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.

The Tissue Systems Pathology Test Objectively Risk-Stratifies Patients With Barrett's Esophagus: Results From a Multicenter US Clinical Experience Study

BACKGROUND

Barrett's esophagus (BE) is a diagnosis of esophageal intestinal metaplasia, which can progress to esophageal adenocarcinoma (EAC), and guidelines recommend endoscopic surveillance for early detection and treatment of EAC. However, current practices have limited effectiveness in risk-stratifying patients with BE.

AIM

This study aimed to evaluate use of the TSP-9 test in risk-stratifying clinically relevant subsets of patients with BE in clinical practice.

METHODS

TSP-9 results for tests ordered by 891 physicians for 8080 patients with BE with clinicopathologic data were evaluated. Orders were from nonacademic (94.3%) and academic (5.7%) settings for nondysplastic BE (NDBE; n=7586; 93.9%), indefinite for dysplasia (IND, n=312, 3.9%), and low-grade dysplasia (LGD, n=182, 2.3%).

RESULTS

The TSP-9 test scored 83.2% of patients with low risk, 10.6% intermediate risk, and 6.2% high risk, respectively, for progression to HGD/EAC within 5 years. TSP-9 provided significant risk-stratification independently of clinicopathologic features, within NDBE, IND, and LGD subsets, male and female, and short- and long-segment subsets of patients. TSP-9 identified 15.3% of patients with NDBE as intermediate/high-risk for progression, which was 6.4 times more than patients with a pathology diagnosis of LGD. Patients with NDBE who scored intermediate or high risk had a predicted 5-year progression risk of 8.1% and 15.3%, respectively, which are similar to and higher than published progression rates in patients with BE with confirmed LGD.

CONCLUSIONS

The TSP-9 test identified a high-risk subset of patients with NDBE who were predicted to progress at a higher rate than confirmed LGD, enabling early detection of patients requiring management escalation to reduce the incidence of EAC. TSP-9 scored the majority of patients with NDBE as low risk, providing support to adhere to 3- to 5-year surveillance per guidelines.

Clinical Utility of Endoscopic Ultrasound-Guided Fine-Needle Aspiration and Biopsy for Rectal and Perirectal Lesions With Categorization of Their Indications

OBJECTIVES

Endoscopic ultrasound-guided fine-needle aspiration and/or biopsy (EUS-FNA/B) is a diagnostic tool for gastrointestinal (GI) lesions. However, its effectiveness in the lower GI tract remains underreported. In this study, we aimed to evaluate the clinical utility of EUS-FNA/B for rectal and perirectal lesions.

METHODS

Seventy-seven consecutive patients with rectal or perirectal lesions underwent EUS-FNA/B between 2009 and 2023. The histological diagnoses by EUS-FNA/B were compared with the final diagnoses to assess the former's diagnostic performance. Additionally, the therapeutic utility of EUS-FNA/B and its clinical applicability across various scenarios were investigated.

RESULTS

Twenty-nine of the 77 patients had rectal lesions, with gastrointestinal stromal tumor (GIST) being the most common in 15 patients. Of the 48 patients with perirectal lesions, 27 and 21 had malignant and benign lesions, respectively. EUS-FNA/B was diagnostic in 61 (79.2%) patients, with the rates of 79.3% and 79.2% for rectal and perirectal lesions. EUS-FNA/B enabled timely treatment decisions by confirming malignancy (n = 32) and prevented unnecessary surgeries/procedures by establishing the benign nature of the lesions (n = 14). A definitive diagnosis of rectal GIST was made using EUS-FNA/B, thereby facilitating the initiation of neoadjuvant chemotherapy followed by anus-saving surgery (n = 10). EUS-FNA/B enabled the implementation of minimally invasive interventions such as EUS-guided drainage (n = 5). Adverse events occurred in five (6.5%) patients, with only one requiring hospitalization.

CONCLUSION

EUS-FNA/B is a valuable modality for patients with rectal or perirectal lesions, which facilitates accurate histological diagnosis, appropriate treatment, and favorable safety profiles.

Endoscopic background mucosal resurfacing to prevent metachronous recurrence of superficial esophageal squamous cell cancer after curative endoscopic submucosal dissection: randomized pilot study with 5-year follow-up (with video)

BACKGROUND AND AIMS

Metachronous recurrence frequently develops in patients with superficial esophageal squamous cell carcinomas (ESCCs) after curative endoscopic submucosal dissection (ESD), especially in those with multiple (>10) small Lugol-voiding lesions (LVLs) over the endoscopic background mucosa (ie, speckled pattern). We conducted a randomized controlled trial to investigate whether endoscopic radiofrequency ablation (RFA) for endoscopic background mucosal resurfacing (EBMR) can decrease the rate of metachronous neoplasia.

METHODS

Patients who received curative ESD and whose Lugol staining showed a speckled pattern over the background mucosa were randomly assigned in a 1:1 ratio to receive either RFA (EBMR group) or endoscopic surveillance alone (control group). EBMR with RFA was performed with a balloon device for circumferential ablation of the total esophageal mucosa 2 to 3 months after ESD. The primary outcome was the metachronous recurrence of squamous neoplasia during a 5-year follow-up period. Secondary outcomes were major adverse events.

RESULTS

Of 112 patients screened, 30 were randomized to receive EBMR (n = 15) or surveillance (n = 15). The mean procedure time of EBMR was 30.7 minutes (range, 25-40). One patient developed post-RFA stenosis, which resolved after 3 sessions of endoscopic dilation. EBMR reduced the risk of metachronous recurrence (0% in the EBMR group vs 53% in the control group, P = .001), with a number needed to treat of 1.9. Reversal of the Lugol-staining speckled pattern to only a few LVLs occurred in all patients and persisted for at least 5 years in the ablation group.

CONCLUSIONS

In this randomized trial of patients with multiple small LVLs over the endoscopic background after curative ESD, EBMR with balloon-type RFA is a promising and safe procedure for preventing metachronous recurrence over 5 years of follow-up. (Clinical trial registration number: NCT03183115.).

SAGES white paper on antibiotic omission in the management of acute uncomplicated diverticulitis: why, when, who, and most importantly, how

BACKGROUND

Historically, the management of acute uncomplicated diverticulitis was centered on antibiotics. However, modern theories regarding the pathogenesis of diverticulitis have challenged the notion that antibiotics are necessary in all cases. Despite major reform in many societal guidelines, the adoption of non-antibiotic therapy for uncomplicated diverticulitis has been limited, especially in North America. The purpose of this SAGES White Paper was to review the available evidence on antibiotic omission in uncomplicated diverticulitis and to explore methods of safe implementation.

METHODS

A task force within the SAGES Colorectal Surgery Committee was formed to work on this White Paper. The committee and its leadership approved an outline that would focus on the following topics: (1) Defining the problem with unnecessary antibiotic exposure; (2) Evaluating the evidence on antibiotic omission in uncomplicated diverticulitis; (3) Identifying the appropriate patient for antibiotic omission; (4) Outlining how to counsel patients who are treated without antibiotics; (5) Reviewing methods to safely implement this practice in both the hospital and community setting. These topics were divided up among members of the task force who performed a structured literature search in preparation for their assignments.

