Peroral Endoscopic Myotomy and Functional Lumen Imaging Probe

Esophageal motor disorders (EMDs) encompass a spectrum of conditions characterized by abnormal motility patterns leading to impaired bolus transit through the esophagus. These disorders can generally be categorized as dysfunction of the esophagogastric junction, dysfunction of peristalsis, or a combination of both. A thorough clinical history focusing on classic symptoms is imperative to guide the diagnostic approach and interpretation of testing appropriately. High-resolution manometry is the cornerstone diagnostic modality for EMDs as it allows for interrogation of esophageal pressure dynamics in real time by measuring peristaltic activity of the esophageal body and the relaxation of the lower esophageal sphincter.

Stent placement can achieve same prognosis as endoscopic nasobiliary drainage in treatment of bile leakage after liver transplantation

BACKGROUND

Both stent placement and endoscopic nasobiliary drainage (ENBD) are commonly used for treating bile leakage following liver transplantation. However, little research has compared the advantages of both methods.

AIM

To compare the prognosis of stent placement and ENBD in treating bile leakage following liver transplantation.

METHODS

We retrospectively collected data for patients with bile leakage after liver transplantation in our center. The efficiency and prognosis were compared between the stent placement and ENBD groups.

RESULTS

We retrospectively collected data from 50 patients diagnosed with bile leakage within 1 month after liver transplantation. Forty patients underwent ENBD and nine received stent placement. Baseline patient characteristics, except white blood cell count, total bilirubin and direct bilirubin levels, were comparable between the two groups. Additionally, there was no significant difference in the rates of reconveyance or postoperative biliary stricture.

CONCLUSION

Stent placement and ENBD are recommended for treating bile leakage after liver transplantation, with similar efficacy and prognosis.

Advances in gastrointestinal endoscopy: A comprehensive review of innovations in cancer diagnosis and management

The field of gastroenterology has experienced revolutionary advances over the past years, as flexible endoscopes have become widely accessible. In addition to enabling faster, less invasive, and more affordable treatment, flexible endoscopes have greatly improved the detection and endoscopic screening of malignancies and prevented many cancer-related deaths. The development and clinical application of new diagnostic endoscopic technologies, such as magnification endoscopy, narrow-band imaging, endoscopic ultrasound with biopsy, and more recently, artificial intelligence enhanced technologies, have made the recognition and detection of various neoplasms and sub-epithelial tumors more possible. This review demonstrates the latest advancements in endoscopic procedures, techniques, and devices applied in the diagnosis and management of gastrointestinal cancer.

Acute fatty liver in pregnancy presenting in the second trimester: A systematic literature review

Objective

We present clinical features and outcomes of second-trimester acute fatty liver of pregnancy (AFLP), a serious but rare condition.

Results

Fourteen pregnant women with AFLP or compatible biopsy were identified in the literature. Diagnosis occurred between 20 and 27 + 6 weeks of gestational age. In total, 50% were primigravid. Thirteen cases met the Swansea criteria while the other case had a compatible liver biopsy. In total, 10 out of 11 cases had microvesicular steatosis on their liver biopsy. Common maternal complications included acute renal failure, hypoglycaemia, liver failure, encephalopathy, intensive care unit admission and need for blood transfusions. Seven deliveries were on the day of diagnosis, five within four weeks, and two within three months. One maternal death, seven fetal deaths and three neonatal deaths occurred.

Conclusion

AFLP diagnosed in the second trimester is a rare condition. Neonatal mortality and maternal morbidity are high. Most cases had nonspecific symptoms and clinical findings, but a majority had compatible biopsies.

North American Expert Consensus on the Post-procedural Care of Patients After Per-oral Endoscopic Myotomy Using a Delphi Process

BACKGROUND & AIMS

There is significant variability in the immediate post-operative and long-term management of patients undergoing per-oral endoscopic myotomy (POEM), largely stemming from the lack of high-quality evidence. We aimed to establish a consensus on several important questions on the after care of post-POEM patients through a modified Delphi process.

METHODS

A steering committee developed an initial questionnaire consisting of 5 domains (33 statements): post-POEM admission/discharge, indication for immediate post-POEM esophagram, peri-procedural medications and diet resumption, clinic follow-up recommendations, and post-POEM reflux surveillance and management. A total of 34 experts participated in the 2 rounds of the Delphi process, with quantitative and qualitative data analyzed for each round to achieve consensus.

RESULTS

A total of 23 statements achieved a high degree of consensus. Overall, the expert panel agreed on the following: (1) same-day discharge after POEM can be considered in select patients; (2) a single dose of prophylactic antibiotics may be as effective as a short course; (3) a modified diet can be advanced as tolerated; and (4) all patients should be followed in clinic and undergo objective testing for surveillance and management of reflux. Consensus could not be achieved on the indication of post-POEM esophagram to evaluate for leak.

CONCLUSIONS

The results of this Delphi process established expert agreement on several important issues and provides practical guidance on key aspects in the care of patients following POEM.

Safety of same day discharge after Zenker's diverticulum peroral endoscopic myotomy

INTRODUCTION

There are limited data on the safety of same-day discharge (SDD) following peroral endoscopic myotomy for Zenker's diverticulum (Z-POEM). Our aim is to assess the frequency and etiology of emergency department (ED) visits or hospital admissions after SDD after Z-POEM.

METHODS

Patients at our institution between 02/2020 and 08/2023 who had SDD after Z-POEM were identified. Criteria for SDD were: 1)no procedure-related serious adverse event; 2)post-POEM esophagram without leak; 3)stable vital signs; 4)ability to take liquids; 5)pain controlled without IV analgesia; 6)social support for transit to ED; 7)ASA class I-III. Relevant post-procedure events, ED visits and hospitalizations within 30 days were reported. A causative relationship between Z-POEM and ED visits and hospitalizations was assigned by consensus.

RESULTS

39 Z-POEMs were performed, and 26 (67 %) patients (58 % male, median age 72 years) had SDD. Mean ZD diameter was 29±14 mm and mean baseline Dakkak and Bennett's score was 2.9 ± 0.9. Within 30 days of Z-POEM, two(7.7 %) ED visits occurred 13 days and 9 days post-procedure for a COPD exacerbation(n = 1) and pneumonia(n = 1), respectively. Both patients were discharged without admission and only the visit for pneumonia was considered related to Z-POEM.

CONCLUSION

Eligible patients who follow and fulfill a strict protocol after Z-POEM may be safely discharged the same day of the procedure.

[Clinical Ultrasound (ClinUS) - Concepts and Controversies]

Clinical ultrasound (ClinUS) is the integration of ultrasound diagnostics into the clinical examination. By comparing clinical ultrasound with other models of ultrasound diagnostics, this overview presents a concept that integrates point-of-care ultrasound, comprehensive specialty-specific ultrasound examinations and specialized multiparametric ultrasound. The applications, advantages and challenges of clinical ultrasound and its special features in comparison to other cross-sectional imaging modalities are discussed using the example of gastroenterology and general medicine in particular.

