

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are increasingly being used for glycemic control and weight management. One of their key mechanisms of action is thought to be delaying gastric emptying. This review explores the perioperative risks associated with GLP-1RAs use, particularly the increased risk of gastric content retention and pulmonary aspiration. Current evidence suggests that patients on GLP-1RAs should be considered at risk for having a full stomach during surgery. Recommendations include careful assessment of medication details, additional monitoring, and preventive measures such as pre-anesthesia gastric ultrasound and rapid sequence induction. Further research is needed to establish comprehensive guidelines for the perioperative management of GLP-1RAs users. Adverse events related to GLP-1RAs use during anesthesia should be thoroughly documented, which is essential to inform future guidelines and to enhance patient safety.

The Effects of GLP-1 Agonists on Musculoskeletal Health and Orthopedic Care

PURPOSE OF REVIEW

The global rise in obesity and type 2 diabetes mellitus (T2DM) presents significant challenges in musculoskeletal care, contributing to increased perioperative complications, impaired bone health, and compromised muscle function. Glucagon-like peptide-1 receptor agonists (GLP-1RAs), initially developed for glycemic control in T2DM, have demonstrated substantial benefits in weight reduction and metabolic regulation. The purpose of this review is to understand the musculoskeletal biologic and clinical implications of GLP-1RAs.

RECENT FINDINGS

Evidence suggests that GLP-1RAs may impact musculoskeletal health through anti-inflammatory effects, bone metabolism modulation, and alterations in muscle composition. GLP-1RAs may promote osteoblastogenesis while dampening osteoclast activity to maintain bone mineral density. The result on fracture risk is unclear. Additionally, while GLP-1RAs cause lean mass loss, GLP-1RAs appear to preserve skeletal muscle, reduce fatty infiltration, and enhance fiber formation and function. Further, GLP-1Rs are present in synovial tissue and cartilage, demonstrating downregulation of inflammatory molecules and chondrocyte apoptotic pathways, though clinical studies show variable effects in the setting of osteoarthritis. Overall, the heterogeneity in findings underscores the need for further research to delineate the long-term musculoskeletal effects of GLP-1RAs. Understanding the musculoskeletal impact of GLP-1RAs is critical for optimizing their integration into orthopedic practice. This review explores the orthopedic implications of GLP-1RAs, highlighting their biologic mechanisms and clinical effects on obesity-related joint inflammation and arthropathy, bone mineral density and fracture risk, and skeletal muscle preservation.

Bridging the gap in obesity research: A consensus statement from the European Society for Clinical Investigation

BACKGROUND

Most forms of obesity are associated with chronic diseases that remain a global public health challenge.

AIMS

Despite significant advancements in understanding its pathophysiology, effective management of obesity is hindered by the persistence of knowledge gaps in epidemiology, phenotypic heterogeneity and policy implementation.

MATERIALS AND METHODS

This consensus statement by the European Society for Clinical Investigation identifies eight critical areas requiring urgent attention. Key gaps include insufficient long-term data on obesity trends, the inadequacy of body mass index (BMI) as a sole diagnostic measure, and insufficient recognition of phenotypic diversity in obesity-related cardiometabolic risks. Moreover, the socio-economic drivers of obesity and its transition across phenotypes remain poorly understood.

RESULTS

The syndemic nature of obesity, exacerbated by globalization and environmental changes, necessitates a holistic approach integrating global frameworks and community-level interventions. This statement advocates for leveraging emerging technologies, such as artificial intelligence, to refine predictive models and address phenotypic variability. It underscores the importance of collaborative efforts among scientists, policymakers, and stakeholders to create tailored interventions and enduring policies.

DISCUSSION

The consensus highlights the need for harmonizing anthropometric and biochemical markers, fostering inclusive public health narratives and combating stigma associated with obesity. By addressing these gaps, this initiative aims to advance research, improve prevention strategies and optimize care delivery for people living with obesity.

CONCLUSION

This collaborative effort marks a decisive step towards mitigating the obesity epidemic and its profound impact on global health systems. Ultimately, obesity should be considered as being largely the consequence of a socio-economic model not compatible with optimal human health.