RESULTS

Antibiotics are associated with several patient and societal adverse effects, including the rising problem of antimicrobial resistance. Randomized controlled trials have demonstrated no superiority to the routine administration of antibiotics in acute uncomplicated diverticulitis. Appropriate patients for antibiotic omission include those who are immunocompetent, non-septic, and have mild symptoms/disease severity on imaging. Existing frameworks for the safe implementation of new practices can be referenced to help increase adoption of non-antibiotic therapy.

CONCLUSION

The existing body of evidence supports antibiotic omission in appropriate cases of acute uncomplicated diverticulitis. In order to increase the widespread adoption of this practice, buy-in from key stakeholders (both healthcare professionals and patients) is necessary.

Impact of Opioid and Cannabis Use on Low-Dose Amitriptyline Efficacy in Cyclical Vomiting Syndrome: A Real-World Study in the United Kingdom

BACKGROUND

Central neuromodulators, specifically tricyclic antidepressants (TCAs), are prescribed as prophylactic treatment for cyclical vomiting syndrome (CVS). It is unclear whether opioids and/or cannabis affect the treatment response to neuromodulators. The aims of this study were to assess: (i) the prevalence of opioid and cannabis use among outpatients with CVS, (ii) clinical characteristics associated with opioid/cannabis use and response to a three-tiered neuromodulator treatment algorithm, and (iii) the effect of opioid/cannabis cessation on response to the treatment algorithm.

METHODOLOGY

Data from consecutive patients newly diagnosed with Rome IV CVS at a single tertiary care neurogastroenterology outpatient clinic (January 2016-June 2024) were retrospectively collected. Patients were advised to stop consuming opioids and/or cannabis and commenced a low-dose TCA.

RESULTS

Sixty-one (46/75) percent of outpatients with CVS responded to the three-tiered treatment algorithm. Among responders, 42 (91%) patients responded to TCA alone (1st line therapy), 3 (7%) patients responded to TCA and selective serotonin reuptake inhibitor or serotonin norepinephrine reuptake inhibitor (2nd line therapy), and 1 (2%) patient required topiramate (3rd line therapy). The mean [SD] dosage of TCA among responders was 26.5 [18.3] mg. Twenty-five (33%) patients consumed opioids, 14 (19%) took cannabis, and five (7%) consumed both opioids and cannabis. While opioid cessation was associated with clinical response to the treatment algorithm (p = 0.03), opioid intake at the initial consultation was not (p = 0.2). Irritable bowel syndrome was independently associated with significantly greater odds (OR [95% CI]) of opioid consumption at baseline (6.59 [1.49-29.24], p = 0.01). Heartburn was independently associated with lower odds of response to the treatment algorithm (0.2 [0.05-0.65], p = 0.006).

CONCLUSION

Low-dose neuromodulators, along with opioid and cannabis cessation, may be important strategies in the management of CVS.

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.

An optimal curriculum for training in endoscopic ultrasound: a summarized evidence-based literature systematic review

BACKGROUND AND OBJECTIVES

Endoscopic ultrasound (EUS) training is strongly correlated with procedure quality and improved patient outcomes. However, EUS fellowship curricula and the environment in which training should take place are not well defined. A well-structured training curriculum should aim to establish a universally accepted competence framework before endosonographers are allowed to start independent practice. This systematic review seeks to identify the essential components of an EUS training curriculum, determine the optimal environment for this training, and highlight gaps and inconsistencies in current guidelines.

MATERIAL AND METHODS

A comprehensive literature review was performed using different databases (PubMed, Science Direct, Cochrane library, Directory of Open Access Journals, and Google Scholar) using Mesh methodology for keyword search in the field of EUS training and following PRISMA guidelines. Inclusion criteria were review articles, original research articles, international societal guidelines, book chapters, and expert consensus addressing EUS educational aspects published in the last two decades (January 2002-August 2023) in peer-reviewed journals in English.

RESULTS

A total of 49 papers were included according to the inclusion criteria in the 20-year period range, from which 31 assessed diagnostic EUS curricula content and 19 any aspect of the therapeutic EUS curricula. The requisites, duration, and/or competence demonstration strategies were addressed in 28 publications, whereas 15 referred to the adequate environment for EUS training. Overall, there was a consensus on the need for a structured, formal EUS curriculum along with standardized and properly supervised training and assessment to ensure competence.

CONCLUSION

The establishment of a structured EUS fellowship curricula should aim to produce competent practitioners, thereby ensuring safe and effective patient-care, uniformly and at the international level. While there is general agreement in the literature on the major aspects of a training curriculum, which we synthesize here, the ideal EUS training context deserves further study and better definition.

'Can we cure IgG4-related diseases?'

IgG4-related disease (IgG4-RD), recognized as a novel clinical entity, is a rare, chronic, immune-mediated systemic fibroinflammatory disorder of unknown origin with either synchronous or metachronous multi-organ involvement. Although the pathogenic mechanism remains unclear, possible multipathogenic factors such as genetic backgrounds, disease-specific or related antigens, and abnormal innate or adaptive immunity may be involved. Many immunocytes, including neutrophil extracellular trap, M2 macrophage, plasmablast, B cells, and T-cells (Th2-CD4+T, follicular helper T cells, and CD4+SLAMF7+cytotoxic T cells) play important roles in the pathogenesis. Conventional therapies with glucocorticoid or rituximab in combination with/without immunomodulators are recommended in all symptomatic patients with active IgG4-RD. Because of a few of randomized clinical trials, the comprehensive management for IgG4-RD has not been established yet. Targeted treatment approaches against the plasmablast to B cell lineage and the CD4+SLAMF7+cytotoxic T cell seem to be promising for the future-directed treatment.

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.

Effects of training in pairs versus training alone on reaching proficiency in minimally invasive Roux-en-Y-gastric bypass on a virtual reality trainer in medical students: a randomized-controlled trial

BACKGROUND

Minimally invasive surgery (MIS) is the standard approach in bariatric surgery. The most common bariatric procedures are sleeve gastrectomy and Roux-en-Y-Gastric Bypass (RYGB). Simulation training, including virtual reality (VR), is useful when learning MIS. Training in pairs has proven beneficial in acquiring basic MIS skills. However, this has not been tested on more complex procedures such as MIS RYGB. The study aimed to assess the learning effects of training MIS RYGB on a VR trainer in pairs compared to solo training.

METHODS

Medical students (n = 60) were randomized into the intervention group, trained in pairs (n = 30), and the control group, trained solo (n = 30). Both groups needed to train MIS RYGB on a VR trainer under the supervision of trained tutors until proficiency was reached. The MIS RYGB proficiency was defined as 105/110 points according to the Bariatric Objective Structured Assessment of Technical Skills (BOSATS) score. The primary outcome was the number of exercise repetitions until proficiency was reached. Secondary outcomes compared the BOSATS scores, bleeding incidents, and the validated score on current motivation.