Risk-scoring system predicting need for hospital-specific interventional care after peroral endoscopic myotomy

OBJECTIVES

Early identification of patients needing hospital-specific interventional care (HIC) following endoscopic treatment is valuable for optimizing postoperative hospital stays. We aimed to develop and validate a risk-scoring system for predicting HIC in patients who underwent peroral endoscopic myotomy (POEM).

METHODS

This study included patients with esophageal motility disorders who underwent POEM at our hospital between April 2015 and March 2023. HIC was defined as any of the following situations: fasting for gastrointestinal rest to manage adverse events (AEs); intravenous administration of medications such as antibiotics and blood transfusion; endoscopic, radiologic, and surgical interventions; intensive care unit management; or other life-threatening events. A risk-scoring system for predicting HIC after postoperative day (POD) 1 was developed using multivariable logistic regression and was internally validated using bootstrapping and decision curve analysis.

RESULTS

Of the 589 patients, 50 (8.5%) experienced HIC after POD1. Risk scores were assigned for four factors as follows: age (0 points for <70 years, 1 point for 70-79 years, 2 points for ≥80 years), preoperative prognostic nutritional index (0 points for >45, 1 point for 40-45, 4 points for <40), postoperative surgical site AEs on second-look endoscopy (7 points), and postoperative pneumonia on chest radiography (6 points). The discriminative ability (concordance statistics, 0.85; 95% confidence interval, 0.78-0.91) and calibration (slope 1.00; 0.74-1.28) were satisfactory. The decision curve analysis demonstrated its clinical usefulness.

CONCLUSION

This risk-scoring system can predict the HIC after POD1 and provide useful information for determining discharge.

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.

Diagnostic work-up of bile duct strictures: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends the combination of endoscopic ultrasound-guided tissue acquisition (EUS-TA) and endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition as the preferred diagnostic approach for tissue acquisition in patients with jaundice and distal extrahepatic biliary stricture in the absence of a pancreatic mass. 2: ESGE suggests that brushing cytology should be completed along with fluoroscopy-guided biopsies, wherever technically feasible, in patients with perihilar biliary strictures. 3: ESGE suggests EUS-TA for perihilar strictures when ERCP-based modalities yield insufficient results, provided that curative resection is not feasible and/or when cross-sectional imaging has shown accessible extraluminal disease. 4: ESGE suggests using standard ERCP diagnostic modalities at index ERCP. In the case of indeterminate biliary strictures, ESGE suggests cholangioscopy-guided biopsies, in addition to standard ERCP diagnostic modalities. Additional intraductal biliary imaging modalities can be selectively used, based on clinical context, local expertise, and resource availability.

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.

Endoscopic retrograde cholangiopancreatography training using a silicone simulator fabricated using a 3D printing technique (with videos)

Endoscopic retrograde cholangiopancreatography (ERCP) training remains challenging. This study used 3D printing techniques to develop and optimize a portable ERCP training simulator and to implement basic and advanced practical techniques. Subsequently, we aimed to determine whether endoscopy trainees acquired proficiency in ERCP techniques and assess any improvements in their skill levels from using this model. An ERCP training model was generated using 3D printing techniques, including five distinct interchangeable and transparent ampullar-common bile duct (CBD) modules. A prospective study using this model was conducted with ten trainees. The technical success rate and examination times for duodenoscope insertion and biliary cannulation were evaluated. In addition, the successful plastic-stent insertion rate and trainee satisfaction were measured. The success rates for duodenoscopy, cannulation, and plastic stent insertion were 94, 100, and 92%, respectively. The mean satisfaction scores for duodenoscope insertion, cannulation, and plastic stent insertion were 4.4, 4.7, and 4.6 on a 5-point scale, respectively. Five attempts decreased the insertion time (R = - 0.591, P < 0.001) and cannulation time (R = - 0.424, P = 0.002). This ERCP-training silicon model is durable, simulates ERCP techniques easily, and helps trainees improve their ERCP techniques.

Comparative Efficacy of Esketamine vs Sufentanil with Propofol for Sedation in EUS: A Randomized, Controlled Study

Purpose

This randomized, controlled trial aimed to assess the sedative effects of esketamine and sufentanil combined with propofol during EUS.

Patients and Methods

Three hundred and forty patients undergone EUS were randomly divided into two groups to receive esketamine 0.25 mg/kg combined with propofol (esketamine group) or sufentanil 0.1 μg/kg combined with propofol (sufentanil group). The primary outcome measure was respiratory depression incidence. The secondary outcomes included the incidence of body movements, propofol dosage, lowest SPO2 during the operation, and management of airway obstruction. In addition, other procedures and anesthesia-related outcomes, and postoperative complications were recorded.

Results

A total of 340 patients underwent randomization. Of these, 172 were assigned to the esketamine group and 168 were assigned to the sufentanil group. 1 patient in the esketamine group was lost in the follow-up. During the EUS, 9 patients (5.3%) in the esketamine group and 26 (15.5%) in the sufentanil group developed respiratory depression; this difference was statistically significant (P = 0.002). Regarding secondary outcomes, the incidence of body movements, induction dosage, supplemental times, and total dosage of propofol were much higher in the sufentanil group than in the esketamine group (P < 0.05). In addition, the lowest SPO2 during the operation, occurrence rate of airway intervention, and management of airway obstruction were significantly different (P < 0.05). Compared to the sufentanil group, the induction time of sedation in the esketamine group was shorter, and the hemodynamics were more stable (P < 0.05). In addition, there were significant differences in the PACU incidence rates of nausea or vomiting between the two groups (P < 0.05), whereas the following day's complications showed no statistical difference.

Conclusion

Esketamine combined with propofol for sedation during EUS can decrease respiratory depression, reduce the dosage of propofol and PONV, and provide a more stable hemodynamic state. Consequently, esketamine could be considered as a potential alternative to sufentanil for sedation during EUS.

A Randomized Controlled Trial of Patient Positioning During Endoscopic Retrograde Cholangiopancreatography (ERCP) Procedures: A Comparison Between Semi-Prone- and Prone-Positioned Patients

The prone "swimmers" position is preferable for endoscopic retrograde cholangiopancreatography (ERCP) as it provides the best visualization for selective bile duct cannulation. However, "swimmers" position does not comply with best-practice patient positioning guidelines. Our objective was to determine whether the semi-prone patient position was suitable for ERCP without negatively influencing the outcomes of the procedure. We conducted a randomized controlled trial, 50 patients in prone and 50 patients in semi-prone patient position, measuring the number of attempts and time to successfully cannulate the bile duct. Safety outcomes measured were airway access, pharyngeal endoscope passage, and complications. Between the two groups, there were no statistical differences in demographic variables, selective bile duct cannulation attempts, or cannulation time. Airway access scored significantly better in the semi-prone position. There was a significant positive correlation between the total number of cannulation attempts and papilla type. No intra- or post-procedural significant complications occurred. The semi-prone position was comparable to the "swimmers" position regarding the number of attempts and time required for selective bile duct cannulation but scored significantly better in airway access by anesthetists. A semi-prone patient position is advisable for ERCP procedures as it complies with best-practice patient positioning guidelines.