Prevention of rebleeding after primary haemostasis using haemostatic powder in non-variceal upper gastrointestinal bleeding: a multicentre randomised controlled trial

BACKGROUND

Non-variceal upper gastrointestinal bleeding (NVUGIB) remains a major cause of morbidity and mortality. Rebleeding rates following endoscopic treatment can reach up to 25% within 72 hours in patients with high-risk lesions.

OBJECTIVE

To evaluate the efficacy of a haemostatic powder (Nexpowder) in reducing rebleeding rates after conventional endoscopic treatment in patients with NVUGIB.

DESIGN

This was a prospective, multicentre, randomised controlled trial involving patients with acute NVUGIB from high-risk lesions who achieved initial endoscopic haemostasis. Participants were randomised 1:1 to receive either the haemostatic powder or no further therapy (control group). The primary outcome was the rebleeding rate within 72 hours post-treatment. Secondary outcomes included the 30-day rebleeding rate and the safety profile.

RESULTS

A total of 341 patients (72.1% male; mean age 64.8 years) were included, with 173 in the powder group and 168 in the control group. Baseline characteristics were similar between groups. Ulcer bleeding was the predominant aetiology (n=317), with Forrest type I bleeding observed in two-thirds of cases. The 72-hour rebleeding rate was significantly lower in the powder group (2.9%, 95% CI 0.9 to 6.6%) compared with the control group (11.3%, 95% CI 6.9 to 17.1%; p =0.005). A significant reduction was also observed in the 30-day cumulative rebleeding rate (7.0% vs 18.8%), with similar findings in the ulcer subgroup for the 3-day rebleeding rate (3.0% vs 12.0%; p =0.004). No adverse events related to the powder application were reported.

CONCLUSION

The application of Nexpowder following endoscopic haemostasis significantly reduced both early (3 days) and late (30 days) rebleeding rates in patients with NVUGIB, particularly in cases of ulcer-related bleeding.

TRIAL REGISTRATION NUMBER

NCT04124588.

Contrast-enhanced vs. standard endoscopic ultrasound fine-needle aspiration for diagnosing malignant biliary tumors: Randomized controlled trial

Background and study aims

Contrast-enhanced endoscopic ultrasound (CH-EUS) is superior to standard EUS for staging biliary duct tumors (BDTs), but its role in guiding EUS-guided fine needle aspiration (EUS-FNA) remains unclear. We compared diagnostic accuracy of CH-EUS-fine needle aspiration (CH-EUS-FNA) and standard EUS-FNA in patients with suspected malignant biliary stenosis.

Patients and methods

A parallel randomized controlled trial was conducted in a tertiary medical center and included jaundiced patients with suspected malignant biliary stenosis on computed tomography. The patients were assigned randomly to EUS-FNA or CH-EUS-FNA groups. Final diagnosis was determined based on EUS-FNA, surgical specimen results, endoscopic retrograde cholangiopancreatography (ERCP), or 12-month follow-up.

Results

Sixty-one patients were included in the study, 31 in the EUS-FNA group and 30 in the CH-EUS-FNA group. Mean age of participants was 74 ± 11.04 years and mean tumor size was 20.39 ± 9.17 mm, with 43 tumors in the distal bile duct. Final diagnoses were cholangiocarcinoma (37 cases), pancreatic ductal carcinoma (12 cases), other malignancies (3 cases), and benign lesion (9 cases). Diagnostic sensitivity, specificity, and accuracy were 83.3%, 100%, and 87.1% for EUS-FNA, and 82.1%, 100%, and 83.3% for CH-EUS-FNA. Plastic biliary stent placement and tumor location did not influence results. Hyperenhancement in the CH-EUS with rapid washout was observed in 90.9% of cholangiocarcinoma cases.

Conclusions

Standard EUS-FNA and CH-EUS-FNA demonstrated comparable diagnostic accuracy in evaluation of extrahepatic bile duct tumors, but with better slightly efficiency and inaccuracy indices than standard EUS-FNA.

