Diagnostic Yield of a Novel 11-Fr Digital Cholangioscope for Indeterminate Biliary Disease Using Macroscopic-On-Site Evaluation: Prospective Comparative Study

BACKGROUND AND AIM

A novel 11-Fr digital cholangioscope (eyeMAX) has recently become available. However, a prospective comparative study of the diagnostic yield of the eyeMAX and of a conventional cholangioscope (SpyGlass DS II) has not been reported. Therefore, the aim of this study was to prospectively compare the diagnostic yield of the eyeMAX and of the SpyGlass DS II for indeterminate biliary disease.

PATIENTS AND METHOD

Forceps biopsy was repeated until visible core tissue was obtained. The primary outcome of this study was the diagnostic accuracy of the biopsy specimens obtained by the eyeMAX. The secondary outcomes were comparisons of the diagnostic yield of visual findings, tissue size, number of forceps biopsies until MOSE positivity, and adverse events.

RESULTS

Fifty patients were prospectively enrolled in the eyeMAX group. And 47 patients in the SpyGlass DS II group were enrolled as a historical control. The number of biopsies was significantly fewer in the eyeMAX group than in the SpyGlass DS II group (p = 0.001). Tissue size was larger in the eyeMAX group (2.96 ± 0.69 mm2) than in the SpyGlass DS II group (1.80 ± 1.61 mm2). The diagnostic accuracy was also higher in the eyeMAX group (96.0%, 48/50) than in the SpyGlass DS II group (80.9%, 38/47). The diagnostic accuracy for the final diagnosis was slightly higher in the eyeMAX group (93.5%, 47/50) than in the SpyGlass DS II group (89.3%, 42/47).

CONCLUSIONS

The eyeMAX has a favorable diagnostic yield in terms of visual findings and the forceps biopsy specimen.

TRIAL REGISTRATION

000049465.

Endohepatology: Applications in Liver Transplant

The term "endohepatology" was coined over the last 15 years to describe the integration of interventional endoscopy and hepatology for the management of patients with chronic liver disease. In this article, we will review the diagnostic and therapeutic applications of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography among liver transplantation candidates and recipients.

EASL Clinical Practice Guidelines on the management of extrahepatic cholangiocarcinoma

Recent years have witnessed significant advances in the imaging, molecular profiling, and systemic treatment of cholangiocarcinoma (CCA). Despite this progress, the early detection, precise classification, and effective management of CCA remain challenging. Owing to recent developments and the significant differences in CCA subtypes, EASL commissioned a panel of experts to draft evidence-based recommendations on the management of extrahepatic CCA, comprising distal and perihilar CCA. Particular attention is given to the need for accurate classification systems, the integration of emerging molecular insights, and practical strategies for diagnosis and treatment that reflect real-world clinical scenarios.

Submucosal Tunneling Endoscopic Resection for Upper Gastrointestinal Subepithelial Lesions: A Systematic Review and Meta-Analysis

AIM

Submucosal tunneling endoscopic resection (STER) is an advanced endoscopic technique used for the minimally invasive removal of subepithelial lesions of the gastrointestinal (GI) tract. The aim of this study was to evaluate the safety and efficacy of STER for upper gastrointestinal subepithelial lesions.

METHODS

A comprehensive search of major scholar databases (until December 15, 2023) was performed. Complete resection rate was considered the primary outcome. En bloc resection, operation duration, length of stay (LOS), local recurrence, and periprocedural complications were considered secondary outcomes. Random-effects (RE) and fixed-effects (FE) models were used to generate the outcome estimates.

RESULTS

A total of 37 studies and 3795 patients were included. Pooled proportion of complete resection was 99% (95% CI 98.4-99.6%, p < 0.001). En bloc resection was achieved at 87.7% of cases. Overall mean operation duration was 64.2 min, while mean LOS was estimated at 4.93 days. The local recurrence rate was 0.1%. The two most common complications associated with STER were subcutaneous emphysema (5.5%) and pneumothorax (3%).

CONCLUSION

STER is a highly feasible and safe treatment modality for upper GI subepithelial lesions.