RESULTS

The intervention group achieved proficiency with significantly fewer repetitions than the control group (p = 0.002). Most participants in the intervention group reached proficiency by the fifth repetition, and none required an eighth repetition. The intervention group had better BOSATS scores than the control group after the second, fourth, and fifth MIS RYGB (91.1 ± 6.4 vs. 87.1 ± 7.0 points, p = 0.025; 104.0 ± 4.7 vs. 100.3 ± 6.1 points, p = 0.014; 106.2 ± 2.8 vs. 101.9 ± 5.8 points, p = 0.026), respectively. Additionally, the intervention group experienced fewer bleeding complications in the fifth and sixth MIS RYGB repetitions than the control group (2 vs. 10, p = 0.001; 0 vs. 8, p < 0.001, respectively).

CONCLUSIONS

Training MIS RYGB on a VR trainer in pairs enables trainees to reach procedural proficiency with fewer exercise repetitions than training alone.

An Esophageal Luminal Diameter of 16 mm Predicts Dysphagia Resolution in Eosinophilic Esophagitis

GOALS AND BACKGROUND

Eosinophilic Esophagitis (EoE) is a chronic inflammatory esophageal disorder, often complicated by strictures requiring dilation. There is limited information on the target esophageal luminal diameter (ELD) post-treatment to relieve symptoms. The aim of this study was to determine the ELD threshold associated with dysphagia resolution in EoE patients in histologic remission.

STUDY

We performed a retrospective cohort study of adult EoE patients with a stricture in histologic remission. Patients were excluded if symptoms, EoE endoscopic reference score (EREFS), and ELD were missing. ELD was estimated by dilator diameter, endoscope passage, or functional lumen imaging probe. Symptoms, demographics, EREFS, and histology were recorded. Univariate and multivariable logistic regression analyses were performed. The ELD threshold for dysphagia was determined using receiver operating characteristics analyses.

RESULTS

Of the 76 patients who met criteria, 63 (82.9%) reported dysphagia. For every one-millimeter decrease in ELD, there was an increased odds of having dysphagia (OR 9.12, 95% CI 33.4, p < 0.001). The threshold ELD for having dysphagia was less than 16 mm (sensitivity: 96.8%, specificity: 92.3%). In a subcohort analysis of patients who were dilated (n = 58, 76.3%), the main predictor for persistent dysphagia post-dilation was the pre-dilation ELD (aOR 0.77, 95% CI 0.65-0.87, p < 0.001).

CONCLUSION

A decrease in ELD is associated with a higher odds of dysphagia in EoE patients in histologic remission. ELD of 16 mm or greater provided the strongest threshold for which symptoms were absent. This may present a reasonable dilation target.

Current Trends in the Management of a Complex Polyp: Endoscopy versus Surgery

Many colorectal cancers arise from either adenomatous polyps or sessile serrated lesions. However, due to the implementation of screening guidelines at the age of 45 years and the ability to perform therapeutic endoscopic polyp resections, the incidence and mortality of colorectal cancer has been decreasing in the United States. Polyps can be distinguished not only by pathology, but characterized by their complexity depending on the size, location, and morphology. Historically, polyps that were endoscopically more challenging to resect were referred for surgical resection. However, due to rapid advancement in endoscopic techniques and availability of tools, many of these complex polyps can be safely and effectively resected endoscopically. In this section, we review the different methods and potential challenges associated with endoscopic resection techniques including endoscopic mucosal resection, endoscopic submucosal dissection, or endoscopic full-thickness resection of a complex polyp.

Prevalence of fatty pancreas and its relation with anthropometric values on the Growth and Obesity Cohort Study

OBJECTIVE

Nonalcoholic Fatty Pancreas Disease (NAFPD) is characterized by excessive lipid accumulation within the pancreas in the absence of alcohol intake, potentially leading to pancreatic dysfunction and metabolic complications, including type 2 diabetes mellitus, acute and chronic pancreatitis, and pancreatic carcinoma. The authors aim to estimate the prevalence of NAFPD and its association with anthropometric parameters in a cohort of Chilean adolescents.

METHOD

The authors conducted a cross-sectional analysis of the "Growth and Obesity Chilean Cohort Study" (GOCS), a longitudinal study involving nearly 1000 children, followed yearly since 2006. All participants underwent anthropometric measurements and abdominal ultrasonography.

RESULTS

A total of 741 adolescents were included; 30 exhibited ultrasonography findings compatible with fatty pancreas (4 %). Adolescents with NAFPD had higher BMI z-score (2.33 (1.52-2.69) vs 0.67 (-0.2-1.4), p < 0.001), waist circumference (WC) (90.9 (81.53-98.58) vs 72.2 (67.55-79.83), p < 0.001), waist-to-height ratio (0.55 (0.48-0.6) vs 0.44 (0.41-0.49), p < 0.001), triponderal index (17.35 (15.14-19.25) vs 13.62 (12.07-15.54), p < 0.001), subcutaneous fat (32.4 (21.77-44.95) vs 16.2 (9.3 - 25.3), p < 0.001), visceral fat (45.15 (36.92-62.08) vs 35.5 (28.55-44.25), p < 0.001), systolic blood pressure (p = 0.009), and diastolic blood pressure but only in boys (p = 0.004) compared with controls. The prevalence of liver steatosis was significantly higher in the NAFPD group (63.3% vs 5.2 %, p < 0.001). After adjusting for sex and BMI, only the association with waist circumference and liver steatosis remains statistically significant.

CONCLUSION

In adolescents, NAFPD has a prevalence of 4 % and is associated with a higher BMI z-score, WC, superficial fat, and blood pressure levels. Liver steatosis exhibited a strong association with NAFPD.

Leucine-rich alpha-2 glycoprotein for detecting small bowel lesions in Crohn's disease: A critical review and the path forward

The study by Ohno et al provides valuable insights into the role of leucine-rich alpha-2-glycoprotein (LRG) as a potential biomarker for identifying small bowel lesions in Crohn's disease (CD). However, several methodological challenges hinder its immediate use in clinical practice. Notably, the current research was retrospective, lacks comparative studies with fecal calprotectin, and did not provide long-term predictive data. Further prospective studies are needed to improve the applicability of LRG. Moreover, integrating LRG with additional biomarkers and employing artificial intelligence techniques may improve its effectiveness in disease monitoring. Future research should address interobserver variability, assess LRG's cost-effectiveness, and standardize endoscopic healing definitions to ensure broader applicability. Advancing these areas is vital for establishing LRG's role in precision medicine strategies for the management of CD.

Diagnosis of Cholangiocarcinoma: The New Biological and Technological Horizons

The diagnosis of cholangiocarcinoma (CCA) remains challenging. Although new technologies have been developed and validated, their routine use in clinical practice is needed. Conventional cytology obtained during endoscopic retrograde cholangiopancreatography-guided brushings is the first-line technique for the diagnosis of CCA, but it has shown limited sensitivity when combined with endoscopic ultrasound-guided biopsy. Other diagnostic tools have been proposed for the diagnosis of CCA, with their respective advantages and limitations. Cholangioscopy with biopsy or cytology combined with FISH analysis, intraductal biliary ultrasound and confocal laser microscopy have made significant advances in the last decade. More recently, developments in the analytical "omics" sciences have allowed the mapping of the microbiota of patients with CCA, and liquid biopsy with proteomic and extracellular vesicle analysis has allowed the identification of new biomarkers that can be incorporated into the predictive diagnostics. Furthermore, in the preoperative setting, radiomics, radiogenomics and the integrated use of artificial intelligence may provide new useful foundations for integrated diagnosis and personalized therapy for hepatobiliary diseases. This review aims to evaluate the current diagnostic approaches and innovative translational research that can be integrated for the diagnosis of CCA.