Predictive factors of spontaneous common bile duct clearance and unnecessary ERCP in patients with choledocholithiasis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line procedure for choledocholithiasis treatment. However, it is associated with a 10 % rate of adverse events. Spontaneous migration of common bile duct (CBD) stones occurs in 6-33 % of choledocholithiasis cases, making ERCP avoidable. This study aimed to identify predictors of spontaneous CBD stones' migration.

METHODS

Retrospective study including patients diagnosed with choledocholithiasis and submitted to ERCP. Patients were divided into 2 groups considering spontaneous stone migration (i.e.: the absence of CBD stones on ERCP). Data on patients' characteristics, imaging findings, biochemical analysis, and ERCP procedure were analyzed to identify predictors of spontaneous migration of CBD stones.

RESULTS

334 patients with a mean age of 71.7 years were included in the study: 76.6 % without and 23.4 % with spontaneous migration of CBD stones. Although some patients' features (gender and clinical presentation), imaging findings (diameters of the largest stone and CBD), biochemical analysis (bilirubin levels at diagnosis and pre-ERCP), and ERCP procedure characteristics (time from diagnosis to ERCP) were different between groups, only three variables were defined as predictors: the absence of acute cholangitis, the largest stone diameter ≤5 mm, and the bilirubin levels pre-ERCP ≤ 2mg/dL. When using those variables together there was a chance of 81-86 % to correctly distinguishing patients with and without spontaneous CBD stone migration.

CONCLUSION

The size of the largest stone at diagnosis was validated as a predictor of CBD stones' spontaneous migration. Furthermore, two new predictors were identified: bilirubin levels pre-ERCP ≤ 2 mg/dL, and no acute cholangitis at the clinical presentation of choledocholithiasis. EUS and ERCP in the same session should be considered in patients with factors predictive of stone migration, especially when combined, to minimize unnecessary ERCP and possible complications.

Endoscopic submucosal dissection for superficial ultra-low rectal tumors: outcomes and predictive factors for procedure difficulty

BACKGROUND

Ultra-low rectal endoscopic submucosal dissection (ESD) presents technical challenges due to anatomical features. The objective of this research was to determine the risk factors linked to unsuccessful curative resections and to create a nomogram predictive model to assess the likelihood of encountering technical challenges.

METHODS

Patients with ultra-low rectal tumors received ESD form June 2017 to December 2022 were retrospectively enrolled. An ESD procedure exceeding 30 min was deemed difficult. A logistic regression analysis was performed to pinpoint important factors and predictors. The effectiveness of the nomogram, which incorporated the identified predictors, was evaluated by employing receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA).

RESULTS

A total of 300 patients with ultra-low rectal tumors were enrolled, with a curative resection rate of 82.0%. Multivariate logistic regression revealed that poor lifting sign (OR = 3.282, P = 0.026), non-granular type laterally spreading tumors (LST-NG, OR = 2.230, P = 0.042) and procedure time ≥ 60 min (OR = 6.976, P = 0.010) contributed to non-curative resection. Predictors for ESD difficulty included tumor diameter ≥ 30 mm (compared with < 30 mm, 30-50 mm, OR = 2.450, P = 0.044; ≥ 50 mm, OR = 5.047, P = 0.009), ≥ 1/2 circumference involvement (OR = 3.183, P = 0.038); dentate line invasion (OR = 3.881, P = 0.026) and less colorectal ESD experience (OR = 3.415, P = 0.032). The nomogram performed well in both train and validation sets (area under the curve (AUC) = 0.873 and 0.810, respectively). Calibration plots exhibited satisfactory agreement between predicted and observed outcomes, and DCA showed superior clinical benefit of the model than individual predictors.

CONCLUSIONS

Poor lifting sign, LST-NG and procedure time ≥ 60 min were associated with non-curative resection for ultra-low rectal ESD. By including factors such as tumor size, location, and the operator's experience with ESD, the nomogram can predict the complexity of the procedure before surgery.

Artificial Intelligence and cancer: Profile of registered clinical trials

Artificial Intelligence (AI) has made significant strides due to advancements in processing algorithms and data availability. Recent years have shown a resurgence in AI, driven by breakthroughs in deep machine learning. AI has attracted particular interest in the medical sector, especially in the field of personalized medicine, which for example uses large-scale genomic and molecular data to predict individual patient treatment responses. The applications of AI in disease diagnosis, monitoring, and treatment are expanding rapidly, leading to a growing number of registered trials. Therefore, this study aimed to identify and evaluate clinical trials registered between January 1st 2016, and September 30th 2023 that connect AI and cancer. Our findings show that the number of clinical trials linking AI with cancer research has grown significantly compared to other diseases, with colorectal and breast tumour types showing the highest number of registered trials. The most frequent intervention was disease diagnosis and monitoring. Regarding countries, China and the United States hold the highest numbers of registered trials. In conclusion, oncology is a field with a great interest in AI, where the developed countries are leading the studies in this field. Unfortunately, developing countries are still crawling in this aspect and government policies should be made to improve that area.

AGA Clinical Practice Update on Advances in Per-Oral Endoscopic Myotomy (POEM) and Remaining Questions-What We Have Learned in the Past Decade: Expert Review

DESCRIPTION

This American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) aims to review the available evidence and provide expert advice regarding advances in per-oral endoscopic myotomy (POEM).

METHODS

This CPU was commissioned and approved by the AGA Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. This review is framed around best practice advice points agreed upon by the authors, based on the current available evidence and expert opinion in this field. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Patients evaluated for POEM should undergo a comprehensive diagnostic workup, which includes clinical history and review of medications, upper endoscopy, timed barium esophagram, and high-resolution manometry. Endoscopic functional luminal impedance planimetry can be a useful adjunct test, particularly in cases when diagnosis is equivocal. BEST PRACTICE ADVICE 2: POEM, laparoscopic Heller myotomy, and pneumatic dilation are effective therapies for type I and type II achalasia; the decision between these treatment modalities should be based on shared decision making, taking into account patient and disease characteristics, patient preferences, and local expertise. POEM should be considered the preferred treatment for type III achalasia. BEST PRACTICE ADVICE 3: Patients with esophagogastric outflow obstruction alone and/or nonachalasia spastic disorders on manometry should undergo a comprehensive evaluation with correlation of symptoms. Evidence for POEM for these manometric findings are limited and should only be considered on a case-by-case basis after other less invasive approaches have been exhausted. BEST PRACTICE ADVICE 4: A single dose of antibiotics at the time of POEM may be sufficient for antibiotic prophylaxis. BEST PRACTICE ADVICE 5: POEM can be performed via either an anterior or posterior tunnel orientation, with comparable efficacy, safety, and rate of postprocedure reflux between these 2 approaches. Endoscopist's preferences and patient's surgical history, including prior laparoscopic Heller myotomy and/or POEM, should be considered when determining tunnel orientation. BEST PRACTICE ADVICE 6: The optimal length of the myotomy in the esophagus and cardia, as it pertains to treatment efficacy and risk for postprocedure reflux, remains to be determined. Adjunct techniques, including real-time intraprocedure functional luminal impedance planimetry, may be considered to tailor or confirm the adequacy of the myotomy. BEST PRACTICE ADVICE 7: The clinical impact of routine esophagram or endoscopy immediately post-POEM remains unclear. Testing can be considered based on local practice preferences, and in cases in which intraprocedural events or postprocedural findings warrant further evaluation. BEST PRACTICE ADVICE 8: Same-day discharge after POEM can be considered in select patients who meet discharge criteria. Patients with advanced age, significant comorbidities, poor social support, and/or access to specialized care should be considered for hospital admission, irrespective of symptoms. BEST PRACTICE ADVICE 9: Pharmacologic acid suppression should be strongly considered in the immediate post-POEM setting, given the increased risk of postprocedure reflux and esophagitis. BEST PRACTICE ADVICE 10: All patients should undergo monitoring for gastroesophageal reflux disease after POEM. Patients with persistent esophagitis and/or reflux-like symptoms despite proton pump inhibitor use, should undergo additional testing to evaluate for other etiologies besides pathologic acid exposure and management to optimize and achieve reflux control. BEST PRACTICE ADVICE 11: Long-term postprocedure surveillance is encouraged to monitor for progression of disease and complications of gastroesophageal reflux disease. BEST PRACTICE ADVICE 12: POEM may be superior to pneumatic dilation for patients with failed initial POEM or laparoscopic Heller myotomy; however, the decision among treatment modalities should be based on shared decision making between the patient and physician, taking into account risk of postprocedural reflux, need for repeat interventions, patient preferences, and local expertise.