Comparing Endoscopic Sleeve Gastroplasty (ESG) and Laparoscopic Sleeve Gastrectomy (LSG) 30-Day Outcomes and Healthcare Utilization: A Multi-Centered Retrospective Cohort Study of 506,597 Patients

BACKGROUND

While the safety and short-term weight-loss outcomes of endoscopic sleeve gastroplasty (ESG) are now well accepted, the modern uptake and its impact on healthcare utilization continue to remain poorly characterized, particularly in contrast to laparoscopic sleeve gastrectomy (LSG).

METHODS

After identifying ESG and LSG cases using a combination of CPT and procedural code variables, non-parsimonious multivariable logistic regression models were conducted to identify predictors of serious complications and outpatient emergency department (ED) visits.

RESULTS

A total of 506,597 patients met inclusion criteria (2285 ESG and 504,312 LSG). ESG patients were younger (42.6 ± 11.8 years versus 45.1 ± 10.7 years, p < 0.0001), had a lower BMI (39.5 ± 7.5 kg/m2 versus 44.9 ± 7.7 kg/m2, p < 0.0001), and were primarily female (86.2% versus 81.5%, p < 0.0001). Multivariable regression modeling revealed no differences in serious complications between ESG and LSG. ESG was protective against ED visits (OR 0.66; 95% 0.54-0.80; p < 0.0001). There were no other differences with respect to mortality or other healthcare metrics, such as outpatient rehydration, between procedures.

CONCLUSIONS

Multivariable logistic regression modeling of prospectively collected 30-day outcomes in a large multi-institutional database demonstrates that ESG does not confer additional risk of 30-day serious complications compared to LSG and has lower odds off post-procedural ED utilization in the same comparison.

Duodenal mucosal ablation with irreversible electroporation reduces liver lipids in rats with non-alcoholic fatty liver disease

BACKGROUND

Duodenal mucosal ablation (DMA) using irreversible electroporation (IRE) with a glucagon-like peptide-1 receptor agonist has been clinically shown to reduce liver lipid deposition in non-alcoholic fatty liver disease (NAFLD). However, the specific metabolic contributions of DMA using IRE in NAFLD remain unclear.

AIM

To assess the feasibility and effectiveness of DMA using IRE in NAFLD rat models.

METHODS

Seven-week-old male Sprague-Dawley rats underwent DMA using IRE after 8 weeks on a high-fat diet. Two weeks post-treatment, duodenal and liver tissues and blood samples were collected. We evaluated differences in the duodenal wall structure, liver lipid deposition, enteroendocrine, claudin, and zonula ocludens-1 in the duodenal mucosa.

RESULTS

DMA using IRE could be safely performed in rats with NAFLD without duodenal bleeding, perforation, or stenosis. The duodenum healed well 2 weeks after DMA and was characterized by slimmer villi, narrower and shallower crypts, and thicker myenterons compared with the sham-control setting. Liver lipid deposition was reduced and serum lipid index parameters were considerably improved in the DMA setting. However, these improvements were independent of food intake and weight loss. In addition, enteroendocrine parameters, such as claudin, and zonula ocludens-1 levels in the duodenal mucosa, differed between the different settings in the DMA group.

CONCLUSION

By altering enteroendocrine and duodenal permeability, simple DMA using IRE ameliorated liver lipid deposition and improved serum lipid parameters in NAFLD rats.

Endoscopic Delivery of a Double-Umbrella-Shaped Hydrogel Occluder with Instant Mechanical Interlock and Robust Wet Adhesion for Gastric Perforation Repair

Achieving robust adhesion of bioadhesives on wet tissues to block gastric perforation remains a challenge due to the gradually deteriorated adhesive-tissue interactions by interfacial acidity and multienzyme gastric fluids, thus accompanying failure shedding and life-threatening risks. Here, we report a biocompatible double-umbrella-shaped endoscopy-deliverable hydrogel occluder (EHO) made of caffeic acid (CA)-grafted chitosan (CS) and polyacrylamide (PAM) by molding technique, which is capable of the customizable, rapid, robust, and long-term sealing of large gastric perforations. In addition to interfacial physiochemical interactions (e.g., H-bonding, chelation) between the tissues and polymers, efficient sealing also integrates the advantages of fast mechanical interlocking in space and gradual self-expansion over time to tolerant acidic and mechanically dynamic environments. The EHO exhibits favorable biodegradability due to the reducible disulfide cross-linkers and remarkable protective barrier functions to impede the infiltration of gastric acid and digestive pepsin into the wound. To validate EHO's therapeutic efficacy, we further demonstrate the robust in vivo sealing to large gastric tissues via endoscopic delivery to the porcine stomach and monitor of healing process with improved retention of endogenous growth factors. Besides, in views of simple hydrogel fabrication using molding technique, the biodegradable EHO can be facilely tailored with various topologies according to application scenarios in surgical and minimally invasive endoscopic delivery, thus offering a promising alternative for clinical repair of gastrointestinal perforations and other organs.