The prevalence of Barrett 's esophagus in Iranian patients with gastrointestinal symptoms: a systematic review and meta-analysis

BACKGROUND

Barrett's esophagus (BE) is a premalignant columnar metaplasia of the esophagus that predisposes victims to esophageal adenocarcinoma (EAC). Depending on differences in the study population and risk factors, the prevalence of BE may vary, from 0.4 to 20% globally. The current study aimed to systematically review and analyse the prevalence of BE in in patients with gastrointestinal symptoms in Iran. Furthermore, gastrointestinal malignancies are among the most common tumours in Iran, making this study even more significant.

METHODS

A systematic search was carried out in PubMed, Web of Science, Scopus, and EMBASE as well as some domestic databases including SID, Magiran, IranDoc, IranMedex from inception to the end of 2023. We included all cross-sectional studies which reported the prevalence of BE and calculated pooled prevalence.

RESULTS

The results of the analysis, including 9 studies in a total of 4978 cases (213 Barret diagnoses), revealed that by the results of these studies, the prevalence of Barret's esophagus is 4.4% [I2 = 94.9% [92.2%; 96.6%]/p-value < 0.0001]. Subgroup analysis, divided by region and year, revealed significant differences between groups.

CONCLUSIONS

The epidemiology of BE in Iran is not completely identified. This is the first systematic review and meta-analysis evaluating the prevalence and of BE in Iran. Due to the importance of BE in progressing to esophageal adenocarcinoma, much importance should be given to its timely diagnosis. It is strongly recommended to conduct more comprehensive studies including more patients in this field.

Executive Summary of the American Radium Society Appropriate Use Criteria for Management of Squamous Cell Carcinoma of the Cervical Esophagus: Systematic Review and Guidelines

OBJECTIVES

Cervical esophageal cancer (CEC) is an uncommon malignancy accounting for <5% of all esophageal carcinomas. Treatment of CEC varies and is adapted from established regimens used for squamous cell carcinoma (SCC) or the lower esophageal and head and neck. The present systematic review and guidelines are intended to assist treatment decision making for patients with CEC based on the available evidence.

METHODS

Using the Population, Intervention, Comparator, Outcome, Timing, and Study Design (PICOTS) framework, the evidence regarding treatment outcomes was assessed using Cochrane and PRISMA 2020 methodology. Eligible studies included prospective Phase II to III trials and retrospective analyses published between January 1, 2013 and February 23, 2024 in the Ovid Medline database. These references were assessed through the American Radium Society (ARS) Appropriate Use Criteria (AUC) methodology. A systematic review PRISMA 2020 checklist confirmed the completion of essential elements. RAND-UCLA consensus methodology was used by the expert panel to rate the appropriateness of the treatment options.

RESULTS

ARS AUC recommendations include (1) larynx preservation using endoscopic resection (EMR or ESD) alone for the typical case with pT1a cN0 cM0 CEC, (2) definitive CRT for the typical case with cT1bN0M0 in patients who cannot undergo endoscopic resection, (3) larynx-preserving using definitive CRT (with or without induction chemotherapy) for the typical case with nonmetastatic locally advanced CEC (advanced T-stage tumors or involved lymph nodes), with surgery reserved for those patients with incomplete response or locoregional recurrence.

CONCLUSIONS

This ARS AUC summary provides guidelines for the management of SCC of the cervical esophagus provides based on available evidence. Topics that warrant further investigation include optimization of (1) patient selection; (2) multimodality therapies including chemotherapy, immunotherapy, and targeted agents; (3) radiation dose, schedule, and treatment volume; and (4) supportive care for patients with CEC. Ongoing trials continue to improve outcomes for patients with CEC.

Stone density can predict the number of ESWL treatments needed in patients with pancreatic duct calculi

OBJECTIVES

Extracorporeal shock wave lithotripsy (ESWL) with endotherapy (ET) is the first-line treatment in patients with chronic pancreatitis (CP) and main pancreatic duct stone (PDS). Our study aimed to evaluate factors that predict the outcome of ESWL in CP patients with PDS.

METHODS

We retrospectively analyzed data of 166 patients with CP and radiopaque PDS. Computed tomography (CT) images were evaluated for stone density, stone size, main pancreatic duct (MPD) size, and skin-to-stone distance (SSD). Long-term pain relief results were determined via telephone interview in 100 patients.

RESULTS

Mean stone density (MSD) > 1336 HU predicted the need to perform more than one ESWL session (odds ratio [OR]: 1.002; 95% confidence interval [CI]: 1.001 to 1.003; p = 0.002), cut-off 1336 HU yielding 71% sensitivity and 65% specificity. Denser stones required more ESWL and following ET, with ≥4 ET sessions resulting in better technical success. (OR: 3.222; 95% CI: 1.240 to 8.371; p = 0.016). Overall technical success (complete stone fragmentation in ESWL or placing a stent past the stone in ET) rate was 81.3%. Clinical success (complete or partial pain relief at the end of the treatments) rate was 83.7% and remained at the same level also in the long-term follow-up (median 5.5 years). Stone size, MPD size, or SSD were not associated with any of the study outcomes.

CONCLUSIONS

Higher MSD than 1336 HU predicts the need for more than one ESWL and ET sessions to fragment the stone and clear the duct, but when successful the long-term result is favorable.

Impact of Artificial Intelligence on Gastroenterology Trainee Education

Artificial intelligence (AI) is transforming gastroenterology, particularly in endoscopy, which has a direct impact on trainees and their education. AI can serve as a valuable resource, providing real-time feedback and aiding in tasks like polyp detection and lesion differentiation, which are challenging for trainees. However, its implementation raises concerns about cognitive overload, overreliance, and even access disparities, which could affect training outcomes. Beyond endoscopy, AI shows promise in clinical management and interpreting diagnostic studies such as motility testing. Thoughtful adoption of AI can optimize training and prepare future trainees for the modern healthcare landscape.

The extracorporeal length of nasobiliary tube as a risk factor for nasobiliary tube migration

BACKGROUND AND AIM

Endoscopic nasobiliary drainage (ENBD) plays a crucial role in the treatment of acute cholangitis and obstructive jaundice. This research aimed to investigate the clinical characteristics and risk factors associated with nasobiliary drainage (NBD) tube migration.

METHODS

A retrospective single-center study was conducted, including all patients who underwent ERCP and placed an NBD tube between January 2022 and December 2023.

RESULTS

A total of 1077 patients were included in this study (mean age 59.8 years). Among these, 75 (7.0%) experienced NBD tube migration during their hospital stay. Univariate analysis showed that the maximum width of the bile duct, type of NBD tube, bile duct stricture, placement of a bile stent and/or pancreatic duct stent, and the extracorporeal length of NBD tube were correlated with NBD tube migration (p < 0.05). Multivariate regression analysis indicated that the type of NBD tube (p = 0.01 OR 1.9, 95% CI (1.16-3.13)) and the extracorporeal length of the NBD tube (p < 0.0001 OR 0.96, 95% CI (0.96-0.99)) were independent risk factors for NBD tube migration. Furthermore, it was found that when the extracorporeal length of the NBD tube was greater than 150 cm, the incidence of NBD tube migration was significantly lower than in the group with lengths less than 150 cm (p < 0.001).