Moderate Sedation or Deep Sedation for ERCP: What Are the Preferences in the Literature?

One of the most essential procedures for individuals with biliopancreatic disorders is endoscopic retrograde cholangiopancreatography (ERCP). It is based on the combination of endoscopy and radiology to study the biliopancreatic ducts and apply therapeutic solutions. ERCP is currently used to treat choledocholithiasis with or without cholangitis, as well as pancreatic duct stones, benign bile, and pancreatic leaks. On the other hand, ERCP is an unpleasant procedure that must be conducted under anesthetic (moderate sedation, deep sedation, or general anesthesia). With procedures becoming more challenging, the role of anesthesia in ERCP has become even more relevant, and the use of general anesthesia has become better defined. In the last decades, many drugs have been used and some new drugs, like dexmedetomidine, have been recently introduced for sedation or anesthesia during ERCP. Moreover, the scientific community is still divided on the level of sedation to be applied, as well as on appropriate airway management. We therefore performed a narrative review of the literature to assess currently available anesthetic medications for elective ERCP and evidence supporting their effectiveness.

Endoscopic Ultrasound and Gastric Sub-Epithelial Lesions: Ultrasonographic Features, Tissue Acquisition Strategies, and Therapeutic Management

Background and objectives: Subepithelial lesions (SELs) of the gastrointestinal (GI) tract present a diagnostic challenge due to their heterogeneous nature and varied clinical manifestations. Usually, SELs are small and asymptomatic; generally discovered during routine endoscopy or radiological examinations. Currently, endoscopic ultrasound (EUS) is the best tool to characterize gastric SELs. Materials and methods: For this review, the research and the study selection were conducted using the PubMed database. Articles in English language were reviewed from August 2019 to July 2024. Results: This review aims to summarize the international literature to examine and illustrate the progress in the last five years of endosonographic diagnostics and treatment of gastric SELs. Conclusions: Endoscopic ultrasound is the preferred option for the diagnosis of sub-epithelial lesions. In most of the cases, EUS-guided tissue sampling is mandatory; however, ancillary techniques (elastography, CEH-EUS, AI) may help in both diagnosis and prognostic assessment.

Recent Advancements and Future Perspectives of Per Oral Endoscopic Myotomy

Per oral endoscopic myotomy (POEM) has emerged as a preferred approach for the treatment of idiopathic achalasia and various esophageal motility disorders, offering a minimally invasive alternative to traditional laparoscopic Heller's myotomy. Over the past decade, POEM has solidified its status as the primary therapeutic choice in these conditions through constant improvements. Its evolution has been marked by continuous progress, driven by the integration of innovative technologies and sophisticated techniques. Notable advancements in the techniques include the advent of shorter myotomies and sling fiber-preserving gastric myotomies. The introduction of novel image-enhanced endoscopic techniques, such as red dichromatic imaging and much safer bipolar devices, promises to enhance safety and reduce the technical demands of the POEM procedure. Furthermore, significant strides have been made in understanding gastroesophageal reflux (GERD) following POEM, enabling the differentiation of "true reflux" from acidification resulting from fermentation through manual pH tracing assessment. This distinction aids in identifying cases necessitating treatment with proton pump inhibitors. Other treatment strategies of post-POEM GERD have expanded to the incorporation of NOTES fundoplication and device-assisted fundoplication if the necessity arises. This comprehensive review delves into recent developments in POEM, encompassing technical variations, the assessment and management of post-POEM reflux, outcomes in special populations, and future prospects. By exploring these facets, we aim to provide a comprehensive overview of the current state of POEM, shedding light on its evolution and the promising directions it is poised to take in the field of third-space endoscopy.

Esophageal Per-Oral Endoscopic Myotomy (E-POEM): Future Directions and Perspectives

PURPOSE OF REVIEW

POEM is a mature procedure endorsed by societal guidelines as a first line therapy for achalasia and spastic esophageal disorders. Nonetheless, several questions remain, including expanding indications for POEM, periprocedural evaluation and management, and the optimal POEM technique to enhance clinical success while mitigating risk for reflux.

RECENT FINDINGS

There is uncertainty regarding several technical aspects of the POEM myotomy; though aggregating evidence supports the use of real-time impedance planimetry to guide the myotomy. While post-POEM reflux remains a concerning long term sequela, there is an increasing focus on the potential role of endoscopic anti-reflux interventions. Lastly, with the widespread adoption of POEM, we continue to witness ongoing efforts to standardize post-procedural care and training in this procedure. POEM is no longer a novel but rather established procedure. Yet, this technique has continued to evolve, with the aim of optimizing treatment success while reducing adverse events and risk for post-procedural reflux.

Early prediction of post-endoscopic retrograde cholangiopancreatography pancreatitis via dynamic changes of leukocyte: A retrospective study

BACKGROUND

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remains a major concern for clinicians. Hence early identification of PEP is meaningful to minimize medical risks.

AIMS

This study aims to explore the value of dynamic leukocyte changes for early prediction of PEP.

METHODS

Patients from January 2017 to December 2018 (training set) and January 2019 to December 2022 (test set) were retrospectively reviewed. The dynamic changes of leukocyte, neutrophil, and lymphocyte were examined to evaluate the diagnostic value of PEP.