Diagnostic yield of biliary brush cytology via ERCP - A 7-year tertiary center experience

BACKGROUND

Biliary brushing cytology during endoscopic retrograde cholangiopancreatography (ERCP) is used to assess the nature of a biliary stricture. Its low sensitivity challenges exclusion of malignancy through this technique. The aim was to evaluate the diagnostic yield of brush cytology in biliary strictures and to identify predictive factors associated with a positive diagnosis of malignancy.

METHODS

Observational retrospective study in a tertiary center. All adult patients undergoing a biliary brushing during ERPC from 2016 to 2022 were included. Logistic regression analyses were performed to identify predictive factors for positive brush cytology.

RESULTS

A total of 5309 patients underwent ERCP within the evaluated period. Out of these, biliary brushing was performed in 518 patients including 568 cytology samples, 57.7% (299) were men, median age 74 (64-84) years old. There were 24% (126) benign strictures and 76% (392) malignant of which the most common etiology were pancreatic cancer 42.5% (220/518), followed by cholangiocarcinoma 22.6% (117/518). The sensitivity, specificity, positive predictive value, and negative predictive value were 48%, 98%, 98% and 37%, respectively. Sensitivity was 45% and 52% in pancreatic adenocarcinoma and cholangiocarcinoma, respectively. Older age (OR 1.02, 95% CI: 1.01-1.03, p=0.01) and higher bilirubin (OR 1.05, 95% CI: 1.03-1.08, p<0.001) were independent predictors for brush cytology positivity. There were 9.7% (45/518) post-ERCP complications.

CONCLUSIONS

Biliary brushing cytology during ERCP is a safe procedure with low sensitivity but high specificity. Older age and higher bilirubin are associated to positive biliary cytology.

Diagnostic accuracy and influencing factors of microprobe endoscopic ultrasound for gastrointestinal subepithelial lesions: a multicenter retrospective study

BACKGROUND

Microprobe endoscopic ultrasonography (MEUS) has been widely adopted in primary hospitals due to its affordability, ease of use, and simple operation. This study aims to assess the diagnostic accuracy of MEUS in classifying gastrointestinal subepithelial lesions (SELs), identify key influencing factors, and explore strategies for improvement.

METHODS

A retrospective analysis was conducted on 855 patients with histopathologically confirmed SELs across five Chinese hospitals. The overall diagnostic accuracy (DA) of MEUS for SELs was calculated. Independent factors were identified using univariate and multivariate logistic regression analyses, followed by subgroup analysis.

RESULTS

Among 896 lesions across 31 SEL types, the overall DA was 70.31%. Non-gastrointestinal stromal tumor (GIST) and non-neuroendocrine tumor (NET) lesions, along with gastric location, were identified as risk factors for lower diagnostic accuracy, while rectal location was protective. In the subgroup analysis, gastric leiomyomas had a DA of 9.85% with 99.17% incorrectly classified as GISTs, compared to 94.78% for gastric GISTs, 84.24% for gastric NETs, and 31.2% for other lesions. Lesions with inhomogeneous echoes were 20 times more likely than those with homogeneous echoes to be diagnosed as gastric GISTs compared to gastric leiomyoma. Additionally, the inhomogeneous echo patterns of gastric GISTs were characterized by hyperechogenic spots in 93.67%, marginal halos in 18.99%, and cystic changes in 13.92%.

CONCLUSION

MEUS is effective for classifying SELs, although differentiating between gastric GISTs and leiomyomas remains challenging. Improved assessment of echo heterogeneity and expanded knowledge of atypical and rare cases may enhance diagnostic accuracy.

Ultrasound assessment of preoperative gastric volume in fasted diabetic surgical patients: A prospective observational cohort study on the effects of glucagon-like peptide-1 agonists on gastric emptying

BACKGROUND

Preoperative gastric ultrasound allows non-invasive qualitative and quantitative assessment of gastric contents aiding in preoperative risk assessment. We hypothesized that appropriately fasted diabetic surgical patients taking GLP-1 agonists would have higher gastric volumes than those not taking GLP-1 agonists.