CONCLUSION

NBD tube migration is not uncommon in clinical practice. The type of NBD tube and the extracorporeal length of the NBD tube were identified as independent risk factors for NBD tube migration. Ensuring that the extracorporeal length of the NBD tube is greater than 150 cm may reduce the incident of NBD tube migration.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Characteristics and Neoplastic Progression in Barrett's Esophagus: A Large Population-Based Study from Iceland

Background: Barrett's esophagus (BE) is a known precursor to esophageal adenocarcinoma (EAC). However, reports on incidence and progression-to-neoplasm rates have been very variable and conflicting. The aims of the study were to evaluate the characteristics of BE and its progression to neoplasm in a large homogeneous population. Methods: This was a retrospective population-based study with patients identified from 11 institutions through the databases in two centralized pathology laboratories. Demographics and relevant clinicopathological features were obtained from medical records among patients with a pathologically confirmed BE by the presence of intestinal metaplasia between 2003 and 2022. Results: A total of 1388 patients were identified with BE: 948 were men (69%); the median age at diagnosis was 62 years (IQR, 53-72). The ratio of long-segment BE to short-segment BE was significantly higher in patients ≥ 60 years (1.15, 284/248) than those ≤ 60 years (0.77, 205/265) (p = 0.0025). At BE diagnosis, 9.4% had neoplasms: LGD (n = 65), HGD (n = 16), and EAC (n = 49). Among 1258 non-dysplastic BE (NDBE) patients, 4.6% developed a neoplasm-LGD (n = 35), HGD (n = 8), and EAC (n = 15)-with a median observation-period of 5 years (IQR, 3-7). Overall, 160 cases with neoplasms were diagnosed in this BE cohort; 130 (74%) were present at initial BE diagnosis, and 58 (26%) progressed to neoplasms from NDBE. Conclusions: The ratio of long-segment BE was found to be significantly higher in patients ≥ 60 years. Around 9% of the patients were diagnosed as harboring a neoplasm concomitantly with BE, accounting for approximately 74% of all neoplasms. After a median follow-up of 5 years, about 5% of BE showed dysplastic or malignant progression.

Might be over-evaluated: Predicting choledocholithiasis in patients with acute biliary pancreatitis

BACKGROUND

The increase in liver cholestasis enzyme and bilirubin levels, especially due to pancreatitis, mimics choledocholithiasis. This study aimed to examine the relationship between demographic and laboratory cut-off values and the presence of choledocholithiasis in patients with acute biliary pancreatitis (ABP).

METHODS

Patients diagnosed with ABP in the Department of General Surgery at Istanbul Faculty of Medicine between January 2010 and December 2022 were retrospectively analyzed. The presence of stones in the common bile duct was determined based on the results of magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography (ERCP). Demographic and laboratory values of patients with and without bile duct stones were compared. Cut-off values were determined using receiver operating characteristic (ROC) curve analysis, and logistic regression analysis and modeling was performed for each variable.

RESULTS

A total of 1,026 ABP patients were evaluated. Patients whose enzyme levels were not elevated and those who did not undergo MRCP were excluded. A total of 584 patients were included in the study, and choledocholithiasis was detected in 188 (32.2%) patients. In multivariate analysis, age, gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP), and direct bilirubin (DB) were found to be statistically associated with choledocholithiasis. The cut-off values were determined as 65 years for age, 394 U/L for GGT, 173 U/L for ALP, and 1.42 mg/dL for direct bilirubin. In the group where all four parameters were below these cut-off values, suggesting a clean common bile duct, it was observed that the negative predictive value was 97%.

CONCLUSION

Based on the demographic and laboratory data of patients with ABP, we were able to predict with more than 97% accuracy that the common bile duct was clean. Considering that our study only included patients who underwent MRCP due to elevated enzyme levels and suspicion of choledocholithiasis, the negative predictive value would be even higher if patients with acute biliary pancreatitis with normal enzyme levels were included. Additionally, no complications were observed in any of the patients during follow-up. This finding suggests that patients whose common bile duct is predicted to be clean can initially be monitored and supported with additional imaging methods if necessary. As a result, unnecessary imaging can be avoided, reducing costs and preventing the mortality and morbidity associated with unnecessary procedures.

Current status and future perspectives for endoscopic treatment of local complications in chronic pancreatitis

Chronic pancreatitis is a progressive disease characterized by irregular fibrosis, cellular infiltration, and parenchymal loss within the pancreas. Chronic pancreatitis treatment includes lifestyle modifications based on disease etiology, dietary adjustments appropriate for each stage and condition, drug therapy, endoscopic treatments, and surgical treatments. Although surgical treatments of symptomatic chronic pancreatitis provide good pain relief, endoscopic therapies are recommended as the first-line treatment because they are minimally invasive. In recent years, endoscopic therapy has emerged as an alternative treatment method to surgery for managing local complications in patients with chronic pancreatitis. For pancreatic stone removal, a combination of extracorporeal shock wave lithotripsy and endoscopic extraction is used. For refractory pancreatic duct stones, intracorporeal fragmentation techniques, such as pancreatoscopy-guided electrohydraulic lithotripsy and laser lithotripsy, offer additional options. Interventional endoscopic ultrasound has become the primary treatment modality for pancreatic pseudocysts, except in the absence of disconnected pancreatic duct syndrome. This review focuses on the current status of endoscopic therapies for common local complications of chronic pancreatitis, including updated information in the past few years.

Morbidity and Mortality Predictors of Acute Respiratory Failure in Acute Pancreatitis: A Cohort Study Conducted in Vietnam

Background and Aim

Acute pancreatitis (AP) can result in severe complications, with acute respiratory failure (ARF) being among the most critical. Research on ARF in AP remains limited. This study aims to investigate the occurrence, outcomes, and predictors of ARF in AP patients at Cho Ray Hospital, a tertiary care center in Vietnam.

Method

A prospective cohort study was conducted with 230 AP patients at a national hospital in Ho Chi Minh City, Vietnam. Patients were divided into ARF and non-ARF groups, and clinical characteristics were compared. Key outcomes included invasive mechanical ventilation, in-hospital mortality, and length of hospital stay.

Results

ARF developed in 26.1% of patients, with a mortality rate of 25.0% in the ARF group versus 1.2% in the non-ARF group. Mechanical ventilation was required in 48.3% of ARF patients. Significant predictors of ARF were abnormal body mass index (BMI) (p = 0.021), prolonged systemic inflammatory response syndrome (SIRS) (p < 0.001), modified computed tomography severity index (mCTSI) (p = 0.041), and a high bedside index for severity in acute pancreatitis (BISAP) score (p < 0.001). BISAP scores ≥ 2 had a sensitivity of 90.0%, specificity of 73.5%, and AUC of 0.878 (95% CI 0.829-0.921) for predicting ARF. Predictors of mortality in ARF patients included cardiovascular failure (HR 15.83, p = 0.001), prolonged SIRS (HR 4.76, p = 0.038), and high BISAP scores (HR 3.41, p = 0.015).