Considerations for Perioperative Management Guidance Regarding GLP-1 Receptor Agonists: Evaluation of Current Practices and Future Directions

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have become increasingly prevalent and have the potential to delay gastric emptying. The American Society of Anesthesiologists (ASA) released guidance regarding the perioperative management of patients receiving GLP-1 RAs, but it is unclear the extent to which hospitals in the U.S. Military Health System have implemented policies consistent with this guidance.

METHODS

A questionnaire was sent to active duty anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) working in the U.S. Military Health System. The questions assessed the presence of institutional GLP-1 RA perioperative policies, adherence to the policy (if applicable), the basis and components of current and recommended future institutional policies, institutional tracking of policy implementation and outcomes, and knowledge, skills, barriers, and continuing medical education goals related to the perioperative management of patients receiving GLP-1 RAs.

RESULTS

The response rate was 32% (N = 265); a little over half of the respondents were anesthesiologists (53%); and respondents' primary practices included over 50 institutions. More than half (54%) indicated that their primary practice location had a GLP-1 RA perioperative policy; 65% of whom indicated that they always followed the policy. In review of practice locations with >1 respondents, there was a lack of perfect agreement across most locations. The most commonly reported basis for the policy was ASA guidance (87%), followed by department leadership (37%). Barriers to any system-wide GLP-1 perioperative management policy included a lack of gastric ultrasound practice and comfort, as well as reported skills and knowledge, pressure not to cancel cases, scheduling problems, and productivity requirements.

CONCLUSIONS

Formal policies were reported by most respondents, but inconsistencies within practice locations suggest that local policy implementation could be improved. Commonly reported barriers to future system-wide policy implementation provide data-driven information for system-wide efforts to improve policy success.

Association between glucagon-like peptide-1 receptor agonist use and peri-operative pulmonary aspiration: a systematic review and meta-analysis

INTRODUCTION

Glucagon-like peptide-1 receptor agonists are known to delay gastric emptying; however, the association between glucagon-like peptide-1 receptor agonist use and peri-operative pulmonary aspiration risk is not known. This systematic review and meta-analysis aimed to summarise the evidence on whether glucagon-like peptide-1 receptor agonist exposure is associated with pulmonary aspiration or increased residual gastric content in fasted patients undergoing procedures requiring anaesthesia or sedation.

METHODS

We searched six databases for studies assessing peri-operative pulmonary aspiration or residual gastric contents in fasted patients or volunteers who were using any form of glucagon-like peptide-1 receptor agonist. Pooled odds ratios were estimated for each outcome using random effects meta-analysis. Certainty of evidence for each outcome was assessed using the GRADE framework.

RESULTS

Of 9010 screened studies, 28 observational studies were included. In a meta-analysis of nine studies involving 304,060 patients and 481 cases of pulmonary aspiration, glucagon-like peptide-1 receptor agonist exposure was not associated with pulmonary aspiration (OR 1.04, 95%CI 0.87-1.25, low certainty of evidence). In a meta-analysis of 18 studies involving 165,522 patients and 3831 cases of residual gastric contents, glucagon-like peptide-1 receptor agonist exposure was associated with an increased risk of residual gastric contents despite appropriate fasting (odds ratio 5.96, 95%CI 3.96-8.98, low certainty of evidence). In a meta-analysis of five studies involving 1706 patients and 208 cases of residual gastric contents, withholding at least one dose of glucagon-like peptide-1 receptor agonist before a procedure was associated with lower odds of residual gastric contents (odds ratio 0.51, 95%CI 0.33-0.81, very low certainty of evidence).

DISCUSSION

Patients using glucagon-like peptide-1 receptor agonists are at increased risk of presenting for anaesthesia with residual gastric contents, though the available evidence does not indicate that this translates to an increased risk of pulmonary aspiration.