METHODS

This prospective, observational cohort study enrolled diabetic patients undergoing elective surgery, comparing those taking (n = 106) and not taking (n = 100) GLP-1 agonists. The primary outcome was gastric volume assessed via gastric ultrasound in the right lateral decubitus position. Secondary outcomes included presence of a full stomach (solids/thick liquids or greater than 1.5 mL/kg clear liquid), need for surgery delay, Perlas grade, and occurrence of intraoperative aspiration. The impact of GLP-1 agonist type, duration of use, and timing of last dose on gastric volume was also examined.

RESULTS

Diabetic patients on GLP-1 agonists had significantly higher median gastric volumes compared to patients not on GLP-1 agonists (0.61 mL/kg vs 0.16 mL/kg, P < 0.001) and increased odds of a full stomach (OR 11.3, 95 % CI 5.2-24.7, P < 0.0001). GLP-1 agonist use correlated with higher Perlas grades (P < 0.001). Gastric volumes were significantly higher with GLP-1 agonist use within 7 days of surgery relative to use within 7-14 days or more than 14 days from surgery (P < 0.001 for both comparisons).

CONCLUSIONS

GLP-1 agonist therapy was associated with higher residual gastric volumes and higher risks of full stomachs in fasted diabetic patients. GLP-1 agonist use within 7 days of surgery was also associated with higher gastric volumes relative to holding therapy for over 7 days, supporting current consensus-based guidelines.

Evolving therapeutic approaches in achalasia: a comprehensive review of peroral endoscopic myotomy (POEM) vs. Heller's myotomy

This comprehensive narrative review thoroughly explores the treatment landscape for achalasia, a rare esophageal motility disorder. Beginning with an introduction outlining the anatomical and clinical aspects of achalasia, the review delves into its historical perspective, tracing the evolution of treatment options from early nonsurgical methods to advanced surgical techniques such as Heller's myotomy and peroral endoscopic myotomy (POEM). Technical perspectives on surgical interventions, including key steps, clinical practice guidelines, and modifications to POEM techniques, are extensively discussed. A comparative analysis between POEM and Heller's myotomy elucidates their indications, contraindications, efficacy, outcomes, and interventions for persistent symptoms or complications. Furthermore, the review explores the adverse events associated with both procedures, highlighting their safety profiles and management strategies. Finally, from a financial perspective, considerations such as operative time, hospital stay length, readmission rates, and quality-adjusted life years are examined, emphasizing the implications for patient decision-making. This review underscores the importance of a multidimensional approach to understanding and managing achalasia, advocating for further research to enhance treatment efficacy and reduce adverse effects.

Glucagon-like peptide-1 receptor agonists and impaired gastric emptying: a pharmacovigilance analysis of the US Food and Drug Administration adverse event reporting system

BACKGROUND

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) potentially increase the risk of pulmonary aspiration resulting from impaired gastric emptying (IGE). We evaluated the association between GLP-1RAs and IGE using the US Food and Drug Administration Adverse Event Reporting System (FAERS).

METHODS

We analysed FAERS data from 2004 Q1 to 2024 Q1, identifying the top 10 drugs linked to IGE and determining the proportion of GLP-1RA use. Disproportionality analysis using the reporting odds ratio was conducted to assess the relative IGE risk for each drug. Logistic regression analysed the impact of age, weight, and sex on IGE risk. Cumulative incidence and time to onset of IGE events were examined using Kaplan-Meier and Weibull shape parameter tests.

RESULTS

Among the top 10 drugs associated with IGE reports, five were GLP-1RAs, accounting for 49.5% (982/1982) of cases. Dulaglutide (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.94-1.00, P=0.033) and semaglutide (OR 0.96, 95% CI 0.94-0.97, P=0.001) showed lower IGE risk with older age. For exenatide, higher weight (OR 0.99, 95% CI 0.98-1.00, P=0.033) and male sex (OR 0.39, 95% CI 0.20-0.68, P=0.033) were associated with lower IGE risk. Median onset times ranged from 40.5 days (semaglutide) to 107.5 days (tirzepatide) from intitiation of therapy. The Weibull shape parameter β was <1 for all GLP-1RAs, indicating a higher IGE risk early in treatment.