Conclusion

ARF significantly worsens outcomes in AP patients. Early identification of key predictors, like abnormal BMI, prolonged SIRS, mCTSI, and BISAP scores, could improve interventions and patient prognosis.

Fast-tracking ERCP learning with the Boškoski-Costamagna Trainer: results of a multicenter randomized clinical trial

BACKGROUND

Achieving competence in endoscopic retrograde cholangiopancreatography (ERCP) requires extensive training. Recognizing the potential of simulator-based education for safe and effective skill development, we aimed to assess whether initial training with the Boškoski-Costamagna ERCP Trainer (BCT) is beneficial compared with conventional training alone (i.e. predictive validity).

METHODS

A prospective multicenter randomized trial involving 16 novice ERCP trainees, randomly assigned to intervention or control groups, was performed. Both underwent hands-on training, with the intervention group receiving additional simulation training during the first 3 months. Each trainee was required to complete a minimum of 60 ERCPs in up to 1 year. The TEESAT score evaluated rates of global overall competence (primary outcome), biliary cannulation, and adverse events (AEs; secondary outcomes). Mixed-effect logistic regression models assessed differences in between-group ERCP procedure competence and success. Learning curves were generated cumulatively over the training period.

RESULTS

1106 ERCPs (562 simulator group; 544 control group) were included. Although no statistically significant difference in global overall competence was observed between the groups, possibly owing to data heterogeneity, simulation training demonstrated higher success for native biliary cannulation (52% vs. 42%; P<0.001) and faster median (interquartile range) biliary cannulation times (3 [6] vs. 5 [8] minutes; P<0.001). The simulator group also showed faster improvements in overall performance, native biliary cannulation, and sphincterotomy. No statistical difference was found in overall AEs between the groups.

CONCLUSION

Early simulation training with the BCT improved technical competence in native biliary cannulation and accelerated overall ERCP learning. This approach has the potential to enhance ERCP training programs.

Role of endoscopic ultrasound in the diagnosis and local ablative therapy of pancreatic neuroendocrine tumors

Advancements in diagnostic technology have led to the improved detection of pancreatic neuroendocrine tumors (PNETs) and thus to an increase in the number of reported cases. Endoscopic ultrasound (EUS) technology, including in combination with contrast-enhanced harmonic imaging, aids in distinguishing PNETs from other tumors, while EUS-guided fine-needle aspiration or biopsy has improved the histological diagnosis and grading of tumors. The recent introduction of EUS-guided ablation using ethanol injection or radiofrequency ablation has offered an alternative to surgery in the management of PNETs. Comparisons with surgery have shown similar outcomes but fewer adverse effects. Although standardized protocols and prospective studies with long-term follow-up are still needed, EUS-based methods are promising approaches that can contribute to a better quality of life for PNET patients.

Adverse Events Associated With Endoscopic Retrograde Cholangiopancreatography: Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events (AEs) are associated with morbidity, mortality, and health care expenditure. We aimed to assess incidences and comparisons of ERCP AEs.

METHODS

We included studies performed after 2000 reporting on ERCP AEs from database inception through March 12, 2024. Outcomes included pancreatitis, bleeding, cholangitis, cholecystitis, perforation, and death. DerSimonian and Laird random effects meta-analyses were performed to calculate incidences of AEs. Subgroup and pairwise meta-analyses were performed. Meta-regression was performed on median recruitment year to assess temporal trends in pancreatitis incidence.

RESULTS

A total of 380 studies were included. The incidence of death attributable to ERCP was 0.2% (95% confidence interval [CI], 0.1%-0.3%; I2, 44%; n = 47,258) in all-comers. The overall incidence of pancreatitis was 4.6% (95% CI, 4.0%-5.1%; I2, 96%; n = 293,378) among all-comers and 6.5% (95% CI, 5.9%-7.1%, I2, 89%; n = 88,809) among first-time patients. Pancreatitis incidence remained stable between 2000 and 2023 (average annual percent change 0.06, 95% CI, -0.27 to 0.39). The overall incidences of the following AEs for all-comers were: bleeding (1.5%; 95% CI, 1.2%-1.7%; I2, 93%; n = 229,655), cholangitis (2.5%; 95% CI, 1.9%-3.3%; I2, 96%; n = 121,619), cholecystitis (0.8%; 95% CI, 0.5%-1.2%; I2, 39%; n = 7799), and perforation (0.5%; 95% CI, 0.4%-0.6%; I2, 90%; n = 306,378).

CONCLUSIONS

ERCP-associated AEs remain common. Incidence of post-ERCP pancreatitis remained static despite improvements in techniques, prevention, and recognition. These results are important to patients, endoscopists, and policy makers to inform consent and to encourage implementation of available risk mitigation strategies.

Updates in the Management of Chronic Pancreatitis: Navigating Through Recent Advances

This article provides an up-to-date review of the management of chronic pancreatitis, highlighting advancements in medical therapy, nutritional support, endoscopic and surgical approaches, and emerging treatments. Nutritional management accentuates addressing malabsorption and nutrient deficiencies. Advances in endoscopy and parenchyma-sparing surgical techniques have opened new avenues for improved patient outcomes, with total pancreatectomy and islet autotransplantation offering the only definitive solution for selected patients. Additionally, emerging therapies, including anti-inflammatory and immune-modulating agents, show promise for future treatment options. Emphasizing a multidisciplinary approach, this review aims to equip health care professionals with a comprehensive overview of current management strategies and future directions.

Surgical Step-Up Approach in Management of Necrotizing Pancreatitis

Necrotizing pancreatitis often demands intervention; contemporary management is directed by the step-up approach. Timing of intervention and specific approach is best directed by a multi-disciplinary team including advanced endosocpists, interventional radiologists, and surgeons with interest and experience managing this complex problem. The intervention is often a combination of percutaneous drainage, transluminal endoscopic approaches, and surgical debridement (minimally invasive or open). Goals of treatment are to evacuate solid infected necrosis, gain enteral access when needed, and to prevent recurrence-cholecystectomy in the setting of biliary pancreatitis. Experienced clinical judgment leads to optimal patient outcomes.

Management of Pancreatic Duct Strictures, Leaks, and Disconnected Pancreatic Duct Syndrome

Pancreatic duct (PD) strictures, leaks, and disconnected ducts are important morphologic consequences of inflammatory disease of the pancreas, resulting in abdominal pain, pancreatic ascites, pancreatic pleural effusion, and external pancreatic fistula. Traditionally, these PD complications were treated surgically, but a better understanding of their pathophysiology, along with advancement in endoscopic interventions, has transformed the therapy from morbid surgical interventions to minimally invasive, safe, and effective endoscopic treatment. This review discusses the current diagnostic and management strategies for PD strictures, leaks, and disconnected pancreatic ducts.

