Advances in Endo-Hepatology: The Role of Endoscopic Ultrasound in the Management of Portal Hypertension

Portal hypertension (PH) is a complication of advanced liver diseases, including cirrhosis and hepatocellular carcinoma, often leading to unfavorable outcomes. Endo-hepatology, particularly endoscopic ultrasound (EUS) has revolutionized the assessment of PH. Notably, EUS-guided portal pressure gradient (EUS-PPG) enables measurement of portal and hepatic venous pressures, offering diagnostic precision for both cirrhotic and non-cirrhotic forms of PH, including porto-sinusoidal vascular disorder (PSVD). EUS-based assessment of PH in advanced liver disease can refine diagnostic workup and prognostication, supporting therapeutic decisions. Additionally, EUS-guided liver biopsy (EUS-LB) achieves high-quality histological samples with fewer complications compared to percutaneous techniques, enabling thorough evaluation of chronic liver diseases and vascular abnormalities. EUS-shear wave elastography (EUS-SWE) further refines stiffness measurements where standard imaging fails. Moreover, EUS plays a major role in controlling variceal hemorrhage, a severe PH complication. EUS-guided coil and cyanoacrylate injection for gastric varices demonstrate a great efficacy, often surpassing conventional endoscopy. Similarly, EUS-based identification and treatment of perforator vessels feeding esophageal varices reduce rebleeding risks, particularly in challenging patients. The combination of these state-of-the-art interventions supports a "one-stop strategy", integrating variceal screening, biopsy, and portal pressure measurement within a single procedure. Despite these advancements, refinements in sedation protocols, patient selection, and cost-effectiveness data are necessary. While noninvasive tools remain central in guidelines, EUS-based methods continue to expand their role, especially in complex cases. This review summarizes the applications and impact of EUS in evaluating PH, emphasizing its importance in contemporary hepatology and its potential as a pivotal diagnostic modality in cirrhosis complicated by PH.

The outcomes of endoscopic ultrasound-guided tissue acquisition for small focal liver lesions measuring ≤2 cm

Objectives

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) for focal liver lesions has gained attention as an alternative to percutaneous biopsy. Although the outcomes of EUS-TA for focal liver lesions have been reported to be favorable, no studies have focused on small focal liver lesions (≤2 cm). The aim of this study was to evaluate the outcomes of EUS-TA for small focal liver lesions (≤2 cm).

Methods

The details of EUS-TA performed for focal liver lesions between 2016 and 2022 were retrospectively reviewed. The outcomes were compared between cases involving ≤2 cm lesions and those involving >2 cm lesions. The primary outcomes were diagnostic ability and adverse events.

Results

EUS-TA for focal liver lesions was performed in 109 cases. Of the 109 cases, 32 (29.3%) involved ≤2 cm lesions and 77 (70.6%) involved >2 cm lesions. Right lobe lesions and transduodenal puncture were significantly fewer in the ≤2 cm group. There were no significant differences in needle gauge, needle type, or number of punctures between the groups. The sensitivity, specificity, and accuracy rates were 96.8%, 100%, and 96.8%, respectively, in the ≤2 cm group and 97.4%, 100%, and 97.4%, respectively, in the >2 cm group, with no significant differences between the groups. There was no difference in adverse events between the groups (0% in the ≤2 cm group and 2.3% in the >2 cm group).

Conclusions

EUS-TA for small focal liver lesions measuring ≤2 cm has favorable outcomes, which are similar to those for lesions measuring >2 cm.

Endoscopic ultrasound-guided tissue acquisition for focal liver lesions in patients with a history of multiple primary malignant neoplasms

Objective

This study aimed to investigate the usefulness of endoscopic ultrasound-guided tissue acquisition (EUS-TA) for diagnosing focal liver lesions in patients with a history of multiple primary malignant neoplasms.

Methods

Among patients who underwent EUS-TA for focal liver lesions between 2016 and 2022, those with a history of multiple malignant neoplasms were included. A histologically confirmed malignant tumor within the past 5 years before EUS-TA was defined as a history of malignant neoplasm. The primary outcomes were diagnostic ability and adverse events of EUS-TA.

Results

This study included 16 patients (median age, 73 [33-90] years), the median tumor size was 32 (6-51) mm, 14 had a history of double malignant neoplasms, whereas two had triple malignant neoplasms. Malignant neoplasms were detected histologically or cytologically in all cases. Immunohistochemistry was performed in 75% (12/16), and the final diagnosis of EUS-TA was metastatic liver tumor in 12 patients, and primary malignant liver tumor in four patients. The primary site could be identified in 11 of 12 metastatic tumor cases. The diagnostic yield of EUS-TA was 100% (16/16) for differentiating benign and malignant tumors and 94% (15/16) for confirming the histological type including the primary site of metastatic lesions. No adverse events were associated with the procedure.

Conclusion

EUS-TA is a useful diagnostic modality for focal liver lesions in patients with a history of multiple malignant neoplasms, allowing for the differential diagnosis of primary and metastatic tumors and identification of the primary site of metastatic lesions.

Endoscopic ultrasound-guided tissue acquisition for focal liver lesions can be safely performed in patients with ascites

Background and study aims In patients with ascites, percutaneous liver biopsy is generally contraindicated. Because endoscopic ultrasound-guided tissue acquisition (EUS-TA) allows tissue sample obtention from the digestive tract lumen, a biopsy without the intervention of ascites may prevent adverse events (AEs). This study aimed to evaluate the safety of EUS-TA for focal liver lesions in the presence of ascites. Patients and methods A retrospective study was conducted using medical records of cases in which EUS-TA was performed on focal liver lesions between 2016 and 2022. Study participants were classified into two groups: those with ascites and those without it, and the outcomes were compared. The primary outcome was AEs. Results We included 109 cases of EUS-TA for focal liver lesions. Ascites was present in 20.1% of cases (22/109) and absent in 79.8% of cases (87/109). There were no significant differences between the two groups in clinical backgrounds and EUS-TA procedure, although fine-needle biopsy needles were significantly more frequently used in patients without ascites. In the ascites group, puncture without intervening ascites was successful in 90.9% of cases (20/22). The incidence of AEs was 4.5% (1/22) in the ascites group and 1.1% (1/87) in the non-ascites group, showing no significant difference. The two AEs were mild self-limiting abdominal pain. Conclusions In focal liver lesions with ascites, EUS-TA allows biopsy without the intervention of ascites in most cases. The incidence of AEs did not differ significantly between patients with and without ascites.

Endoscopic ultrasound-guided fine-needle aspiration in the diagnostic value of focal liver lesions: A systematic analysis of 88 cases (with video)

BACKGROUND AND AIMS

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is an important diagnostic tool for suspected parenchymal lesions in the gastrointestinal tract and adjacent organs. Our study aimed to evaluate the safety and effectiveness of EUS-FNA in focal liver lesions (FLLs).

METHOD

Data from 88 patients diagnosed with FLLs by imaging who underwent EUS-FNA from 1 January 2017 to 31 August 2022 were reviewed in our retrospective study at the Second Affiliated Hospital of Soochow University and Ruijin Hospital of the School of Medicine of Shanghai Jiao Tong University. The EUS-FNA biopsy results were compared with the final diagnosis to evaluate diagnostic value. The relevant factors were analysed to determine their influence on EUS-FNA biopsy results.