Targeting the Gut Microbiota's Role in Host Energy Absorption With Precision Nutrition Interventions for the Prevention and Treatment of Obesity

The field of precision nutrition aims to develop dietary approaches based on individual biological factors such as genomics or the gut microbiota. The gut microbiota, which is the highly individualized and complex community of microbes residing in the colon, is a key contributor to human physiology. Although gut microbes play multiple roles in the metabolism of nutrients, their role in modulating the absorption of dietary energy from foods that escape digestion in the small intestine has the potential to variably affect energy balance and, thus, body weight. The fate of this energy, and its subsequent impact on body weight, is well described in rodents and is emerging in humans. This narrative review is focused on recent clinical evidence of the role of the gut microbiota in human energy balance, specifically its impact on energy available to the human host. Despite recent progress, remaining gaps in knowledge present opportunities for developing and implementing strategies to understand causal microbial mechanisms related to energy balance. We propose that implementing rigorous microbiota-focused measurements in the context of innovative clinical trial designs will elucidate integrated diet-host-gut microbiota mechanisms. These mechanisms are primed to be targets for precision nutrition interventions to optimize energy balance to achieve desired weight outcomes. Given the magnitude and impact of the obesity epidemic, implementing these interventions within comprehensive weight management paradigms has the potential to be of public health significance.

Endoscopic treatment of unresectable perihilar cholangiocarcinoma: beyond biliary drainage

Perihilar cholangiocarcinoma (PHCC) is an aggressive biliary malignancy originating from the epithelial cells of the bile duct, typically located in the extrahepatic biliary tree, proximal to the cystic duct. PHCC often presents with a rapid onset of jaundice. While radical surgical resection remains the only curative treatment, only a minority of patients are eligible due to early metastasis and challenges associated with preoperative evaluations. Comprehensive treatments, including chemotherapy, radiotherapy, targeted therapy, and immunotherapy, are crucial for managing PHCC. However, in advanced stages, complications such as cholestatic liver injury, malnutrition, and biliary infections pose significant obstacles to these treatments. Therefore, biliary drainage (BD) is essential in the management of PHCC. In addition to external drainage methods like percutaneous transhepatic biliary drainage (PTBD), endoscopic biliary drainage (EBD), particularly endoscopic retrograde cholangiopancreatography (ERCP), offer an effective option for internal drainage, which is more physiologically compatible and better tolerated. Furthermore, the integration of various endoscopic techniques has expanded the management of PHCC beyond mere drainage. Techniques such as radiofrequency ablation (RFA), photodynamic therapy (PDT), and endoscopic ultrasound (EUS) based methods present new therapeutic avenues, albeit with variable results. This review aims to summarize current advancements and ongoing debates in the field of endoscopic treatment for unresectable PHCC.

"Evaluation of hepatobiliary disorders using magnetic resonance cholangiopancreatography in a low-resource setting in Kano, Nigeria: a retrospective study"

BACKGROUND

Biliary disorders are a major health concern in Nigeria, where magnetic resonance cholangiopancreatography (MRCP), a non-invasive imaging tool offering effective duct visualization without radiation, is emerging as a key diagnostic modality. This retrospective study in Kano explored its role in diagnosing biliary and pancreatic disorders.

MATERIALS AND METHODS

This retrospective study reviewed MRCP images and records of patients with suspected biliary disorders at Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria. A 1.5T magnetic resonance imaging (MRI) machine obtained MRCPs following standard protocols, and key findings (e.g., calculus size and masses) were documented. Demographic and clinical data were analyzed in IBM-Statistical Package for Social Sciences (SPSS), with p<0.05 considered significant. Ethical approval was obtained, and patient confidentiality was upheld.

RESULTS

A study of 101 participants (mean age: 44 ± 19.41 years, range: 3 months to 80 years) revealed a male predominance (55.4%). Obstructive jaundice (46.5%) was the most common MRCP indication, with imaging abnormalities observed in 84.2%, primarily obstructive cholelithiasis (22.8%) and pancreatic head masses (13.9%).

CONCLUSION

MRCP successfully detected hepatobiliary and pancreatic abnormalities in most patients, with obstructive jaundice being the primary indication and obstructive cholelithiasis the most frequent diagnosis. The study also found a correlation between main pancreatic duct diameter and age, where larger diameters signalled abnormalities, reinforcing MRCP's diagnostic significance.

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.