Advancements in the application of artificial intelligence in the field of colorectal cancer

Colorectal cancer (CRC) is a prevalent malignant tumor in the digestive system. As reported in the 2020 global cancer statistics, CRC accounted for more than 1.9 million new cases and 935,000 deaths, making it the third most common cancer worldwide in terms of incidence and the second leading cause of cancer-related deaths globally. This poses a significant threat to global public health. Early screening methods, such as fecal occult blood tests, colonoscopies, and imaging techniques, are crucial for detecting early lesions and enabling timely intervention before cancer becomes invasive. Early detection greatly enhances treatment possibilities, such as surgery, radiation therapy, and chemotherapy, with surgery being the main approach for treating early-stage CRC. In this context, artificial intelligence (AI) has shown immense potential in revolutionizing CRC management, serving as one of the most effective screening tools. AI, utilizing machine learning (ML) and deep learning (DL) algorithms, improves early detection, diagnosis, and treatment by processing large volumes of medical data, uncovering hidden patterns, and forecasting disease development. DL, a more advanced form of ML, simulates the brain's processing power, enhancing the accuracy of tumor detection, differentiation, and prognosis predictions. These innovations offer the potential to revolutionize cancer care by boosting diagnostic accuracy, refining treatment approaches, and ultimately enhancing patient outcomes.

The Role of Artificial Intelligence Combined With Digital Cholangioscopy for Indeterminant and Malignant Biliary Strictures: A Systematic Review and Meta-analysis

BACKGROUND

Current endoscopic retrograde cholangiopancreatography (ERCP) and cholangioscopic-based diagnostic sampling for indeterminant biliary strictures remain suboptimal. Artificial intelligence (AI)-based algorithms by means of computer vision in machine learning have been applied to cholangioscopy in an effort to improve diagnostic yield. The aim of this study was to perform a systematic review and meta-analysis to evaluate the diagnostic performance of AI-based diagnostic performance of AI-associated cholangioscopic diagnosis of indeterminant or malignant biliary strictures.

METHODS

Individualized searches were developed in accordance with PRISMA and MOOSE guidelines, and meta-analysis according to Cochrane Diagnostic Test Accuracy working group methodology. A bivariate model was used to compute pooled sensitivity and specificity, likelihood ratio, diagnostic odds ratio, and summary receiver operating characteristics curve (SROC).

RESULTS

Five studies (n=675 lesions; a total of 2,685,674 cholangioscopic images) were included. All but one study analyzed a deep learning AI-based system using a convoluted neural network (CNN) with an average image processing speed of 30 to 60 frames per second. The pooled sensitivity and specificity were 95% (95% CI: 85-98) and 88% (95% CI: 76-94), with a diagnostic accuracy (SROC) of 97% (95% CI: 95-98). Sensitivity analysis of CNN studies (4 studies, 538 patients) demonstrated a pooled sensitivity, specificity, and accuracy (SROC) of 95% (95% CI: 82-99), 88% (95% CI: 72-95), and 97% (95% CI: 95-98), respectively.

CONCLUSIONS

Artificial intelligence-based machine learning of cholangioscopy images appears to be a promising modality for the diagnosis of indeterminant and malignant biliary strictures.

Impact of Sepsis Onset Timing on All-Cause Mortality in Acute Pancreatitis: A Multicenter Retrospective Cohort Study

BACKGROUND

Sepsis complicates acute pancreatitis (AP), increasing mortality risk. Few studies have examined how sepsis and its onset timing affect mortality in AP. This study evaluates the association between sepsis occurrence and all-cause mortality in AP, focusing specifically on the impact of sepsis onset timing.

METHODS

This multicenter retrospective cohort study included 494 ICU-admitted AP patients from the MIMIC-IV database and 91 from our center. Patients were grouped by sepsis occurrence and onset timing. Clinical outcomes were in-hospital and 90-day all-cause mortality. Machine learning identified key variables associated with mortality. Multivariable regression analyzed the impact of sepsis and its onset timing on mortality. To reduce baseline differences, propensity score matching (PSM) based on time to sepsis was conducted. After PSM, Kaplan-Meier survival analyses incorporated data from our center for validation. Restricted cubic spline analysis examined any nonlinear relationship between sepsis onset timing and mortality.

RESULTS

Patients with sepsis had significantly higher in-hospital and 90-day mortality rates than those without sepsis (p < 0.05). Sepsis was identified as a significant risk factor for in-hospital mortality and remained significantly associated after adjusting for key variables (p < 0.05). However, sepsis onset timing did not significantly impact in-hospital or 90-day mortality. These findings were validated after PSM and with our center's data. No nonlinear relationship between sepsis onset timing and mortality was found.

CONCLUSION

Sepsis significantly increases all-cause mortality in AP patients, but the timing of its onset has limited impact. Continuous monitoring and intervention for sepsis during hospitalization are recommended to improve prognosis.

Determining the value of endoscopic retrograde cholangiopancreatography in the management of patients with acute pancreatitis and related complications

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic to a therapeutic tool in acute pancreatitis management, largely due to the availability of less invasive diagnostic modalities such as endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP).

AREAS COVERED

This review explores the therapeutic applications of ERCP across various acute pancreatitis etiologies and its role in managing complications such as bile duct obstructions, pancreatic duct disruptions, and infected necrosis. The discussion highlights the procedure's expanding indications and its critical role in addressing complex cases.

EXPERT OPINION

ERCP remains central to the management of acute pancreatitis complications. As endoscopic techniques and devices continue to advance, its therapeutic scope is likely to grow. Performing ERCP for appropriate indications and optimizing its use is essential for minimizing risks and improving outcomes.

Radiomics in early detection of bilio-pancreatic lesions: A narrative review

Radiomics is transforming the field of early detection of bilio-pancreatic lesions, offering significant advancements in diagnostic accuracy and personalized treatment planning. By extracting high-dimensional data from medical images such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET), radiomics reveals complex patterns that remain undetectable through traditional imaging evaluation. This review synthesizes recent developments in radiomics, particularly its application to early detection of pancreatic cancer (PC) and biliary duct cancer (BDC). It highlights the role of machine learning algorithms and multi-parametric models in improving diagnostic performance and discusses challenges such as standardization, reproducibility, and the need for larger, multicenter datasets. The integration of radiomics with genomic data and liquid biopsies also presents future opportunities for more individualized patient care.

Comparison of laparoscopic cholecystectomy in children at paediatric centres and adult centres: a systematic review and meta-analysis

INTRODUCTION

Paediatric laparoscopic cholecystectomy (LC) is performed by both paediatric and adult surgeons. The aim of this review was to compare outcomes at paediatric centres (PCs) and adult centres (ACs).

METHODS

A literature search was conducted, in accordance with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, for papers published between January 2000 and December 2020. Statistical analysis was performed using Stata® version 16 (StataCorp, College Station, TX, US).

RESULTS

A total of 92 studies involving 74,852 paediatric LCs met the inclusion criteria. Over half (59%) of the LCs were performed at ACs. No significant differences were noted in the male-to-female ratio, mean age or mean body mass index between PCs and ACs. The main indications were cholelithiasis (34.1% vs 34.4% respectively, p=0.83) and biliary dyskinesia (17.0% vs 23.5% respectively, p<0.01). There was no significant difference in the median inpatient stay (2.52 vs 2.44 days respectively, p=0.89). Bile duct injury was a major complication (0.80% vs 0.37% respectively, p<0.01). Reoperation rates (2.37% vs 0.74% respectively, p<0.01) and conversion to open surgery (1.97% vs 4.74% respectively, p<0.01) were also significantly different. Meta-analysis showed no significant difference in overall complications (p=0.92).