RESULTS

The 88 patients analysed in this study resulted in a final diagnosis of 86 malignant and two benign cases. The overall diagnostic accuracy of EUS-FNA in FLLs was 93.18 % (82/88; 95 % Confidence Interval [CI], 87.9-98.5), with a sensitivity, specificity, positive predictive value, and negative predictive value of 93.02 % (80/86; 95 %CI, 87.6-98.4), 100 % (2/2; 95 %CI, 100-100), 100 % (80/80; 95 %CI, 100-100), and 25 % (2/8; 95 %CI, -5-55.0), respectively. The parameters related to lesion and procedure were not significantly different between these two groups (p > 0.05). The number of puncture needles in the groups showed a statistically significant difference between multiple and single punctures (p = 0.001).

CONCLUSION

Our data revealed that EUS-FNA is a safe and reliable diagnostic method for FLLs that shows high accuracy.

Clinical course of asymptomatic duodenal subepithelial lesions

BACKGROUND/AIMS

There is limited knowledge regarding the management of duodenal subepithelial lesions (SELs) owing to a lack of understanding of their natural course. This study aimed to assess the natural course of asymptomatic duodenal SELs and provide management recommendations.

METHODS

Patients diagnosed with duodenal SELs and followed up for a minimum of 6 months were retrospectively investigated.

RESULTS

Among the 443,533 patients who underwent esophagogastroduodenoscopy between 2008 and 2020, duodenal SELs were identified in 0.39% (1,713 patients). Among them, 396 duodenal SELs were monitored for a median period of 72.5 months (interquartile range, 37.7-111.3 mo). Of them, 16 SELs (4.0%) showed substantial changes in size or morphology at a median follow-up of 35.1 months (interquartile range, 21.7-51.4 mo). Of these SELs with substantial changes, tissues of two SELs were acquired using endoscopic ultrasound-guided fine needle aspiration biopsy: one was a lipoma and the other was non-diagnostic. Three SELs were surgically or endoscopically removed; two were diagnosed as gastrointestinal stromal tumors, and one was a lipoma. An initial size of 20 mm or larger was associated with substantial changes during follow-up (p = 0.016).

CONCLUSION

While the majority of duodenal SELs may not exhibit substantial interval changes, regular follow-up with endoscopy may be necessary for cases with an initial size of 20 mm or larger, considering a possibility of malignancy.

Endoscopic Ultrasound-Guided Fine Needle Biopsy of Focal Liver Lesions: An Effective Mini-Invasive Alternative to the Percutaneous Approach

Despite the introduction of serological neoplastic biomarkers and typical radiological characteristics in clinical practice, liver biopsy (LB) is often still necessary to establish a histological diagnosis, especially in ambiguous cases. Nowadays, LB via the percutaneous approach (PC-LB), under computed tomography (CT) scan or ultrasonography (US) guidance, is the route of choice. However, certain focal liver lesions can be challenging to access percutaneously. In such cases, endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) may represent an attractive, minimally invasive alternative. This retrospective observational study aimed to evaluate the efficacy, diagnostic performance, and safety of EUS-FNB conducted on 58 focal liver lesions located in both liver lobes. The adequacy of FNB samples for focal liver lesions located in the left and right lobes was 100% and 81.2%, respectively, and the difference was statistically significant (p = 0.001). Technical success was 100% for both liver lobes. The overall sensitivity and specificity were 95% and 100%, respectively. EUS-FNB is effective in making an accurate diagnosis with an excellent safety profile for focal liver lesions located in both liver lobes.

Diagnostic yield of endoscopic and EUS-guided biopsy techniques in subepithelial lesions of the upper GI tract: a systematic review

BACKGROUND AND AIMS

Obtaining adequate tissue samples in subepithelial lesions (SELs) remains challenging. Several biopsy techniques are available, but a systematic review including all available techniques to obtain a histologic diagnosis of SEL is lacking. The aim of this study was to evaluate the diagnostic yield and adverse event rates of endoscopic biopsies, EUS-guided FNA (EUS-FNA), EUS-guided fine-needle biopsy (FNB) (EUS-FNB), and mucosal incision-assisted biopsy (MIAB) for SELs in the upper GI tract.

METHODS

A search strategy in multiple databases was performed. The primary outcome was diagnostic yield, defined as the percentage of procedures in which histology was obtained and resulted in a definitive histopathologic diagnosis. Secondary outcome measures included reported procedure-related adverse events, which were graded according to the AGREE (Adverse Events in Gastrointestinal Endoscopy) classification.

RESULTS

A total of 94 original articles were included. Studies were classified per endoscopic technique to obtain histopathology. This resulted in 8 included studies for endoscopic biopsy methods, 55 studies for EUS-FNA, 33 studies for EUS-FNB, and 26 studies for MIAB. Pooled rates for diagnostic yield were 40.6% (95% confidence interval [CI], 30.8-51.2) for endoscopic biopsy, 74.6% (95% CI, 69.9-78.7) for EUS-FNA, 84.2% (95% CI, 80.7-87.2) for EUS-FNB, and 88.2% (95% CI, 84.7-91.1) for MIAB. Reported procedure-related adverse events graded AGREE II or higher were 2.8% to 3.9% for endoscopic biopsies, 1.0% to 4.5% for EUS-FNA, .9% to 7.7% for EUS-FNB, and 1.9% to 7.9% for MIAB.

CONCLUSIONS

Based on the available evidence, MIAB and EUS-FNB seem to be most effective in terms of achieving a high diagnostic yield, with similar rates of adverse events.

Contrast-enhanced guided endoscopic ultrasound procedures

Contrast-enhanced endoscopic ultrasound (CH-EUS) can overcome the limitations of endoscopic ultrasound-guided acquisition by identifying microvessels inside inhomogeneous tumours and improving the characterization of these tumours. Despite the initial enthusiasm that oriented needle sampling under CH-EUS guidance could provide better diagnostic yield in pancreatic solid lesions, further studies did not confirm the supplementary values in cases of tissue acquisition guided by CH-EUS. This review details the knowledge based on the available data on contrast-guided procedures. The indications for CH-EUS tissue acquisition include isoechoic EUS lesions with poor visible delineation where CH-EUS can differentiate the lesion vascularisation from the surrounding parenchyma and also the mural nodules within biliopancreatic cystic lesions, which occur in select cases. Additionally, the roles of CH-EUS-guided therapy in patients whose pancreatic fluid collections or bile ducts that have an echogenic content have indications for drainage, and patients who have nonvisualized vessels that need to be highlighted via Doppler EUS are presented. Another indication is represented if there is a need for an immediate assessment of the post-radiofrequency ablation of pancreatic neuroendocrine tumours, in which case CH-EUS can be used to reveal the incomplete tumour destruction.

Endoscopic ultrasound-guided tissue acquisition for the diagnosis of focal liver lesion

In patients with liver tumors, the histopathology examination can assist in diagnosis, staging, prognosis, and therapeutic management strategy. Endoscopic ultrasound (EUS)-guided tissue acquisition using fine needle aspiration (FNA) or more newly fine needle biopsy (FNB) is a well-developed technique in order to evaluate and differentiate the liver masses. The goal of the EUS-FNA or EUS-FNB is to provide an accurate sample for a histopathology examination. Therefore, malignant tumors such as hepatocarcinoma, cholangiocarcinoma and liver metastasis or benign tumors such as liver adenoma, focal hyperplastic nodular tumors and cystic lesions can be accurately diagnosed using EUS-guided tissue acquisition. EUS-FNB using 19 or 22 Ga needle provide longer samples and a higher diagnostic accuracy in patients with liver masses when compared with EUS-FNA. Few data are available on the diagnostic accuracy of EUS-FNB when compared with percutaneously, ultrasound, computer tomography or transjugulary-guided liver biopsies. This review will discuss the EUS-guided tissue acquisition options in patients with liver tumors and its efficacy and safety in providing accurate samples. The results of the last studies comparing EUS-guided liver biopsy with other conventional techniques are presented. The EUS-guided tissue acquisition using FNB can be a suitable technique in suspected liver lesions in order to provide an accurate histopathology diagnosis, especially for those who require endoscopy.