Endoscopic Sleeve Gastroplasty for the Treatment of Metabolic Syndrome: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is an incisionless weight loss procedure that has been demonstrated to be safe and effective for the treatment of obesity; however, the efficacy of ESG for the treatment of comorbid type 2 diabetes mellitus (T2DM) and other components of metabolic syndrome (MetS) has been less well studied. We aimed to conduct a systematic review and meta-analysis of available literature to evaluate the outcomes of ESG on T2DM and MetS.

METHODS

Bibliographic databases were systematically searched for studies assessing the outcomes of ESG on T2DM and MetS. Studies were included if they reported at least one objective outcome related to T2DM or other components of MetS, including hyperlipidemia (HLD), hypertriglyceridemia, and hypertension (HTN). This study was deemed IRB exempt.

RESULTS

Ten studies with 4320 patients were included. At 12 months, ESG was associated with significant improvements in T2DM, HLD, and HTN, with risk difference of - 0.72 [95% CI, - 0.87 to - 0.58, p < 0.00001], - 0.65 [95% CI, - 0.78 to - 0.52, p < 0.00001], and - 0.60 [95% CI, - 0.66 to - 0.53, p < 0.00001], respectively. Disease improvement was defined as patients being able to stop some or all of their related treatment medications. Additionally, there were significant reductions in hemoglobin A1c (HGBA1c), fasting blood glucose, homeostatic model assessment for insulin resistance (HOMA-IR), low-density lipoprotein, and triglycerides.

CONCLUSIONS

ESG is an effective modality for the treatment of comorbid T2DM and MetS in patients with obesity. Additional studies are needed to establish long-term responses and to compare ESG against established pharmacologic and surgical techniques.

Efficacy of 12 months therapy with glucagon-like peptide-1 receptor agonists liraglutide and semaglutide on weight regain after bariatric surgery: a real-world retrospective observational study

BACKGROUND

The role of glucagon-like peptide-1 receptor agonists (GLP1-RAs) in patients with weight regain after bariatric surgery remains unclear. The objective of this study was to determine the efficacy and safety of 12 months of GLP1-RA treatment in a real-world patient population with weight regain after bariatric surgery.

METHODS

A single-centre retrospective observational study. Patients with post-bariatric weight regain subsequently treated with GLP1-RA were identified, and the effect on weight after 12 months of treatment was determined. Data are presented as medians (interquartile ranges) or frequencies (%), and Wilcoxon signed-rank tests and Mann-Whitney U tests were used for paired and nonpaired group comparisons, respectively.

RESULTS

Forty patients (80% female) were included in the analysis. Liraglutide (3.0 mg, daily subcutaneous injection, n = 22) or semaglutide (1.0 mg, weekly subcutaneous injection, n = 18) was started 74.5 (51.0, 108.3) months after surgery following a weight regain of 14.7 (10.3, 19.6)%. After 12 months of GLP1-RA treatment, a total body weight, BMI, and percentage excess body weight reduction of 10.5 (6.1, 14.7) kg, 3.7 (2.5, 5.3) kg/m2, and 41.7 (22.1, 70.5)% were observed, corresponding to a loss of 99.3 (61.0, 135.4)% of the weight regained (P-value < 0.0001). The observed reduction in BMI was significantly lower with liraglutide than with semaglutide, 3.1 (2.0, 4.7) vs. 4.7 (3.7, 6.0) kg/m2 (P-value = 0.04). Adverse events were reported in 13 (32.5%) patients, all of which were mild and transient.

CONCLUSION

GLP1-RA therapy with liraglutide or semaglutide for 12 months is efficacious and safe for the treatment of weight regain following bariatric surgery.

CLINICAL TRIAL NUMBER

Not applicable.

Efficacy of Polysaccharide Hemostatic Powder on Blood Oozing Among Patients With Postendoscopic Sphincterotomy Bleeding: A Randomized Controlled Trial

INTRODUCTION

Postendoscopic sphincterotomy (EST) bleeding presents challenges for endoscopists using side-viewing duodenoscopes. Recently, polysaccharide hemostatic powder (PHP) has shown promising results in managing gastrointestinal hemorrhage. Given the established efficacy of endoscopic clips in addressing post-EST bleeding, we aim to evaluate the efficacy of PHP and its noninferiority to endoscopic clips in patients with nonpulsatile post-EST bleeding.

METHODS

Patients with nonpulsatile post-EST bleeding were randomized to receive either PHP or endoscopic clips. The primary end point was the immediate hemostasis rate, with secondary end points including delayed bleeding rate, overall treatment success rate, mean hemostasis time, and other major complications.