CONCLUSIONS

GLP-1RAs were notably associated with reports of impaired gastric emptying in the FAERS. Age, weight, and sex were significantly associated with impaired gastric emptying risk for certain GLP-1RAs. IGE events tended to occur early in treatment, with risk diminishing over time. These findings provide valuable references for future research on perioperative safety with GLP-1RAs.

Guidelines for endoscopic management of nonvariceal upper gastrointestinal bleeding (second edition)

The Japan Gastroenterological Endoscopy Society has prepared Guidelines for Endoscopic Practice in Nonvariceal Upper Gastrointestinal Bleeding as part of the initiative to develop evidence-based endoscopic practice guidelines. Hemorrhagic gastroduodenal (peptic) ulcers are the primary cause of nonvariceal upper gastrointestinal bleeding. With the advent of a super-aged society, the cases caused by Helicobacter pylori are on the decline, whereas those caused by drugs (e.g. aspirin) have been increasing. Endoscopic hemostasis is currently the first-line treatment for nonvariceal upper gastrointestinal bleeding, and various methods have been devised for this purpose. It is recommended to stabilize the vital signs of the patient before and after endoscopic hemostasis with appropriate management based on an assessment of the severity of illness, in addition to the administration of acid secretion inhibitors. These guidelines describe the evaluation and initial treatment of nonvariceal upper gastrointestinal bleeding, as well as the selection of endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding and its management after endoscopic hemostasis. This is achieved by classifying nonvariceal upper gastrointestinal bleeding into two main categories, namely, peptic ulcer and other types of gastrointestinal bleeding. We prepared statements for any available literature with supporting evidence, including the levels of evidence and recommendations. New evidence has been pooled since the publication of the first edition in this area; however, the levels of evidence and recommendations mostly remain low.

Left-sided portal hypertension: what an interventional radiologist can offer?

Left-sided portal hypertension (LPH) refers to increased splenic venous pressure caused by splenic vein stenosis or occlusion. Pancreatitis is the leading cause of LPH. Typically, LPH remains asymptomatic, but it can lead to life-threatening hemorrhage from ruptured fundal varices in about 10% of patients. Further, it may be complicated by hypersplenism. Interventional radiology plays an essential role in LPH patients with failed endoscopic treatment. Variceal embolization is an effective salvage measure in bleeding gastric varices, but it carries a risk of recurrence and worsening of hypersplenism. Considering the pathophysiology, splenic vein recanalization (SVR) appears to be the best treatment; nevertheless, its lower technical success rate limits its utility only to a subgroup of LPH patients. Partial splenic embolization (PSE), a non-surgical alternative to splenectomy, reduces the splenic volume and venous outflow, thereby lowering variceal pressure. PSE is technically easier, which may explain its widespread use. Nonetheless, PSE can be complicated by life-threatening sepsis and portal vein thrombosis. Despite all attempts, some LPH patients eventually require a splenectomy. Importantly, the choice of therapy requires multidisciplinary discussion and is often influenced by availability, expertise, and clinical context. This article discusses various interventional strategies for managing LPH with the available evidence. KEY POINTS: Question Pressure within the main portal vein is normal in left-sided portal hypertension; thus, transjugular intrahepatic portosystemic shunt is ineffective. Findings Splenic vein stent placement can restore hepatopetal splenic blood flow and decompress splenic venous pressure. Clinical relevance Partial splenic embolization (PSE) is the most widely used interventional approach to manage left-sided portal hypertension-related complications.

Digital single-operator cholangioscopy for difficult anastomotic biliary strictures in living donor liver transplant recipients after failure of standard ERCP: SPYPASS-2 study (with videos)

BACKGROUND AND AIMS

Liver transplantation (LT) is a curative treatment for end-stage liver disease. Anastomotic biliary strictures (ABSs) are more common in living donor LT (LDLT). However, the success rate of ERCP for ABSs remains unsatisfactory. In this study, we evaluated the efficacy of single-operator cholangioscopy (SOC) for ABS treatment in LDLT recipients where standard ERCP failed to access the stricture.

METHODS

This prospective study included 40 LDLT patients undergoing ERCP with SOC (SpyGlass DS II; Boston Scientific Corp, Natick, Mass, USA) to treat ABSs when guidewire placement across the ABS was difficult during conventional ERCP (cannulation time >10 minutes) between October 2021 and May 2023. Our primary endpoint was technical success, defined as successful guidewire placement across the ABS and/or subsequent treatment. Secondary endpoints were rates of clinical success, adverse events, and reintervention.