Diagnostic and therapeutic role of endoscopic ultrasound in liver diseases: A systematic review and meta-analysis

BACKGROUND

In hepatology, the clinical use of endoscopic ultrasound (EUS) has experienced a notable increase in recent times. These applications range from the diagnosis to the treatment of various liver diseases. Therefore, this systematic review summarizes the evidence for the diagnostic and therapeutic roles of EUS in liver diseases.

AIM

To examine and summarize the current available evidence of the possible roles of the EUS in making a suitable diagnosis in liver diseases as well as the therapeutic accuracy and efficacy.

METHODS

PubMed, Medline, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched until October 2023. The methodological quality of the eligible articles was assessed using the Newcastle-Ottawa scale or Cochrane Risk of Bias tool. In addition, statistical analyses were performed using the Comprehensive Meta-Analysis software.

RESULTS

Overall, 45 articles on EUS were included (28 on diagnostic role and 17 on therapeutic role). Pooled analysis demonstrated that EUS diagnostic tests had an accuracy of 92.4% for focal liver lesions (FLL) and 96.6% for parenchymal liver diseases. EUS-guided liver biopsies with either fine needle aspiration or fine needle biopsy had low complication rates when sampling FLL and parenchymal liver diseases (3.1% and 8.7%, respectively). Analysis of data from four studies showed that EUS-guided liver abscess had high clinical (90.7%) and technical success (90.7%) without significant complications. Similarly, EUS-guided interventions for the treatment of gastric varices (GV) have high technical success (98%) and GV obliteration rate (84%) with few complications (15%) and rebleeding events (17%).

CONCLUSION

EUS in liver diseases is a promising technique with the potential to be considered a first-line therapeutic and diagnostic option in selected cases.

Forty years of Helicobacter pylori infection and changes in findings at esophagogastroduodenoscopy

BACKGROUND

It is 40 years since the discovery of Helicobacter pylori infection. Over that time major changes have occurred in esophagogastroduodenoscopy (EGD) findings. The aim of this review is to describe these changes, and the important role H. pylori infection has played in their evolution.

METHODS

References were identified through searches of PubMed using the search terms-endoscopy time trends, peptic ulcer disease, gastroesophageal reflux disease, upper gastrointestinal cancer, gastric polyps, H. pylori, eosinophilic gastrointestinal disorders, and celiac disease, from 1970 through December 2021.

RESULTS

The prevalence of H. pylori infection has fallen and consequently, H. pylori-positive peptic ulcer disease has become rare. Gastroesophageal reflux disease is now the commonest disorder diagnosed at EGD, and Barrett's esophagus has increased in parallel. Cancer of the distal stomach has fallen while esophageal adenocarcinoma and reflux-related cardia cancer have risen. Gastric polyps have changed from hyperplastic and adenomas to sporadic fundic gland polyps. Antimicrobial resistance has made H. pylori infection more difficult to eradicate. Eosinophilic gastrointestinal disorders, particularly eosinophilic esophagitis, have emerged as important new allergic disorders. Celiac disease has changed and increased.

CONCLUSIONS

EGD findings appear to have changed from features suggesting a H. pylori-positive "phenotype" 40 years ago to a H. pylori-negative "phenotype" today. These changes have major implications for the management of gastrointestinal disorders.

Distinct ways to perform a liver biopsy: The core technique setups and updated understanding of these modalities

There is dramatically increased incidence of several liver diseases worldwide; thus, an unmet need to diagnose and stage these pathological entities heralds the wide application of liver biopsy (LB) techniques. The ways of LB are versatile, including percutaneous LB, transjugular LB, and more recently an approach of minimal invasiveness, that is, EUS-guided LB (EUS-LB). In this review article, we come to the conclusion that EUS-LB may serve as a feasible, reliable, and safe alternative to percutaneous LB and transjugular LB in terms of improved diagnostic yield, excellent sampling performance, and controlled adverse events among patients with focal, infiltrative, and parenchymal liver diseases. Furthermore, extensive efforts have been made to optimize and refine several technical pillars within EUS-LB modality such as the selection of needle size/type, priming manner of biopsy needle, and choice of pass/actuation technique, all of which aim at obtaining better specimen quantity and quality. Another advantageous aspect and unique property pertinent to EUS-guided modality indicate that multiple screening, surveillance, and intervention procedures can be combined into one single endoscopic session. Accordingly, some pilot studies have clarified the clinical usefulness by integrating EUS-LB with simultaneous measurement of portal pressure gradient or examination of liver stiffness. However, more studies, in particular, randomized controlled trials or real-world evidence, are practically warranted to elucidate the validity and safety of EUS-LB as a regular/routine part of managing liver diseases.

Overview on the endoscopic treatment for obesity: A review

Obesity rates have increased, and so has the need for more specific treatments. This trend has raised interest in non-surgical weight loss techniques that are novel, safe, and straightforward. Thus, the present review describes the endoscopic bariatric treatment for obesity, its most recent supporting data, the questions it raises, and its future directions. Various endoscopic bariatric therapies for weight reduction, such as intragastric balloons (IGBs), aspiration therapy (AT), small bowel endoscopy, endoscopic sleeve gastroplasty, endoluminal procedures, malabsorption endoscopic procedures, and methods of regulating gastric emptying, were explored through literature sourced from different databases. IGBs, AT, and small bowel endoscopy have short-term effects with a possibility of weight regain. Minor adverse events have occurred; however, all procedures reduce weight. Vomiting and nausea are common side effects, although serious complications have also been observed.

Factors Affecting Weight Reduction after Intragastric Balloon Insertion: A Retrospective Study

BACKGROUND AND OBJECTIVES

Intragastric balloon (IGB) is a safe option for obesity management. However, studies determining the factors influencing the procedure's outcomes are scarce. Therefore, our goal was to determine the factors affecting weight reduction after IGB insertion.

MATERIALS AND METHODS

This retrospective study included 126 obese patients who underwent IGB treatment using the ORBERA^® Intragastric Balloon System. Patients' records were retrieved; and demographic data, initial body mass index (BMI), complications, compliance with both diet and exercise programs, and percentage of excess weight reduction were recorded.

RESULTS

The study included 108 female (85.7%) and 18 male (14.3%) patients. The mean age was 31.7 ± 8.1 years. The percentage of excess weight loss (EWL) was 55.8 ± 35.7%. The mean weight loss was 13.01 ± 7.51 kg. A significant association was found between EWL and age, initial weight, initial body mass index, and the number of pregnancies. No major complications were observed. However, the balloon had to be removed early in two patients (1.59%) due to its rupture and in two other patients (1.59%) due to severe gastritis.

CONCLUSIONS

IGB therapy is a safe and effective option for obesity management, associated with low rates of complications. The EWL after IGB insertion is significantly higher among older patients, those with a relatively low initial body mass index, those with a longer duration of IGB insertion, and female patients with less parity. Larger prospective studies are needed to support our results.

Novel Endoscopic Bariatric Therapies for the Management of Nonalcoholic Steatohepatitis

Obesity is strongly associated with nonalcoholic fatty liver disease as well as advanced forms of the disease such as nonalcoholic steatohepatitis (NASH), cirrhosis, and hepatocellular carcinoma. While lifestyle and diet modifications have been the cornerstone of treatment for NASH thus far, they are only effective for less than half of the patients. New endoscopic bariatric therapies (EBTs) have already proved to be safe and effective for the treatment of obesity and type 2 diabetes mellitus, and may provide an intermediate, less invasive, cost-effective option for patients with NASH. In this review, we aim to describe the data and evidence as well as outline future areas of development for endobariatric therapies for the treatment of NASH. In conclusion, EBTs present an effective and safe therapeutic modality for use in the growing pandemic of obesity-related liver disease and should be investigated further with large-scale trials in this patient population.