RESULTS

A total of 498 patients (36 PEP cases) in training set and 948 patients (71 PEP cases) in test set were analyzed. Four predictors were finally identified in training set containing margin and ratio of 3h-post ERCP leukocyte count (Po Leu) to pre-ERCP leukocyte count (Pr Leu), 3h post-ERCP neutrophil-to-lymphocyte ratio (NLR) and pre-ERCP fibrinogen levels. ROC analysis revealed the optimal thresholds were 2.3 (x109/L), 1.6, 4.8 and 3.1 (g/L), respectively. The sensitivity and specificity of Po Leu - Pr Leu and Po Leu/Pr Leu were 71.0%, 82.7%, 66.1% and 86.3% to diagnosis PEP in patients with hyperamylasemia.

CONCLUSIONS

For early identification of PEP, the elevation of amylase and lipase still exhibits the highest sensitivity, while the dynamic changes of leukocyte would be helpful for the different diagnosis of hyperamylasemia.

Endoscopic ultrasound in portal hypertension: navigating venous hemodynamics and treatment efficacy

Portal hypertension-related complications increase mortality in patients, irrespective of its etiology. Classically, endoscopic ultrasound (EUS) was used to assess the portal venous system and collaterals, considering size and hemodynamic parameters, which correlate with portal hypertension (PH) and related complications. Furthermore, therapeutic EUS guides treatment interventions, such as embolization of the gastric varices through coil placement and tissue adhesive injection, yielding encouraging clinical results. Recently, the direct measurement of portal pressure, emerging as an alternative to hepatic venous pressure gradient, has shown promise, and further research in this area is anticipated. In this review, we aimed to provide a detailed description of various possibilities for diagnosing vascular anatomy and hemodynamics in PH and actual knowledge on the EUS usefulness for PH vessel-related complications. Also, future promises for this field of endo-hepatology are discussed.

A Human-AI interaction paradigm and its application to rhinocytology

This article explores Human-Centered Artificial Intelligence (HCAI) in medical cytology, with a focus on enhancing the interaction with AI. It presents a Human-AI interaction paradigm that emphasizes explainability and user control of AI systems. It is an iterative negotiation process based on three interaction strategies aimed to (i) elaborate the system outcomes through iterative steps (Iterative Exploration), (ii) explain the AI system's behavior or decisions (Clarification), and (iii) allow non-expert users to trigger simple retraining of the AI model (Reconfiguration). This interaction paradigm is exploited in the redesign of an existing AI-based tool for microscopic analysis of the nasal mucosa. The resulting tool is tested with rhinocytologists. The article discusses the analysis of the results of the conducted evaluation and outlines lessons learned that are relevant for AI in medicine.

EUS-Guided Vascular Interventions: Recent Advances

Endoscopic ultrasound (EUS)-guided vascular interventions were first reported in 2000 in a study that evaluated the utility of EUS in sclerotherapy of esophageal varices. Currently, gastric variceal therapy and portosystemic pressure gradient (PPG) measurements are the most widely utilized applications. Ectopic variceal obliteration, splenic artery embolization, aneurysm/pseudoaneurysm treatment, portal venous sampling, and portosystemic shunt creation using EUS are some of the other emerging interventions. Since the release of the American Gastroenterological Association (AGA)'s commentary in 2023, which primarily endorses EUS-guided gastric variceal therapy and EUS-PPG measurement, several new studies have been published supporting the use of EUS for various vascular conditions. In this review, we present the recent advances in this field, critically appraising new studies and trials.

The Success Rate Is Lower but Completion Rate of Laparoscopic Cholecystectomy Is higher in Endoscopic Transpapillary Gallbladder Drainage than Percutaneous Gallbladder Drainage for Acute Cholecystitis

BACKGROUND

We investigated the success and complication rates of endoscopic transpapillary gallbladder drainage (ETGBD) and percutaneous transhepatic gallbladder drainage (PTGBD) and the outcomes of subsequent cholecystectomy for acute cholecystitis.

METHODS

Patients (N=178) who underwent cholecystectomy after ETGBD or PTGBD were retrospectively assessed.

RESULTS

ETGBD was successful in 47 (85.5%) of 55 procedures, whereas PTGBD was successful in 123 (100%) of 123 sessions ( P <0.001). Complications related to ETGBD and PTGBD occurred in 6 (12.8%) of 47 and 16 (13.0%) of 123 patients, respectively ( P =0.97). After propensity matching, 43 patients from each group were selected. Median time from drainage to cholecystectomy was 48 (14 to 560) days with ETGBD and 35 (1 to 90) days with PTGBD ( P =0.004). Laparoscopy was selected more often in the ETGBD group (97.7%) than in the PTGBD group (79.1%) ( P =0.007), and conversion from laparoscopy to open cholecystectomy was more common with PTGBD (41.2%) than with ETGBD (7.1%) ( P <0.001). Mean operation time was significantly shorter with ETGBD (135.8±66.7 min) than with PTGBD (195.8±62.2 min) ( P <0.001). The incidence of Clavien-Dindo grade ≥III postoperative complications was 9.3% with ETGBD and 11.6% with PTGBD ( P =0.99).

CONCLUSIONS

The success rate is lower but completion of laparoscopic cholecystectomy is more in endoscopic gallbladder drainage than percutaneous gallbladder drainage for acute cholecystitis.

Endoscopic pyloromyotomy for treatment of gastroparesis: A new standard or still an experimental approach?

Gastroparesis (GP) can be a severe and debilitating disease. Its pathophysiology is complex and not completely understood. Two principal mechanisms are responsible for the development of symptoms - gastric hypomotility and pylorospasm. Pylorus targeted therapies aim to decrease presumably elevated pyloric tone - pylorospasm. There is a growing body of evidence about their role in the treatment algorithm of GP. G-POEM (endoscopic pyloromyotomy) is an extensively studied pylorus targeted therapy. Its efficacy ranges between 56 and 80% and the number of recurrences among those with treatment effect seems low. G-POEM is a safe procedure with very low frequency of severe adverse events. At present, G-POEM should not be considered as an experimental approach and may be offered to all patients with refractory and severe GP. Nevertheless, G-POEM is not a first line treatment. Conservative measures such as diet modification and pharmacotherapy should always be tried before G-POEM is considered. Further research must focus on better patient selection as at present there are no standardized criteria. Functional imaging such as impedance planimetry (EndoFlip) may hold promise in this regard.

Unveiling clinicopathologic features and outcomes for endoscopic submucosal dissection of early gastric cancer at gastric angulus in China

BACKGROUND

With advances in endoscopic submucosal dissection (ESD) technique, an increasing number of the Chinese population are being diagnosed with early gastric cancers (EGCs) at gastric angulus. However, the relationship between gastric angulus and EGCs remains obscure.

OBJECTIVES

We aimed to unveil the unreported location characteristics of gastric angulus in Chinese EGC patients and the correlation between the degree of submucosal fibrosis and ESD outcomes.

METHODS

We retrospectively reviewed the medical records of EGC patients treated with ESD from January 2010 to March 2023. We retrospectively investigated and analyzed 740 EGC patients using multiple analyses.