RESULTS

The mean patient age was 59.7 ± 7.2 years, and the mean time from LDLT to the occurrence of ABS was 212 ± 230 days. Technical and clinical success were achieved in 92.5% (37/40) and 82.5% (33/40) of patients, respectively. The rates of post-ERCP cholangitis, pancreatitis, and bleeding were 10.0%, 15.0%, and 2.5%, respectively. Intestinal perforation did not occur, and all adverse events were mild in severity. Early stent migration within 1 month occurred in 2 patients (5.4%), and 4 patients (10.8%) required reintervention within 1 month.

CONCLUSIONS

This study shows the efficacy and safety of SOC-facilitated management for difficult ABSs in LDLT patients after failure of standard ERCP. (Clinical trial registration number: NCT05065125.).

Minimally invasive treatment strategies for submucosal tumors of the upper gastrointestinal tract: Advances in innovative endoscopy-based therapies

The increasing detection of submucosal tumors (SMTs) in the upper gastrointestinal tract (UGI) is due to the increased clinical use of endoscopy and imaging technology. Some of these SMTs have malignant potential and may cause clinical symptoms. Thus, it is recommended in clinical guidelines to consider resection of these SMTs. Endoscopic techniques have become widely used in the diagnosis and treatment of SMT in the UGI as compared with traditional surgery due to their advantages of minimally invasive, quick recovery, and economical cost. Recently, new endoscopic techniques and instruments have been continuously implemented, leading to revolutionary innovation in endoscopic treatments. However, the safety and efficacy of these innovative techniques remain unclear. Therefore, we have comprehensively summarized the various techniques used in the treatment of UGI tumors in recent years, evaluated the indications and effects of each technique, and compared their benefits and disadvantages. We hope that this review will provide a more comprehensive reference for clinical and endoscopic practitioners, and help them develop more individualized treatment plans for different patients. This will ultimately expand the patient population that can benefit from these innovative technologies.

Preliminary exploration of the application of cyanoacrylate glue in Forrest IIa and IIb peptic ulcer hemorrhage

OBJECTIVE

This study aims to preliminarily investigate the therapeutic effect of cyanoacrylate glue (CG) on Forrest IIa and IIb peptic ulcer hemorrhage (PCH).

METHODS

From January 2020 to May 2024, we retrospectively collected data on patients with Forrest IIa and IIb PCH treated with CG using emergency endoscopic hemostasis at a single center and subsequently evaluated and compared the efficacy of CG with respect to ulcer location, Forrest staging, and ulcer size.

RESULTS

A total of 93 patients were enrolled, achieving 100% technical success without 24-h rebleeding. The rebleeding rate at 72 h was 1.1% (95% confidence interval [CI]: 0.2-5.9%), and the rebleeding rate at 7 days was 2.2% (95% CI: 0.6-7.6%). The median age of the patients was 43.0 years. There were 42 patients (45.2%) with Forrest IIa ulcers and 51 patients (54.8%) with Forrest IIb ulcers. Sixty patients (64.5%) had ulcers ranging in size from 1.0 to 2.0 cm, while 33 patients (35.5%) had ulcers larger than 2.0 cm. The ulcers were located in the antrum (19 cases), angulus (38 cases), gastric body (11 cases), and duodenal bulb (25 cases). Median procedure time was 12.0 min, with duodenal PCH requiring significantly less time than stomach PCH (P < 0.05). CG treatment efficacy was comparable between Forrest IIa/IIb ulcers as well as across ulcer sizes (P > 0.05).

CONCLUSIONS

CG is particularly effective and safe for PCH located in the duodenal bulb, as well as for both Forrest IIa and IIb PCH.