Endoscopic Ultrasound-Guided Fine-Needle Biopsy versus Fine-Needle Aspiration in the Diagnosis of Focal Liver Lesions: Prospective Head-to-Head Comparison

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) or fine-needle aspiration (EUS-FNA) from focal liver lesions are indicated in selected cases, but there has been no previous comparison of needle types of the same size. The aim of our study was to compare the histologic diagnostic accuracy and adequacy of cores obtained with EUS-FNB needles in contrast to those obtained with FNA needles in focal liver lesions. This prospective one-center study included patients with left lobe hepatic focal lesions with contraindications for percutaneous liver biopsy or need for EUS for concomitant lesions. Each patient had one pass of 22G EUS-FNB (Franseen) needle and one pass of 22G EUS-FNA in a crossover manner, without macroscopic on-site evaluation. Each sample was analyzed separately for histologic adequacy and diagnosis. The final diagnosis was based on histology results or on imaging follow-up in the case of negative biopsies. The EUS-FNB samples (n = 30) were found to be more adequate for histologic analysis, with more cellularity and longer tissue aggregates than the EUS-FNA samples (n = 30). The accuracy of EUS-FNB was 100%, whereas that of EUS-FNA was 86.7% (p = 0.039). No post-procedure complications were noted. The 22G EUS-FNB needle proved superior to 22G EUS-FNA in terms of tissue acquisition diagnostic accuracy and histologic adequacy in focal liver lesions.

Differentiating Gastrointestinal Stromal Tumors from Leiomyomas Using a Neural Network Trained on Endoscopic Ultrasonography Images

BACKGROUND

Endoscopic ultrasonography (EUS) is crucial to diagnose and evaluate gastrointestinal mesenchymal tumors (GIMTs). However, EUS-guided biopsy does not always differentiate gastrointestinal stromal tumors (GISTs) from leiomyomas. We evaluated the ability of a convolutional neural network (CNN) to differentiate GISTs from leiomyomas using EUS images. The conventional EUS features of GISTs were also compared with leiomyomas.

PATIENTS AND METHODS

Patients who underwent EUS for evaluation of upper GIMTs between 2010 and 2020 were retrospectively reviewed, and 145 patients (73 women and 72 men; mean age 54.8 ± 13.5 years) with GISTs (n = 109) or leiomyomas (n = 36), confirmed by immunohistochemistry, were included. A total of 978 images collected from 100 patients were used to train and test the CNN system, and 384 images from 45 patients were used for validation. EUS images were also evaluated by an EUS expert for comparison with the CNN system.

RESULTS

The sensitivity, specificity, and accuracy of the CNN system for diagnosis of GIST were 92.0%, 64.3%, and 86.98% for the validation dataset, respectively. In contrast, the sensitivity, specificity, and accuracy of the EUS expert interpretations were 60.5%, 74.3%, and 63.0%, respectively. Concerning EUS features, only higher echogenicity was an independent and significant factor for differentiating GISTs from leiomyomas (p < 0.05).

CONCLUSIONS

The CNN system could diagnose GIMTs with higher accuracy than an EUS expert and could be helpful in differentiating GISTs from leiomyomas. A higher echogenicity may also aid in differentiation.

Endoscopic Ultrasonography-guided Gastrojejunostomy for Patients with Gastric Outlet Obstruction and Pyloric Metal Stent Dysfunction

A 52-year-old woman with a gastric outlet obstruction (GOO) caused by pyloric cancer underwent pyloric endoscopic self-expandable metal stent (SEMS) insertion. She presented with abdominal distension 40 days later. The SEMS was dysfunctional, and endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) was performed using an endoscopic nasobiliary drainage tube. A 16 mm×31 mm Niti-S ™ HOT SPAXUS™ (TaeWoong Medical, Gimpo, Korea) was inserted successfully between the stomach and the adjacent jejunum. After the procedure, the patient had a good oral intake for more than seven months. GOO is a mechanical obstructive condition caused by various benign and malignant conditions. Traditionally, surgical GJ and SEMS insertion have been used to treat GOOs. EUS-GJ is a feasible treatment option for patients with GOO and a pyloric metal stent dysfunction.

Natural History of Asymptomatic Esophageal Subepithelial Tumors of 30 mm or Less in Size

BACKGROUND

No definite guidelines for the management of small esophageal subepithelial tumors (SETs) have been established, because there are limited data and studies on their natural history. We aimed to assess the natural history and propose optimal management strategies for small esophageal SETs.

METHODS

Patients diagnosed as esophageal SETs ≤ 30 mm in size between 2003 and 2017 using endoscopic ultrasound (EUS) with a minimal follow-up of 3 months were enrolled, and their esophagogastroduodenoscopy (EGD) and EUS were retrospectively reviewed.

RESULTS

Of 275 esophageal SETs in 262 patients, the initial size was < 10 mm, 10-20 mm, and 20-30 mm in 104 (37.8%), 105 (38.2%), and 66 (24.0%) lesions, respectively. Only 22 (8.0%) SETs showed significant changes in size and/or echogenicity and/or morphology at a median of 40 months (range, 4-120 months). Tissues of 6 SETs showing interval changes were obtained using EUS-guided fine needle aspiration biopsy; 1 was identified as a gastrointestinal stromal tumor (GIST) and was surgically resected, while the other 5 were leiomyomas and were regularly observed. Eight SETs showing interval changes were resected surgically or endoscopically without pathological confirmation; 1 was a GIST, 2 were granular cell tumors, and the other 5 were leiomyomas.

CONCLUSION

Regular follow-up with EGD or EUS may be necessary for esophageal SETs ≤ 30 mm in size considering that small portion of them has a possibility of malignant potential. When esophageal SETs ≤ 30 mm show significant interval changes, pathological confirmation may precede treatment to avoid unnecessary resection.

Role of endoscopic ultrasound-guided liver biopsy: a meta-analysis

BACKGROUND

Endoscopic ultrasound-guided liver biopsy (EUS-LB) is an evolving technique. In this meta-analysis, we aimed to evaluate the value of EUS-LB for parenchymal and focal liver lesions. Besides, we aimed to assess the influences of needle-related factors on the performance of EUS-LB. Additionally, we aimed to assess the influence of various criteria on specimen adequacy.

METHODS

We searched the PubMed, Embase, Cochrane Library databases up to 10 October 2021. The primary outcome was diagnostic yield, specimen adequacy, qualified specimens evaluated by rapid on-site evaluation (ROSE). The secondary outcome was adverse events. Subgroup analyses were based on needle type, needle size, fine-needle biopsy (FNB) needle type. A sensitivity analysis was conducted on specimen adequacy based on two definition criteria.

RESULTS

In total, 33 studies were included. Pooled rates of diagnostic yield, specimen adequacy, qualified specimen by ROSE, adverse events were 95%, 84%, 93%, 3%. Subgroup analyses showed that Acquire needles generated higher diagnostic yield than SharkCore needles (99% vs. 88%, p = .047). Additionally, FNB needles demonstrated a higher rate of adverse events than FNA needles (6% vs. 1%, p = .028). Sensitivity analysis on specimen adequacy based on various criteria demonstrated that the specimen adequacy rate defined by the AASLD criterion was lower than that of the commonly-used criterion (37% vs. 84%, p = .001).

CONCLUSION

EUS-LB is effective and safe for liver biopsy. Acquire needles provide better specimens than SharkCore needles. FNB needles may increase the risk of adverse events compared with FNA needles. The AASLD criterion is harder to achieve than the commonly-used criterion.