RESULTS

Following gastric antrum (53.1%), the gastric angulus (21.8%) emerged as the second-most prevalent site for EGCs. It had highest incidence of severe submucosal fibrosis and ulceration than the other parts. Multivariate analysis showed independent associations of submucosal fibrosis at the angulus with ulceration (OR: 3.714, 95% CI: 1.041-13.249), procedure duration (OR: 1.037, 95% CI: 1.014-1.061), and perforation complication (OR: 14.611, 95% CI: 1.626-131.277) (all P < 0.05).

CONCLUSIONS

The gastric angulus demonstrates the highest incidence of severe submucosal fibrosis and ulceration for EGCs identified by ESD. This condition is linked to unfavorable outcomes, typically increased perforation risks and prolonged operation duration. Therefore, meticulous dissection is crucial for patients with EGCs in the gastric angulus.

Diagnosis and management of type II endoscopic retrograde cholangiopancreatography-related perforations: a multicenter retrospective study

BACKGROUND

The management of type II endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is still controversial. This study aimed to compare the effects of covered self-expandable metallic stent (SEMS), surgery, and conservative treatment for type II perforation.

METHODS

From January 2010 to December 2021, this study collected relevant data from five large hospitals in China. The data of ERCP difficulty grading and ERCP-related perforation in 26,673 cases that underwent ERCP during 11 years were retrospectively analyzed. Of 55 patients with type II perforation, 41 patients were implanted with a biliary covered SEMS (stent group), 10 underwent surgery (surgery group), and 4 received conservative treatment (conservative group).

RESULTS

Among the 55 patients with type II perforation, ERCP and computed tomography diagnostic rates of type II perforation were 10.91% (6/55) and 89.09% (49/55), respectively. The incidence of type II perforation in grade 5 ERCP (0.43%, 11/2,537) was significantly higher than that in grade 1-3 ERCP (0.16%, 32/19,471). (P = 0.004) and grade 1-4 ERCP (0.26%,12/4,665) (P = 0.008), respectively. Among the 10 patients in the surgical group, primary repair was performed in only 7 patients in whom location of the perforation could be identified. The incidence of retroperitoneal abscess was significantly lower in the stent group than in the surgery group (P = 0.018) and the conservative group (P = 0.001), respectively. The average hospital stay in the stent group was shorter than that in the surgery group (P = 0.000) and conservative group (P = 0.001), respectively.

CONCLUSIONS

The incidence of type II perforation was dependent on the degree of difficulty of ERCP. The treatment of type II perforation with a covered SEMS can significantly reduce the incidence of retroperitoneal abscess and shorten the hospital stay, with better results than surgical and conservative treatments.

Seven-Year Experience of Intramural Surgery in the Middle East: A Safety and Feasibility Analysis

Background: Intramural surgery techniques, particularly esophageal peroral endoscopic myotomy (E-POEM), gastric peroral endoscopic myotomy (G-POEM), and peroral endoscopic myotomy for Zenker's (Z-POEM), have emerged as forefront minimally invasive endoscopic procedures. While several studies have reported on the outcomes in North America and Asia, evidence in the Middle East and North Africa remains limited. This study aims to evaluate the feasibility and safety of intramural surgery techniques within this region. Methods: This retrospective cohort study was conducted with approval from the institutional review board. All patients who underwent esophageal peroral endoscopic myotomy, gastric peroral endoscopic myotomy, and peroral endoscopic myotomy for Zenker's from January 2016 to August 2023 were included. Results: In total, 119 patients underwent intramural surgery procedures during this period. The esophageal peroral endoscopic myotomy group had 81 (68%) patients, the gastric peroral endoscopic myotomy had 34 (28.6%) patients, and the peroral endoscopic myotomy for Zenker's had 4 (3.4%) patients. The full cohort was 48.7% female, with a mean overall age of 40.5 years. The mean overall body mass index was 27.5 kg/m2. The chief complaint was dysphagia (n = 80, 67.2%). All cases were successfully completed endoscopically. During the first 30 days, the most common complications were nausea/vomiting requiring admission (n = 4, 4.76%) and pneumomediastinum (n = 2, 2.38%). At a follow-up of 19 months, there were four mortalities; the causes of death were cardiac arrest (three cases) and end-stage prostate cancer (one case). Conclusions: Intramural surgery techniques are safe and technically feasible with low complication rates. Our study suggests that clinical success in the Middle East and Northern Africa population is comparable to larger international series.

Revolutionizing Gastrointestinal Disorder Management: Cutting-Edge Advances and Future Prospects

In recent years, remarkable strides have been made in the management of gastrointestinal disorders, transforming the landscape of patient care and outcomes. This article explores the latest breakthroughs in the field, encompassing innovative diagnostic techniques, personalized treatment approaches, and novel therapeutic interventions. Additionally, this article emphasizes the use of precision medicine tailored to individual genetic and microbiome profiles, and the application of artificial intelligence in disease prediction and monitoring. This review highlights the dynamic progress in managing conditions such as inflammatory bowel disease, gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal cancers. By delving into these advancements, we offer a glimpse into the promising future of gastroenterology, where multidisciplinary collaborations and cutting-edge technologies converge to provide more effective, patient-centric solutions for individuals grappling with gastrointestinal disorders.

Leveraging a realistic synthetic database to learn Shape-from-Shading for estimating the colon depth in colonoscopy images

Colonoscopy is the choice procedure to diagnose, screening, and treat the colon and rectum cancer, from early detection of small precancerous lesions (polyps), to confirmation of malign masses. However, the high variability of the organ appearance and the complex shape of both the colon wall and structures of interest make this exploration difficult. Learned visuospatial and perceptual abilities mitigate technical limitations in clinical practice by proper estimation of the intestinal depth. This work introduces a novel methodology to estimate colon depth maps in single frames from monocular colonoscopy videos. The generated depth map is inferred from the shading variation of the colon wall with respect to the light source, as learned from a realistic synthetic database. Briefly, a classic convolutional neural network architecture is trained from scratch to estimate the depth map, improving sharp depth estimations in haustral folds and polyps by a custom loss function that minimizes the estimation error in edges and curvatures. The network was trained by a custom synthetic colonoscopy database herein constructed and released, composed of 248400 frames (47 videos), with depth annotations at the level of pixels. This collection comprehends 5 subsets of videos with progressively higher levels of visual complexity. Evaluation of the depth estimation with the synthetic database reached a threshold accuracy of 95.65%, and a mean-RMSE of 0.451cm, while a qualitative assessment with a real database showed consistent depth estimations, visually evaluated by the expert gastroenterologist coauthoring this paper. Finally, the method achieved competitive performance with respect to another state-of-the-art method using a public synthetic database and comparable results in a set of images with other five state-of-the-art methods. Additionally, three-dimensional reconstructions demonstrated useful approximations of the gastrointestinal tract geometry. Code for reproducing the reported results and the dataset are available at https://github.com/Cimalab-unal/ColonDepthEstimation.