CONCLUSIONS

The number of LCs performed, intraoperative cholangiography use and conversion rates were higher at ACs whereas bile duct injury and reoperation rates were higher at PCs. Despite a higher incidence of bile duct injury at PCs, the incidence at both PCs and ACs was <1%. In complex cases, a joint operation by both paediatric and adult surgeons might be a better approach to further improve outcomes. Overall, LC was found to be a safe operation with comparable outcomes at PCs and ACs.

Diagnosis of Lung Abscess and Pancreatic Collection Using Transesophageal and Transgastric Point-of-Care Ultrasound in a Critically Ill Patient

Effectively managing critically ill septic patients requires careful utilization of imaging techniques. While point-of-care ultrasound (POCUS) is invaluable in the ICU, it faces challenges with conventional transcutaneous ultrasound, especially in obese patients. A 22-year-old obese female presented with abdominal pain and renal dysfunction. Abdominal CT confirmed acute biliary pancreatitis, progressing to respiratory failure. Transesophageal and transgastric ultrasound revealed a pulmonary abscess and peripancreatic collection. Expectant management of the lung abscess and percutaneous drainage of the pancreatic collection led to successful recovery. This case highlights POCUS's pivotal role in timely diagnosis, particularly in severe pancreatitis, showcasing its versatility in critical care.

Safety evaluation of extracorporeal shockwave lithotripsy for pancreatic stones: Experience based on a large chronic pancreatitis cohort

BACKGROUND

The safety of extracorporeal shock wave lithotripsy for pancreatic stones (P-ESWL) and adverse events were not evaluated and classified within large sample population. This study aimed to evaluate the safety and classify the adverse events of P-ESWL based on a large sample cohort.

METHODS

This is an observational study based on the large prospective chronic pancreatitis (CP) cohort. Patients with painful pancreatic stones over 5 mm who underwent P-ESWL between March 2011 and June 2018 at Shanghai Changhai Hospital were included. Adverse events after P-ESWL including complications and transient adverse events (TAEs) were recorded. Risk factors of adverse events were analyzed through univariable and multivariable logistics regression analysis. Sensitivity analysis was conducted to test the stability of the study.

RESULTS

Totally 2,071 patients underwent 5,002 sessions of P-ESWL were included. The overall complication rate and TAEs rate after all P-ESWL procedures were 5.2% and 20.9%. The complications and TAEs rate decreased obviously within the first 6 sessions. Several independent risk factors for adverse events after P-ESWL were identified. Sensitivity analysis suggested the stability of the results.

CONCLUSIONS

P-ESWL is a safe treatment for pancreatic stones. Multiple P-ESWL sessions did not increase the complications and TAEs rate. ClincialTrials.gov number, NCT05916547.

Transpancreatic precut sphincterotomy: Can nonexperts match the outcomes of experts?

BACKGROUND

Nonexpert endoscopists cannot achieve high-quality performance during difficult biliary cannulation, representing a significant challenge; precutting is an effective approach for managing these cases. Transpancreatic biliary sphincterotomy (TPBS) is considered more effective than needle-knife precutting owing to its wire-guided technique, which may be suitable for nonexpert endoscopists; however, comparisons between nonexpert and expert endoscopists performing TPBS are not well documented.

METHODS

Consecutive patients who underwent TPBS between January 2010 and April 2024 were evaluated. Rates of successful biliary duct cannulation, time to TPBS and bile duct cannulation, and adverse events were compared between both groups. Logistic regression analysis was conducted to identify factors associated with successful bile duct cannulation using TBPS.

RESULTS

The study included 140 patients (77 and 63 in the nonexpert and expert groups, respectively). The rates of successful biliary cannulation and overall adverse events (including pancreatitis, 9.1% vs. 9.5%) were 88.3% and 93.7% (p = .38) and 15.6% and 9.5% (p = .32) in the nonexpert and expert groups, respectively. Multivariate analysis revealed that early TPBS (<22 min) was a significant predictive factor for successful bile duct cannulation.

CONCLUSIONS

TBPS may be an effective technique for nonexpert endoscopists; additionally, early TPBS is a significant predictive factor for successful bile duct cannulation.

Video recording in GI endoscopy

The current approach to procedure reporting in endoscopy aims to capture essential findings and interventions but inherently sacrifices the rich detail and nuance of the entire endoscopic experience. Endoscopic video recording (EVR) provides a complete archive of the procedure, extending the utility of the encounter beyond diagnosis and intervention, and potentially adding significant value to the care of the patient and the field in general. This white paper outlines the potential of EVR in clinical care, quality improvement, education, and artificial intelligence-driven innovation, and addresses critical considerations surrounding technology, regulation, ethics, and privacy. As with other medical imaging modalities, growing adoption of EVR is inevitable, and proactive engagement of professional societies and practitioners is essential to harness the full potential of this technology toward improving clinical care, education, and research.

A Narrative Review on the Role of Artificial Intelligence (AI) in Colorectal Cancer Management

The role of artificial intelligence (AI) tools and deep learning in medical practice in the management of colorectal cancer has gathered significant attention in recent years. Colorectal cancer, being the third most common type of malignancy, requires an innovative approach to augment early detection and advanced surgical techniques to reduce morbidity and mortality. With its emerging potential, AI improves colorectal cancer management by assisting with accuracy in screening, pathology evaluation, precision, and postoperative care. Evidence suggests that AI minimizes missed cases during colorectal cancer screening, plays a promising role in pathology and imaging diagnoses, and facilitates accurate staging. In surgical management, AI demonstrates comparable or superior outcomes to laparoscopic approaches, with reduced hospital stays and conversion rates. However, these outcomes are influenced by clinical expertise and other dependable factors, including expertise in implementing AI-based software and detecting possible errors. Despite these advancements, limited multicenter studies and randomized trials restrict the comprehensive evaluation of AI's true potential and integration into standard practice. We used Pubmed, Google Scholar, Cochrane Library, and Scopus databases for this review. The final number of articles selected, depending on inclusion and exclusion criteria, is 122. We included papers published in the English language, literature published in the last 10 years, and adult patient populations above 35 years with colorectal cancer. We thoroughly included randomized controlled trials, cohort studies, meta-analyses, systematic reviews, narrative reviews, and case-control studies. The use of AI paves the way for the adoption of more personalized medicine. This review highlights the advantages of AI at various disease stages for colorectal cancer patients and evaluates its potential for cost-effective implementation in clinical practice.

A staged approach to resecting a large rectal polyp using endoscopic mucosal resection and trans-anal endoscopic microsurgery: a case report

Large rectal adenomatous polyps are not uncommon. Proctectomy sparing interventions are favored when feasible. We present a case of a 62-year-old woman, who presented with diarrhea for several years. Colonoscopy revealed a very large 60 mm rectal polyp, biopsied as tubulovillous adenoma. This was successfully resected using a staged approach with endoscopic mucosal resection and trans-anal endoscopic microsurgery. Endoscopic mucosal resection removed 70% of the lesion with central scarred not amenable to resection but amenable to transanal excision. Pathology demonstrated tubulovillous adenoma with negative margins. Flexible sigmoidoscopy at 6-month follow-up revealed well healed scar without recurrence or residual disease. This demonstrates a staged resection for a large rectal polyp which is minimally invasive and organ preserving.