Status of bariatric endoscopy-what does the surgeon need to know? A review

BACKGROUND

Obesity is a chronic and multifactorial disease with a variety of potential treatment options available. Currently, there are several multidisciplinary therapeutic options for its management, including conservative, endoscopic, and surgical treatment.

AIM

To clarify indications, technical aspects, and outcomes of bariatric endoscopy.

METHODS

Narrative review of current literature based on electronic databases including MEDLINE (PubMed), Cochrane Library, and SciELO.

RESULTS

Bariatric endoscopy is in constant development and comprises primary and revisional treatment options as well as management of surgical complications. Various devices act upon different mechanisms of action, which may be individualized to each patient. Despite favorable results for the endoscopic treatment of obesity, prospective randomized studies with long-term follow-up are required to fully validate primary and revisional endoscopic therapies. Regarding the management of bariatric surgery complications, endoscopic therapy may be considered the procedure of choice in a variety of situations. Still, as there is no standardized algorithm, local experience should be considered in decision-making.

CONCLUSION

The treatment of patients with obesity is complex, and a multidisciplinary approach is essential. Bariatric endoscopy has shown impressive results both in the treatment of obesity and its surgical complications, and therefore, must be part of the armamentarium in the fight against this disease.

Use of Artificial Intelligence in the Prediction of Malignant Potential of Gastric Gastrointestinal Stromal Tumors

BACKGROUND AND AIMS

This study aimed to investigate whether AI via a deep learning algorithm using endoscopic ultrasonography (EUS) images could predict the malignant potential of gastric gastrointestinal stromal tumors (GISTs).

METHODS

A series of patients who underwent EUS before surgical resection for gastric GISTs were included. A total of 685 images of GISTs from 55 retrospectively included patients were used as the training data set for the AI system. Convolutional neural networks were constructed to build a deep learning model. After applying the synthetic minority oversampling technique, 70% of the generated images were used for AI training and 30% were used to test AI diagnoses. Next, validation was performed using 153 EUS images of 15 patients with GISTs. In addition, conventional EUS features of 55 patients in the training cohort were evaluated to predict the malignant potential of GISTs and mitotic index.

RESULTS

The overall sensitivity, specificity, and accuracy of the AI system for predicting malignancy risk were 83%, 94%, and 82% in the training dataset, and 75%, 73%, and 66% in the validation cohort, respectively. When patients were divided into low-risk and high-risk groups, sensitivity, specificity, and accuracy increased to 99% in the training dataset and 99.7%, 99.7%, and 99.6%, respectively, in the validation cohort. No conventional EUS features were found to be associated with either malignant potential or mitotic index (P > 0.05).

CONCLUSIONS

AI via a deep learning algorithm using EUS images could predict the malignant potential of gastric GISTs with high accuracy.

Photodynamic Therapy and Hyperthermia in Combination Treatment-Neglected Forces in the Fight against Cancer

Cancer is one of the leading causes of death in humans. Despite the progress in cancer treatment, and an increase in the effectiveness of diagnostic methods, cancer is still highly lethal and very difficult to treat in many cases. Combination therapy, in the context of cancer treatment, seems to be a promising option that may allow minimizing treatment side effects and may have a significant impact on the cure. It may also increase the effectiveness of anti-cancer therapies. Moreover, combination treatment can significantly increase delivery of drugs to cancerous tissues. Photodynamic therapy and hyperthermia seem to be ideal examples that prove the effectiveness of combination therapy. These two kinds of therapy can kill cancer cells through different mechanisms and activate various signaling pathways. Both PDT and hyperthermia play significant roles in the perfusion of a tumor and the network of blood vessels wrapped around it. The main goal of combination therapy is to combine separate mechanisms of action that will make cancer cells more sensitive to a given therapeutic agent. Such an approach in treatment may contribute toward increasing its effectiveness, optimizing the cancer treatment process in the future.

Hepatic Squamous Cell Carcinoma Diagnosed by Endoscopic Ultrasound-Guided Fine-Needle Aspiration

Primary hepatic squamous cell carcinoma (SCC) is a rare malignancy with aggressive clinical features. This is the first case report of a primary hepatic SCC diagnosed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), which is a reliable and safe procedure for the histopathological diagnosis of liver lesions, even if the percutaneous approach is difficult due to ascites or hypervascularity at the puncture site. A 52-year-old man presented to the emergency department of a tertiary referral hospital with right upper quadrant abdominal pain and abdominal distention. Given the laboratory data, a diagnosis of spontaneous bacterial peritonitis (SBP) was made. Concurrently, an abdominal computed tomography (CT) scan revealed an 8 cm hypodense mass with delayed peripheral enhancement in the left hepatic lobe and paraaortic and perihepatic lymphadenopathy. As persistent ascites precluded percutaneous liver biopsy, we performed EUS-FNA of the liver mass, and the obtained specimen showed SCC. As otorhinolaryngological consultation and whole-body investigations, including chest CT, upper and lower endoscopy, and positron emission tomography CT, were all unremarkable except for the liver lesion and lymph nodes, a diagnosis of primary hepatic SCC with systemic lymph node metastasis was made. After treatment of SBP with antibiotics, we initiated chemotherapy concurrent with radiation therapy, adapted to his liver function. Radiation and three cycles of chemotherapy were not effective as the disease progressed, as seen on the follow-up CT scan, and the patient died of hepatic failure on the 134th day after diagnosis. In conclusion, EUS-FNA was a reliable method for tissue sampling in liver malignancies, particularly in selected patients with contraindications for percutaneous biopsy.

Essential Oils Derived from Momordica charantia Seeds Exhibited Antiulcer Activity against Hydrogen Chloride/Ethanol and Indomethacin

Momordica charantia (MC) is popular for its medicinal uses especially for treating diabetic-related complications. However, the antiulcer activity of essential oil derived from the seeds has not been systematically studied. This study aims to evaluate the gastroprotective activities of essential oil derived from the seed of MC induced by hydrochloride acid/ethanol (HCl/EtOH) and indomethacin and pylorus-ligation model. Gastric ulceration was induced by oral administration of HCl/EtOH solution or indomethacin on day 7 after animals have been pretreated with testing compounds. The first group received just distilled water and the second group received ranitidine (100 mg/kg). Groups 3, 4, and 5 received 10, 50, and 100 mg/kg of essential oil based on their body weight (10 mL/kg), respectively. Macroscopically, pretreatment of essential oil extracted from MC significantly decreased ulceration induced by HCl/EtOH and indomethacin in vivo. Microscopically, essential oil also significantly suppressed the formation of edema, epithelial disruption, and mucosa erosions. Moreover, essential oil significantly elevated the pH without decreasing the total acidity of the gastric juice and was able to increase the amount of adherent mucus compared to control. Current results provide scientific basis to the ethno-pharmacological usage of the MC in preventing ulcer formation induced by HCl/EtOH and indomethacin.

The current state of bariatric endoscopy

A variety of endoscopic bariatric and metabolic treatments (EBMTs) have been developed in recent years to combat the growing prevalence of obesity in the United States (US) and worldwide. This manuscript reviews the current state of bariatric endoscopy, detailing all US Food and Drug Administration (FDA) approved EBMTs including space-occupying intragastric balloons (IGBs), aspiration therapy, and endoscopic tissue apposition devices. Additionally, this review describes non-FDA approved treatments including additional IGBs, endoluminal bypass liners, duodenal mucosal resurfacing, and endoscopically placed anastomosis devices.