Low Rates of Aborted Endoscopy Due to Gastric Food Retention in Patients on Glucagon-Like-Peptide-1 Receptor Agonists

BACKGROUND

Glucagon-like peptide-1 receptor agonist (GLP-1 RA) use has dramatically increased with expanded indications for weight loss. Delayed gastric emptying due to these medications can lead to residual food in the stomach, which can increase the risk of periprocedural aspiration during endoscopic procedures. The aim of this study is to document rates of gastric food retention and aspiration events during upper endoscopy in patients on GLP-1 RA.

METHODS

A retrospective cohort study was performed including all patients who underwent upper endoscopic procedures at two hospitals during 2018-2023. Procedure abortion due to the presence of food was taken as primary study endpoint. The secondary endpoint was aspiration events in patients with food noted on endoscopy.

RESULTS

Out of a total of 32,275 total upper endoscopic procedures performed during the study period, 1179 procedures were performed in patients taking GLP-1 RAs (GLP-1 cohort). In total, 37 endoscopies (0.1%) were aborted due to retained gastric food; 7 patients (0.6%) in the GLP-1 cohort vs 30 patients (0.096%) in the non GLP-1 cohort (p < 0.01). There were no episodes of aspiration in patients with retained food.

CONCLUSIONS

In a large retrospective cohort, GLP-1 RA use did increase rates of gastric food retention during upper endoscopy, though the absolute risk was minimal. There were no aspiration events related to gastric food retention. Because of the small number of events, there were no clear modifiable risk factors for gastric food retention. This study supports the practice of individualized periprocedural management in patients on GLP-1 RA.

Nesidioblastosis post-bariatric surgery in an adult patient: a case report and review of literature

Introduction and importance

Adult-onset nesidioblastosis is an exceedingly rare yet significant cause of persistent hyperinsulinemic hypoglycemia. This condition is often associated to bariatric surgeries such as Roux-en-Y gastric bypass and sleeve gastrectomy. Characterized by abnormal β-cell hyperplasia and hypertrophy, its diagnosis presents a unique challenge due to overlapping features with insulinomas and post-bariatric hypoglycemia syndrome (PBHS).

Case presentation

We report a 55-year-old woman with a history of gastric sleeve and Roux-en-Y gastric bypass surgeries who presented with a 1.5-year history of recurrent hypoglycemic episodes. Her symptoms, including blurred vision, tremors, and altered consciousness, persisted despite medical therapy with octreotide, acarbose, and nifedipine. Extensive imaging, including magnetic resonance imaging and endoscopic ultrasound, ruled out insulinomas, raising suspicion of non-insulinoma pancreatogenous hypoglycemia syndrome. The patient underwent laparoscopic subtotal distal pancreatectomy with spleen preservation. Histopathological examination confirmed nesidioblastosis, revealing irregular islet distribution and β-cell hypertrophy. Post-surgery, the patient achieved normoglycemia without recurrence of hypoglycemic episodes during follow-up.

Discussion

This case highlights the complexity of diagnosing nesidioblastosis in adults, especially following bariatric surgeries. Nesidioblastosis involves β-cell hyperplasia and hypertrophy driven by hormonal factors like GLP-1, whereas PBHS results from altered incretin patterns causing excessive insulin release. Advanced imaging and multidisciplinary collaboration are important for accurate diagnosis. Surgical management remains a cornerstone for refractory cases, as demonstrated in this patient's remarkable recovery.

Conclusion

Nesidioblastosis is a rare condition but should be considered in the differential diagnosis of post-bariatric surgery hypoglycemia. This case highlights the importance of distinguishing nesidioblastosis from PBHS to ensure appropriate and effective management strategies.

Obesity and mitochondrial uncoupling - an opportunity for the carbon monoxide-based pharmacology of metabolic diseases