Safety of high-carbohydrate fluid diet 2 h versus overnight fasting before non-emergency endoscopic retrograde cholangiopancreatography: A single-blind, multicenter, randomized controlled trial

BACKGROUND

Although overnight fasting is recommended prior to endoscopic retrograde cholangiopancreatography (ERCP), the benefits and safety of high-carbohydrate fluid diet (CFD) intake 2 h before ERCP remain unclear. This study aimed to analyze whether high-CFD intake 2 h before ERCP can be safe and accelerate patients' recovery.

METHODS

This prospective, multicenter, randomized controlled trial involved 15 tertiary ERCP centers. A total of 1330 patients were randomized into CFD group ( n = 665) and fasting group ( n = 665). The CFD group received 400 mL of maltodextrin orally 2 h before ERCP, while the control group abstained from food/water overnight (>6 h) before ERCP. All ERCP procedures were performed using deep sedation with intravenous propofol. The investigators were blinded but not the patients. The primary outcomes included postoperative fatigue and abdominal pain score, and the secondary outcomes included complications and changes in metabolic indicators. The outcomes were analyzed according to a modified intention-to-treat principle.

RESULTS

The post-ERCP fatigue scores were significantly lower at 4 h (4.1 ± 2.6 vs. 4.8 ± 2.8, t = 4.23, P <0.001) and 20 h (2.4 ± 2.1 vs. 3.4 ± 2.4, t = 7.94, P <0.001) in the CFD group, with least-squares mean differences of 0.48 (95% confidence interval [CI]: 0.26-0.71, P <0.001) and 0.76 (95% CI: 0.57-0.95, P <0.001), respectively. The 4-h pain scores (2.1 ± 1.7 vs. 2.2 ± 1.7, t = 2.60, P = 0.009, with a least-squares mean difference of 0.21 [95% CI: 0.05-0.37]) and positive urine ketone levels (7.7% [39/509] vs. 15.4% [82/533], χ2 = 15.13, P <0.001) were lower in the CFD group. The CFD group had significantly less cholangitis (2.1% [13/634] vs. 4.0% [26/658], χ2 = 3.99, P = 0.046) but not pancreatitis (5.5% [35/634] vs. 6.5% [43/658], χ2 = 0.59, P = 0.444). Subgroup analysis revealed that CFD reduced the incidence of complications in patients with native papilla (odds ratio [OR]: 0.61, 95% CI: 0.39-0.95, P = 0.028) in the multivariable models.

CONCLUSION

Ingesting 400 mL of CFD 2 h before ERCP is safe, with a reduction in post-ERCP fatigue, abdominal pain, and cholangitis during recovery.

TRAIL REGISTRATION

ClinicalTrials.gov , No. NCT03075280.

Risk prediction of cholangitis after stent implantation based on machine learning

The risk of cholangitis after ERCP implantation in malignant obstructive jaundice patients remains unknown. To develop models based on artificial intelligence methods to predict cholangitis risk more accurately, according to patients after stent implantation in patients' MOJ clinical data. This retrospective study included 218 patients with MOJ undergoing ERCP surgery. A total of 27 clinical variables were collected as input variables. Seven models (including univariate analysis and six machine learning models) were trained and tested for classified prediction. The model' performance was measured by AUROC. The RFT model demonstrated excellent performances with accuracies up to 0.86 and AUROC up to 0.87. Feature selection in RF and SHAP was similar, and the choice of the best variable subset produced a high performance with an AUROC up to 0.89. We have developed a hybrid machine learning model with better predictive performance than traditional LR prediction models, as well as other machine learning models for cholangitis based on simple clinical data. The model can assist doctors in clinical diagnosis, adopt reasonable treatment plans, and improve the survival rate of patients.

Pneumo-peritoneum, pneumo-retroperitoneum and subcutaneous emphysema following endoscopic retrograde cholangiopancreatography with sphincterotomy-an uncommon complication case report

Endoscopic retrograde cholangiopancreatography (ERCP) is invasive for pancreaticobiliary diseases. Perforation is a rare but severe complication among its associated risks. A 45-year-old female with biliary colic and multiple gallbladder calculi was diagnosed with choledocholithiasis based on imaging showing CBD dilation and gallstones. ERCP was planned for stone removal. Sphincterotomy was performed, but stone retrieval attempts failed, leading to severe pneumo-peritoneum and respiratory compromise. Immediate CBD stenting was done, avoiding surgical intervention. The patient recovered uneventfully, later undergoing laparoscopic cholecystectomy with CBD exploration and stone removal. ERCP-related perforations, rare but severe, involve retroperitoneal air collection. Clinical signs include abdominal discomfort, and imaging confirms diagnosis. Management varies by type, with some requiring surgical repair. Conservative management sufficed in this case, with successful patient recovery. ERCP-related complications like pneumo-peritoneum require prompt diagnosis and conservative management if no perforation is evident.

Global trends and hotspots of ChatGPT in medical research: a bibliometric and visualized study

Objective

With the rapid advancement of Chat Generative Pre-Trained Transformer (ChatGPT) in medical research, our study aimed to identify global trends and focal points in this domain.

Method

All publications on ChatGPT in medical research were retrieved from the Web of Science Core Collection (WoSCC) by Clarivate Analytics from January 1, 2023, to January 31, 2024. The research trends and focal points were visualized and analyzed using VOSviewer and CiteSpace.

Results

A total of 1,239 publications were collected and analyzed. The USA contributed the largest number of publications (458, 37.145%) with the highest total citation frequencies (2,461) and the largest H-index. Harvard University contributed the highest number of publications (33) among all full-time institutions. The Cureus Journal of Medical Science published the most ChatGPT-related research (127, 10.30%). Additionally, Wiwanitkit V contributed the majority of publications in this field (20). "Artificial Intelligence (AI) and Machine Learning (ML)," "Education and Training," "Healthcare Applications," and "Data Analysis and Technology" emerged as the primary clusters of keywords. These areas are predicted to remain hotspots in future research in this field.

Conclusion

Overall, this study signifies the interdisciplinary nature of ChatGPT research in medicine, encompassing AI and ML technologies, education and training initiatives, diverse healthcare applications, and data analysis and technology advancements. These areas are expected to remain at the forefront of future research, driving continued innovation and progress in the field of ChatGPT in medical research.

Double Postbulbar Block in the Prevention of Postmanipulation Pancreatitis

Abstract The problems of preventing postmanipulation pancreatitis (PMP) remain the subject of debate and a lot of research from leading scientific clinics around the world. The article is devoted to the assessment of prevention methods of PMP in patients with lesion of the pancreaticobiliary zone who underwent transpapillary interventions. Aim of the study Evaluation of the effectiveness of the author’s method of preventing PMP.

Material and methods A prospective two-center randomized study included 545 patients treated in the Department of Liver Surgery and General Surgery in 2020–2022, who underwent ERCP and endoscopic papillosphincterotomy. There were 146 (26.8%) male patients, and 399 (73.2%) female patients, aged from 18 to 92 years, the mean age 62.7±7.4 years. Patients were divided into 3 groups according to the method of preventing PMP: in the 1st group, standard drug premedication was supplemented with two postbulbar blocks with a solution of lidocaine 0.5% 10 ml before and after the intervention (RF Patent No. 2779221, 09/05/2022), in the 2nd group standard premedication was combined with placebo was used, and in the comparison group 3 no submucosal injections were performed. The monitoring of clinical manifestations of PMP and the level of amylase was carried out every 12 hours until the parameters normalized. Statistical processing was carried out using program STATISTICA 6.1 for Windows.