Clinical outcomes after multiple self-expandable metallic stent placement using stent-in-stent technique for malignant gastric outlet obstruction

Self-expandable metallic stent (SEMS) placement is widely used for relieving symptoms in malignant gastric outlet obstruction (MGOO). This study aimed to evaluate the efficacy and safety of multiple gastroduodenal stent placement using the stent-in-stent technique and to identify factors predictive of stent patency.We retrospectively analyzed data from 170 patients with GOO receiving SEMS using the stent-in-stent technique between July 2006 and July 2018. Of these, 90 had been treated with SEMS placement for MGOO. Technical and clinical success rates were evaluated. Clinical outcomes and predictors of stent patency were also analyzed.Second SEMS placement was used in 34.4% of cases and 9.7% were treated with third SEMS placement because of prior stent dysfunction. Median stent patency time was 15.7 weeks for the first SEMS, 10.4 weeks for the second, and 11.3 weeks for the third. The technical and clinical success rates were 100% and 97.8% for the first SEMS, 100% and 90.3% for the second, respectively, and both 100% for the third. Multivariable analysis showed that use of covered SEMS and chemotherapy after first and second SEMS placement was significant predictors of stent patency. Serious complications such as bleeding or perforation did not occur in any patient.Second and third gastroduodenal SEMS placement using the stent-in-stent technique is safe and effective for management of first stent dysfunction in MGOO. Stent patency is significantly associated with the use of covered SEMS and chemotherapy after SEMS placement.

Causes of eosinophilic ascites – A systematic review

Background . In the last years an uprising interest for a relatively unknown entity, eosinophilic ascites (EA), has been recorded.

Our aim is to investigate the potential causes of EA development, as well as clinical, laboratory, endoscopic and radiologic features, management and outcome in these patients.

Methods . The following research was performed on PubMed (MEDLINE) database using the medical subject headings [Mesh] terms “Ascites” AND “Eosinophils”.

Results . A total of 284 results, dating from 1962 onwards, were found and abstracts were examined. 131 papers were excluded and the remaining 153 publications, consisting in case reports and series of cases, were analyzed.

From 171 patients with EA, 127 subjects (74%) had EGE, 17 (10%) parasitic and fungal infections, 11(7%) Hypereosinophilic syndrome and 16 patients (9%) less common diseases (eosinophilic pancreatitis, chronic eosinophilic leukemia, myelofibrosis, T-cell lymphoma, Churg Strauss Syndrome, Systemic lupus erythematosus, Familial paroxysmal polyserositis and Ménétrier’s disease). High eosinophil blood count and IgE levels as well as gastrointestinal symptoms are frequent. The diagnosis is based on ascitic fluid analysis, imaging and endoscopic biopsies. Therapy with corticosteroids results in resolution of eosinophilic ascites in almost all patients.

Conclusion . In most cases, in the absence of allergy, parasitic infections, malignancy, hematological disorders, peritoneal tuberculosis, inflammatory bowel disease or autoimmune disease, EA develops as a manifestation of eosinophilic gastroenteritis.

Various Intragastric Balloons Under Clinical Investigation

Obesity is a chronic disease with an exponentially increasing incidence rate, and its negative effects are well documented in numerous studies. As a result, the importance of bariatric therapy cannot be overemphasized, and many bariatric treatment methods with varying mechanisms have been developed. Of the available treatment methods, intragastric balloons, introduced in the 1980s, have been shown to be a safe and effective treatment modality; various intragastric balloon products have been developed and are currently being widely used in clinical settings. However, the disadvantages of intragastric balloons, such as unclear long-term weight loss benefits and complications experienced during insertion and removal, preclude their wider use. In this review, we discuss different intragastric balloon products, focusing on those under clinical investigation, and suggest future research directions.

Subepithelial esophageal tumors: a single-center review of resected and surveilled lesions

BACKGROUND AND AIMS

Subepithelial esophageal tumors (SETs) are frequent incidental findings. Although symptomatic tumors are surgically or endoscopically resected, there is no consensus on the management of asymptomatic esophageal leiomyomas.

METHODS

Appropriate International Classification of Diseases, Ninth Revision codes followed by medical record review were used to identify patients with SETs from January 1992 to March 2017, with abstraction of basic demographics, surveillance intervals, and mortality. Patients were contacted to complete a phone questionnaire to assess follow-up as well as the validated Brief Esophageal Dysphagia Questionnaire (BEDQ).

RESULTS

Eighty-four leiomyomas, 5 leiomyosarcomas, 13 GI stromal tumors (GISTs), and 4 granular cell tumors were found. Among patients with leiomyomas, 58 (69%) were resected and 26 (31%) were followed under surveillance. Resected esophageal leiomyomas were larger than those under surveillance (49.7 mm vs 17.9 mm, P < .003). Esophageal leiomyoma growth during surveillance was only .5 mm over a mean 70-month follow-up (range, 4-288). No malignant transformation was seen, and only 2 patients required subsequent resection. The phone survey was completed by 35 patients and revealed minimal symptom burden, with only 2 patients (15%) under esophageal leiomyoma surveillance reporting symptoms (BEDQ score ≥10) over a mean 96.7-month follow-up. EUS had high diagnostic accuracy with a positive predictive value of 68% and a negative predictive value of 100% for leiomyomas or GISTs compared with surgical pathology.

CONCLUSIONS

EUS demonstrated high diagnostic accuracy in resected SETs. Esophageal leiomyomas demonstrate minimal growth or symptomatic progression. Therefore, long-term EUS surveillance of small asymptomatic esophageal leiomyomas may be unnecessary.

Extra-mucosal enucleation is still a safe and feasible treatment option of giant esophageal leiomyomas

Esophageal leiomyoma (EL) is rare but still the most common benign tumor of the esophagus. Extra-mucosal enucleation (EME) is the treatment of choice. Many recent reports have favored esophageal resection for giant Esophageal leiomyomas (ELs). The consequence of esophageal resection is well known and it would be radical to consider it as a preferred treatment for giant EL since most of them are still benign. We share case series of five giant ELs managed by EME, avoiding a mucosal breach and hence avoiding potentially morbid esophageal resections.

Filling the Void: A Review of Intragastric Balloons for Obesity

Endoscopic bariatric therapies are predicted to become much more widely used in North America for obese patients who are not candidates for bariatric surgery. Of all the endoscopic bariatric therapies, intragastric balloons (IGBs) have the greatest amount of clinical experience and published data supporting their use. Three IGBs are FDA approved and are now commercially available in the USA (Orbera, ReShape Duo, and Obalon) with others likely soon to follow. They are generally indicated for patients whose BMI ranges from 30 to 40 mg/kg² and who have failed to lose weight with diet and exercise. IGBs have been shown to be safe, effective, and relatively straightforward to place and remove. Accommodative symptoms commonly occur within the initial weeks post-placement; however, major complications are rare. Gastric ulceration can occur in up to 10% of patients, while balloon deflation with migration and bowel obstruction occurs in <1% of patients. The effectiveness of the Orbera and ReShape Duo IGBs ranges from 25 to 50% EWL (excess weight loss) after 6 months of therapy. The use of IGBs is likely to grow dramatically in the USA, and gastroenterologists and endoscopists should be familiar with their indications/contraindications, efficacy, placement/removal, and complications.

Modified Devine Exclusion for Unresectable Distal Gastric Cancer in Symptomatic Patients

Background

In patients with outlet obstruction syndrome and/or severe anemia secondary to unresectable gastric cancer (GC), partial stomach-partitioning gastrojejunostomy, or modified Devine exclusion, is a surgical alternative.

Methods

A retrospective study was conducted on patients with unresectable distal GC treated with modified Devine exclusion as palliative surgery between February 2005 and December 2015. It consisted of a series of 10 patients with outlet obstruction syndrome and/or severe anemia. The outcomes of this technique were based on oral tolerance, blood transfusions, postoperative complications, and survival.