Obesity, a chronic and progressive disease with a complex etiology, remains a significant global health challenge. Despite advancements in lifestyle interventions, pharmacological therapies, and bariatric surgery, substantial barriers to effective and sustained obesity management persist. Resistance to weight loss and gradual weight regain are commonly reported, limiting the long-term success of both non-pharmacological and pharmacological strategies. A possible contributor is metabolic adaptation, a phenomenon characterized by reduced metabolic rate and energy expenditure following weight loss, which hinders therapeutic efficacy. To address these challenges, increasing attention has been directed toward strategies that counteract maladaptive mechanisms by modulating metabolic rate and enhancing energy expenditure. One promising approach involves mitochondrial uncoupling, where electron transport and oxygen consumption are disconnected from ATP synthesis, promoting energy dissipation. Preclinical studies have demonstrated the potential of various chemical compounds with uncoupling activity as anti-obesity agents. Additionally, carbon monoxide (CO) has emerged as a significant gaseous signaling molecule in human physiology, with anti-inflammatory, antioxidative, and cytoprotective properties. Advances in CO-based pharmacology have led to the development of controlled-release CO donors, enabling precise therapeutic application. Experimental studies suggest that CO modulates mitochondrial bioenergetics, induces mild mitochondrial uncoupling, and regulates mitochondrial biogenesis. By integrating these findings, this review uniquely connects scientific threads, offering a comprehensive synthesis of current knowledge while proposing innovative directions in mitochondrial, metabolic and CO-based pharmacological research. It highlights the potential of CO-based pharmacology to regulate metabolic rate, support weight loss, and address obesity-related dysfunctions, thus suggesting novel pathways for advancing obesity treatment.

Intragastric Balloon as a Bridge Before Metabolic and Bariatric Surgery: A Systematic Review and Meta-analysis

The intragastric balloon (IGB) acts as a restrictive procedure with acceptable short-term weight loss outcomes and a low incidence of major complications. This systematic review and meta-analysis aimed to assess whether preoperative insertion of an IGB can reduce perioperative complications and improve weight loss outcomes following metabolic bariatric surgery (MBS). PubMed, Embase, Scopus, and Web of Science databases were searched using relevant keywords to include studies on IGB as a bridge before MBS. The main outcome of this study was to compare the weight loss results and complications after MBS between the IGB group and the control group. For the meta-analysis of variables with severe and non-severe heterogeneity, random-effects and fixed-effects meta-analyses were used, respectively. Eleven articles were included. The IGB and control groups included 318 and 501 patients, respectively. The pooled random-effects analysis of six studies showed that preoperative IGB insertion resulted in a body mass index (BMI) loss of 7.45 kg/m2 over a mean follow-up of 6.14 months. The major complication rate for IGB was 5%. The mean BMI change after MBS between the IGB and control groups was not significantly different after 15.06 months (mean difference - 4.08, p = 0.07). Additionally, a fixed-effects analysis of ten studies found no significant difference in post-MBS complication rates between the IGB and control groups (OR 0.66, p = 0.12). Even though using IGB as a bridging approach to subsequent MBS can result in significant reductions in preoperative BMI, this weight loss does not appear to positively impact the overall outcomes of MBS in patients in the long term.

Diagnostic yields and clinical impact of endoscopic ultrasound-guided tissue acquisition for biliary lesions

BACKGROUND/PURPOSE

Diagnostic yields of endoscopic ultrasound-guided tissue acquisition (EUS-TA) for biliary lesions have not been fully established due to limited evidence. We aimed to clarify the efficacy of EUS-TA for biliary lesions.

METHODS

Diagnostic yields and adverse event rates of EUS-TA for biliary lesions were evaluated. The subject cases were only limited to cases in which the biliary lesions itself was punctured. Diagnostic yields of endoscopic retrograde cholangiography (ERC)-guided biopsy/cytology performed within the same period were also evaluated to assess the additional effect of EUS-TA.

RESULTS

EUS-TA was attempted in 71 cases (28 hilar bile duct, 19 distal bile duct, 4 ampulla of Vater, and 20 gallbladder), and the final diagnosis was malignant in 54 cases (76.1%). The sensitivity, specificity, and accuracy of EUS-TA were 96.3% (52/54), 100% (17/17), and 97.2% (69/71), respectively. Adverse events were observed in one case (1.4%, peritonitis). The accuracy of ERC biopsy/cytology was 82.5% (212/257 cases); additional EUS-TA diagnosed 30 cases as malignant additionally and improved the accuracy (94.2%; 242/257 cases; p < .01).

CONCLUSIONS

EUS-TA is an accurate and safe diagnostic test for biliary lesions. The addition of EUS-TA may be considered when there is a suspicion of a false-negative ERC result.