Results The frequency of mild pancreatitis, corresponding to the criteria for PMP, did not exceed 18% in groups 1 and 3 (p=0.3408), but was lower with pseudo postbulbar block, 9% (χ2=2.83, р=0.0926), the difference was not statistically significant. The incidence of severe pancreatitis was significantly lower in group 1 with double postbulbar block where there were no cases of pancreatic necrosis among 143 patients (χ2=6.19, р=0.0129). The mortality did not differ significantly among groups (χ2=0.15, р=0.7004). The duration of the hospital period had significant differences between groups (Student’s t-test 1.973, p=0.001). The hospital period with double postbulbar block turned out to be significantly shorter.

Conclusion 1. Double postbulbar blockade significantly reduces the risk of developing severe postmanipulation pancreatitis, regardless of existing risk factors. 2. Double postbulbar block significantly reduces the duration of the hospital period after endoscopic papillosphincterotomy. 3. Pseudo postbulbar block using saline requires further evaluation as a possible way to prevent mild pancreatitis.

Colorectal cancer screening: A review of current knowledge and progress in research

Colorectal cancer (CRC) is one of the most prevalent malignancies worldwide, being the third most commonly diagnosed malignancy and the second leading cause of cancer-related deaths globally. Despite the progress in screening, early diagnosis, and treatment, approximately 20%-25% of CRC patients still present with metastatic disease at the time of their initial diagnosis. Furthermore, the burden of disease is still expected to increase, especially in individuals younger than 50 years old, among whom early-onset CRC incidence has been increasing. Screening and early detection are pivotal to improve CRC-related outcomes. It is well established that CRC screening not only reduces incidence, but also decreases deaths from CRC. Diverse screening strategies have proven effective in decreasing both CRC incidence and mortality, though variations in efficacy have been reported across the literature. However, uncertainties persist regarding the optimal screening method, age intervals and periodicity. Moreover, adherence to CRC screening remains globally low. In recent years, emerging technologies, notably artificial intelligence, and non-invasive biomarkers, have been developed to overcome these barriers. However, controversy exists over the actual impact of some of the new discoveries on CRC-related outcomes and how to effectively integrate them into daily practice. In this review, we aim to cover the current evidence surrounding CRC screening. We will further critically assess novel approaches under investigation, in an effort to differentiate promising innovations from mere novelties.

Topic highlight on texture and color enhancement imaging in gastrointestinal diseases

Olympus Corporation developed texture and color enhancement imaging (TXI) as a novel image-enhancing endoscopic technique. This topic highlights a series of hot-topic articles that investigated the efficacy of TXI for gastrointestinal disease identification in the clinical setting. A randomized controlled trial demonstrated improvements in the colorectal adenoma detection rate (ADR) and the mean number of adenomas per procedure (MAP) of TXI compared with those of white-light imaging (WLI) observation (58.7% vs 42.7%, adjusted relative risk 1.35, 95%CI: 1.17-1.56; 1.36 vs 0.89, adjusted incident risk ratio 1.48, 95%CI: 1.22-1.80, respectively). A cross-over study also showed that the colorectal MAP and ADR in TXI were higher than those in WLI (1.5 vs 1.0, adjusted odds ratio 1.4, 95%CI: 1.2-1.6; 58.2% vs 46.8%, 1.5, 1.0-2.3, respectively). A randomized controlled trial demonstrated non-inferiority of TXI to narrow-band imaging in the colorectal mean number of adenomas and sessile serrated lesions per procedure (0.29 vs 0.30, difference for non-inferiority -0.01, 95%CI: -0.10 to 0.08). A cohort study found that scoring for ulcerative colitis severity using TXI could predict relapse of ulcerative colitis. A cross-sectional study found that TXI improved the gastric cancer detection rate compared to WLI (0.71% vs 0.29%). A cross-sectional study revealed that the sensitivity and accuracy for active Helicobacter pylori gastritis in TXI were higher than those of WLI (69.2% vs 52.5% and 85.3% vs 78.7%, respectively). In conclusion, TXI can improve gastrointestinal lesion detection and qualitative diagnosis. Therefore, further studies on the efficacy of TXI in clinical practice are required.

Neuroendocrine Neoplasia: From Pathophysiology to Novel Therapeutic Approaches

Neuroendocrine neoplasia (NEN) represents a sensational field of modern medicine; immense progress in emerging biochemical, molecular, endocrine, immunohistochemical, and serum tumour markers of disease, respectively, which are part of early diagnosis, genetic testing, and multidisciplinary approaches [...].

Cost-effectiveness Analysis of Single-Use Duodenoscope Applied to Endoscopic Retrograde Cholangiopancreatography

OBJECTIVES

Secondary infections due to transmission via the duodenoscope have been reported in up to 3% of endoscopic retrograde cholangiopancreatographies. The use of single-use duodenoscopes has been suggested. We investigate the cost-effectiveness of these duodenoscopes use in cholangiopancreatography.

MATERIALS AND METHODS

A cost-effectiveness analysis was implemented to compare the performance of cholangiopancreatographies with reusable duodenoscopes versus single-use duodenoscopes. Effectiveness was analyzed by calculating quality-adjusted life years (QALY) from the perspective of the National Health System. Possibility of crossover from single-use to reusable duodenoscopes was considered. A willingness-to-pay of €25,000/QALY was set, the incremental cost-effectiveness ratio (ICER) was calculated, and deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Considering cholangiopancreatographies with single-use and reusable duodenoscopes at a cost of €2900 and €1333, respectively, and a 10% rate of single-use duodenoscopes, ICER was greater than €3,000,000/QALY. A lower single-use duodenoscope cost of €1211 resulted in an ICER of €23,583/QALY. When the unit cost of the single-use duodenoscope was €1211, a crossover rate of more than 9.5% made the use of the single-use duodenoscope inefficient.

CONCLUSIONS

Single-use duodenoscopes are cost-effective in a proportion of cholangiopancreatographies if its cost is reduced. Increased crossover rate makes single-use duodenoscope use not cost-effective.

Concurrent acute pancreatitis, pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum following ERCP-related perforation: A rare and insightful case study

This case report details an extraordinary occurrence following endoscopic retrograde cholangiopancreatography (ERCP) in a 42-year-old woman. Despite ERCP being a commonly performed procedure, this case presented an unusual combination of acute pancreatitis, pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum resulting from a Stapfer type III perforation. The patient managed conservatively with nil per os, nasogastric tube, intravenous fluids, pain relief, and antibiotics, exhibited clinical improvement. Remarkably, resolution of complications occurred without surgical intervention. This case underscores the significance of vigilance in diagnosing and appropriately managing ERCP-related complications, contributing to the broader understanding of these rare events and fostering improved patient outcomes.