Results

Early oral tolerance and a low rate of blood transfusions were observed postoperatively. There was no postoperative mortality and a very low complication rate without anastomotic leakage. Median survival was 9 months.

Conclusions

Partial stomach-partitioning gastrojejunostomy is a safe procedure for unresectable GC which can improve the quality of life of these patients.

The role of EUS and EUS-guided FNA in the management of subepithelial lesions of the esophagus: A large, single-center experience

BACKGROUND

Referral for endosonographic evaluation of subepithelial lesions seen in the gastrointestinal (GI) tract is fairly common. Although rarely studied separately in details, esophageal lesions have some unique differences from other GI sites and might deserve some special considerations regarding follow-up and management.

MATERIALS AND METHODS

All cases referred for endoscopic ultrasound (EUS) evaluation of subepithelial esophageal lesions at Bezmialem University Hospital, a tertiary center in Istanbul, Turkey were retrospectively reviewed. Data were collected for patient and lesion characteristics as well as for pathology results and follow-up if available. Lesions were subcategorized according to their size, location, and final diagnosis.

RESULTS

A total of 164 EUS examinations were identified. In 22.5% of cases, the lesion could not be identified by EUS. Of the remaining cases, 57.6% had a lesion larger than 1 cm in size. Extramural compression was the diagnosis in 12% and leiomyoma in around 60%. Thirteen patients had follow-up examinations with only two showing an increase in size after 12 months. Sixty-five EUS-guided fine needle aspirations (EUS-guided FNAs) were performed, with around 50% having nondiagnostic samples and 94% of the remaining samples confirming the presumptive diagnosis.

CONCLUSIONS

The majority of subepithelial lesions in the esophagus are benign with extremely low malignancy potential. EUS examinations performed for lesions smaller than 2 cm as well as FNAs taken from lesions smaller than 3 cm might have minimal impact on their ultimate management and outcome. More than one FNA pass should be attempted in order to improve the yield.

A Magnetic Soft Endoscopic Capsule-Inflated Intragastric Balloon for Weight Management

Overweight and obesity have been identified as a cause of high risk diseases like diabetes and cancer. Although conventional Intragastric Balloons (IGBs) have become an efficient and less invasive method for overweight and obesity treatment, the use of conventional tools such as catheter or endoscope to insert and remove the IGBs from the patient's body causes nausea, vomiting, discomfort, and even gastric mucous damage. To eliminate these drawbacks, we develop a novel magnetic soft capsule device with gas-filled balloon inflation. The balloon is made from a thin and biocompatible material that can be inflated to a desired volume using biocompatible effervescent chemicals. In addition, both the outer balloon and inner capsule are designed to be soft and chemical resistance. The soft capsule shell is fabricated using scaffold-solvent approach while the outer balloon utilizes a novel fabrication approach for 3D spherical structure. A prototype of the proposed capsule and balloon is given. Experiments are successfully carried out in stimulated gastric environment and fresh porcine stomach to validate the effectiveness and reliability of the proposed approach.

The Role of Endoscopic Ultrasound in the Diagnostic Assessment of Subepithelial Lesions of the Upper Gastrointestinal Tract

INTRODUCTION

The identification of subepithelial lesions is a relatively frequent finding at endoscopy however their natural history is not well known. Our aim was to analyze the role of endoscopic ultrasound (EUS) in the diagnostic approach of subepithelial lesions of the upper gastrointestinal tract.

METHODS

Retrospective study which included 324 patients undergoing upper radial EUS for evaluation of subepithelial lesions from 2008 to 2014. The EUS features, presumptive diagnosis and management decision were analyzed.

RESULTS

324 patients included, 60% with gastric subepithelial lesions, 28% oesophageal and 12% from the duodenum. Based on EUS features the presumptive diagnosis was: 25% gastrointestinal stromal tumor, 21% lipoma, 19% leiomyoma, 17% pancreatic rest, 7% submucosa cysts, 1% granular cell tumors, 1% carcinoids, 1% mucosa lesions and 8% not defined. After EUS the suggested approach was no follow-up in 45%, follow-up with re-examination with EUS in 35% and additional tissue sampling or endoscopic/surgical resection in 20%. The latter was based on EUS features of risk at the diagnosis (53%), such as size ≥2 cm, hypoechogenicity, heterogeneity, lobulation, calcifications, cystic component and regional adenopathies; impossibility to define a presumptive diagnosis (39%) or EUS features change at follow-up (8%). The combination of multiple features correlated with a higher probability of this recommended strategy (p < 0.001), in 100% when 4 or more features were present. Among the 33 patients who underwent fine needle aspiration, in 66% the result was inconclusive. During follow-up, none of the patients who were managed with surveillance radial EUS presented complications.

CONCLUSION

EUS is the method of choice in the study of subepithelial lesions of the upper gastrointestinal tract, in most cases defining a diagnosis. The need for a definitive diagnosis or therapeutic approaches can be based on ultrasound risk features, presented, in the majority, at presentation. This study shows that EUS is capable of safely and accurately define those subepithelial lesions that can be managed only with surveillance ultrasound while waiting for better results with fine needle aspiration.

Long-Term Palliative Effect of Stenting in Gastric Outlet Obstruction Due to Transarterial Chemoembolization with Yttrium-90 in a Patient with Metastatic Neuroendocrine Tumor

Internal radioembolization with yttrium-90 is a promising treatment method, predominantly for liver tumors. However, the shifting of yttrium-90-loaded spherules into the arteries and veins that supply the duodenum and stomach, leading to ulceration, hemorrhage, perforation, and outlet obstruction of these organs, is one of the major undesirable consequences of this technique. We report a case of gastric outlet obstruction (GOO) due to antropyloric stenosis with ulceration, edema, and inflammation following transarterial yttrium-90 treatment for a metastatic neuroendocrine tumor in a 58-year-old man. Stenting was used for palliation in this case. GOO improved after stenting and recovery of oral intake was permanent after stent removal.

Up-regulated extracellular matrix components and inflammatory chemokines may impair the regeneration of cholestatic liver

Although the healthy liver is known to have high regenerative potential, poor liver regeneration under pathological conditions remains a substantial problem. We investigated the key molecules that impair the regeneration of cholestatic liver. C57BL/6 mice were randomly subjected to partial hepatectomy and bile duct ligation (PH+BDL group, n = 16), partial hepatectomy only (PH group, n = 16), or sham operation (Sham group, n = 16). The liver sizes and histological findings were similar in the PH and sham groups 14 days after operation. However, compared with those in the sham group, the livers in mice in the PH+BDL group had a smaller size, a lower cell proliferative activity, and more fibrotic tissue 14 days after the operation, suggesting the insufficient regeneration of the cholestatic liver. Pathway-focused array analysis showed that many genes were up- or down-regulated over 1.5-fold in both PH+BDL and PH groups at 1, 3, 7, and 14 days after treatment. Interestingly, more genes that were functionally related to the extracellular matrix and inflammatory chemokines were found in the PH+BDL group than in the PH group at 7 and 14 days after treatment. Our data suggest that up-regulated extracellular matrix components and inflammatory chemokines may impair the regeneration of cholestatic liver.

Acute pancreatitis caused by intragastric balloon: A case report

Obesity represents a global hazard that predisposes to many serious health problems. Various solutions have been proposed to overcome obesity ranging from dietary balance to bariatric surgery. Intragastric balloons are a widely used measure to decrease weight, although they are advocated as safe devices, some major complications have been reported. We report a case of acute pancreatitis after insertion of a gastric balloon for weight reduction. Abdominal pain associated with nausea and vomiting maybe due to acute pancreatitis caused by compression of the pancreas by the balloon. It is advisable that physicians recognise these complications early to avoid serious and severe end-results.

ASGE Bariatric Endoscopy Task Force systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting endoscopic bariatric therapies

The increasing global burden of obesity and its associated comorbidities has created an urgent need for additional treatment options to fight this pandemic. Endoscopic bariatric therapies (EBTs) provide an effective and minimally invasive treatment approach to obesity that would increase treatment options beyond surgery, medications, and lifestyle measures. This systematic review and meta-analysis were performed by the American Society for Gastrointestinal Endoscopy (ASGE) Bariatric Endoscopy Task Force comprising experts in the subject area and the ASGE Technology Committee Chair to specifically assess whether acceptable performance thresholds outlined by an ASGE Preservation and Incorporation of Valuable endoscopic Innovations (PIVI) document for clinical adoption of available EBTs have been met. After conducting a comprehensive search of several English-language databases, we performed direct meta-analyses by using random-effects models to assess whether the Orbera intragastric balloon (IGB) (Apollo Endosurgery, Austin, Tex) and the EndoBarrier duodenal-jejunal bypass sleeve (DJBS) (GI Dynamics, Lexington, Mass) have met the PIVI thresholds. The meta-analyses results indicate that the Orbera IGB meets the PIVI thresholds for both primary and nonprimary bridge obesity therapy. Based on a meta-analysis of 17 studies including 1683 patients, the percentage of excess weight loss (%EWL) with the Orbera IGB at 12 months was 25.44% (95% confidence interval [CI], 21.47%-29.41%) (random model) with a mean difference in %EWL over controls of 26.9% (95% CI, 15.66%-38.24%; P ≤ .01) in 3 randomized, controlled trials. Furthermore, the pooled percentage of total body weight loss (% TBWL) after Orbera IGB implantation was 12.3% (95% CI, 7.9%–16.73%), 13.16% (95% CI, 12.37%–13.95%), and 11.27% (95% CI, 8.17%–14.36%) at 3, 6, and 12 months after implantation, respectively, thus exceeding the PIVI threshold of 5% TBWL for nonprimary (bridge) obesity therapy. With the data available, the DJBS liner does appear to meet the %EWL PIVI threshold at 12 months, resulting in 35% EWL (95% CI, 24%-46%) but does not meet the 15% EWL over control required by the PIVI. We await review of the pivotal trial data on the efficacy and safety of this device. Data are insufficient to evaluate PIVI thresholds for any other EBT at this time. Both evaluated EBTs had ≤5% incidence of serious adverse events as set by the PIVI document to indicate acceptable safety profiles. Our task force consequently recognizes the Orbera IGB for meeting the PIVI criteria for the management of obesity. As additional data from the other EBTs become available, we will update our recommendations accordingly.

Endoscopic therapy for weight loss: Gastroplasty, duodenal sleeves, intragastric balloons, and aspiration

A new paradigm in the treatment of obesity and metabolic disease is developing. The global obesity epidemic continues to expand despite the availability of diet and lifestyle counseling, pharmacologic therapy, and weight loss surgery. Endoscopic procedures have the potential to bridge the gap between medical therapy and surgery. Current primary endoscopic bariatric therapies can be classified as restrictive, bypass, space-occupying, or aspiration therapy. Restrictive procedures include the USGI Primary Obesity Surgery Endolumenal procedure, endoscopic sleeve gastroplasty using Apollo OverStitch, TransOral GAstroplasty, gastric volume reduction using the ACE stapler, and insertion of the TERIS restrictive device. Intestinal bypass has been reported using the EndoBarrier duodenal-jejunal bypass liner. A number of space-occupying devices have been studied or are in use, including intragastric balloons (Orbera, Reshape Duo, Heliosphere BAG, Obalon), Transpyloric Shuttle, and SatiSphere. The AspireAssist aspiration system has demonstrated efficacy. Finally, endoscopic revision of gastric bypass to address weight regain has been studied using Apollo OverStitch, the USGI Incisionless Operating Platform Revision Obesity Surgery Endolumenal procedure, Stomaphyx, and endoscopic sclerotherapy. Endoscopic therapies for weight loss are potentially reversible, repeatable, less invasive, and lower cost than various medical and surgical alternatives. Given the variety of devices under development, in clinical trials, and currently in use, patients will have multiple endoscopic options with greater efficacy than medical therapy, and with lower invasiveness and greater accessibility than surgery.

Clinical outcomes of re-stenting in patients with stent malfunction in malignant gastric outlet obstruction

BACKGROUND AND AIMS

Self-expanding metal stents (SEMS) have been used for the palliative treatment of malignant gastric outlet obstruction (GOO). The aim of this study was to evaluate the clinical outcomes of salvage SEMS for stent malfunction and to identify the prognostic factors for a longer patency.

METHODS

A total of 108 patients who underwent a secondary salvage SEMS placement for a primary stent malfunction were retrospectively reviewed at the Seoul National University Hospital between August 2004 and May 2013. The duration of patency for salvage SEMS was defined as the time between salvage SEMS placement and the recurrence of obstructive symptoms that were confirmed either endoscopically or radiologically.

RESULTS

The technical and clinical success rates for salvage SEMS were 100 and 82.4% (95% confidence interval [CI] 74.0-89.0), respectively. A salvage SEMS malfunction occurred in 29 (26.9%) of the 108 patients. The median duration of patency for salvage SEMS was 59.5 days (range 3-928, 95% CI 73.7-118.3). Longer SEMS patencies of more than 60 days were significantly associated with palliative chemotherapy (odds ratio = 2.539, 95% CI 1.031-6.252, p = .043). For salvage SEMS, covered-uncovered stents had a longer patency duration, as compared with other combinations of primary and salvage stent types.

CONCLUSIONS

Longer patency durations for salvage SEMS were associated with palliative chemotherapy after salvage SEMS insertion. Salvage SEMS could be a feasible and effective treatment for primary stent malfunction in malignant GOO.

Efficacy and safety of a partially covered duodenal stent for malignant gastroduodenal obstruction: a pilot study

BACKGROUND

Duodenal stent placement has emerged as an effective and safe palliative treatment for patients with malignant gastroduodenal obstruction. An uncovered enteral stent, however, is susceptible to repeat stenosis because of tumor ingrowth. Although covering an enteral stent with a membrane prevents tumor ingrowth, stent migration continues to be a major unresolved problem. Partially covered metal stents may avoid both tumor ingrowth and stent migration.

OBJECTIVE

To evaluate the clinical and technical efficacy and the safety of a partially covered duodenal stent for malignant gastroduodenal obstruction.

DESIGN

Retrospective, observational study.

SETTING

Tertiary-care medical center.

PATIENTS

Twenty patients with malignant gastroduodenal obstruction received palliative treatment with partially covered duodenal stents.

INTERVENTIONS

Endoscopic stent placement.

MAIN OUTCOME MEASUREMENTS

Technical success, clinical success, patency, and adverse events.

RESULTS

Stent placement was successful in all 20 patients (technical success rate, 100%), and symptoms improved in 19 (clinical success rate, 95%). The Gastric Outlet Obstruction Scoring System score improved significantly (P < .001). Eight patients (40%) developed tumor overgrowth, whereas none showed stent migration. Median stent patency was 79.5 days (range 13-198 days). Adverse events occurred in 3 patients, including 2 with transient bacteremia and 1 with asphyxia because of impaction of food material into the stent.

LIMITATIONS

Single center, retrospective design, and a small number of patients.

CONCLUSION

Partially covered duodenal stents were effective and safe for malignant gastroduodenal obstruction and may prevent tumor ingrowth and stent migration.