RESULTS

A total of 104 patients with nonpulsatile post-EST bleeding were included. Immediate hemostasis was achieved in 100% of the PHP group and 92.3% in the endoscopic clip group (risk difference, 7.7%, 95% confidence interval (CI) = 0.5%-15.0%, P = 0.022). Four patients in the endoscopic clip group experienced immediate hemostasis failure. Hemostasis time was shorter in the PHP group (50.77 vs 62.81 seconds, P = 0.011). One delayed bleeding case (2.1%) occurred in the clip group, whereas none were observed in the PHP group. The overall treatment success rate was higher in the PHP group compared with the endoscopic clip group (100% vs 90.4%; P = 0.022). No differences were observed in adverse events.

DISCUSSION

PHP is not inferior to endoscopic clip and could be of use in immediate hemostasis for nonpulsatile post-EST bleeding, with the added advantage of ease of use. Further research is needed to assess its efficacy in preventing delayed bleeding ( chictr.org.cn , ChiCTR2400092280).

Characterization and clinical outcomes of rare biliary adenosquamous carcinoma

BACKGROUND

Data are scarce regarding biliary adenosquamous carcinoma (BASC) due to its low incidence. BASC displays a worse prognosis than adenocarcinoma and its specific treatment is still an unmet medical need. We conducted a description analysis of BASC including clinicopathologic parameters and treatment outcomes.

METHODS

All consecutive patients with histologically proven BASC diagnosed in six French hospitals between 2000 and 2022 were enrolled and described.

RESULTS

A total of 16 BASC, accounting for 1.4 % of all biliary tract carcinoma, were included and the BASC incidence increased steadily over the past 22 years. The median age at diagnosis was 70.7 years (min-max 31.4-82.0 years) with most women (62.5 %). At diagnosis, half of BASC patients had a localized stage. The primary tumor locations were shared between gallbladder cancers (n = 7) and cholangiocarcinoma (n = 7), with mainly an extra-hepatic disease (71.4 %). Median overall survival was 9.5 months (95 % CI = 2.1-14.8 months). A total of 13 (81.6 %) patients had undergone surgery with a median relapse-free survival of 3.8 months (95 % CI = 0.0-10.5 months). Five (38.5 %) patients received an adjuvant chemotherapy. A total of seven (43.8 %) patients were treated with chemotherapy for the occurrence of metastases with a median progression-free survival of 2.8 months (95 % CI = 0.8-4.1 months). No objective response was observed and stable disease was achieved in two patients (28.6 %).

CONCLUSIONS

BASC is a rare disease with an increased incidence, highlighting the diagnostic challenges. BASC population was associated with a poor prognostic and limited therapeutic response. Further molecular investigations should be performed to investigate new therapeutic options.

Non-Curative Endoscopic Submucosal Dissection: Current Concepts, Pitfalls and Future Perspectives

Endoscopic submucosal dissection (ESD) is very effective for the treatment of digestive tract neoplasia. However, it is very demanding, with a long learning curve, and, therefore, a significant rate of non-curative resections is expected, considering lesion characteristics, location, and endoscopist experience. The management of patients after a non-curative ESD is not definitely established. It must consider patients' comorbidities and expected survival, as well as the morbidity and mortality of complementary treatments such as surgery, chemotherapy, or radiotherapy. On the other hand, there is a window of opportunity to offer those additional treatments to complete neoplastic treatment and give patients an oncological cure. This decision is sometimes difficult, since the diverse histological criteria that define a non-curative ESD do not have the same weight regarding residual risk and oncological progression. The prediction of residual lesion would be paramount to decide whether to refer patients to surgery; nowadays, this prediction is far from perfect, since most of the patients that undergo surgery due to a non-curative ESD do not have residual neoplasia in the surgical specimen. In this review, ESD curativeness and the management of non-curative ESDs performed for esophageal, gastric, and colorectal lesions will be addressed.

Association of semaglutide with retained gastric contents on endoscopy: Retrospective analysis

Background and study aims

We investigated the effect of semaglutide, a glucagon-like peptide-1 (GLP-1) agonist therapy, on retained gastric contents during endoscopy through a retrospective case-control study.

Patients and methods

We performed a retrospective case-control study to evaluate the effect of semaglutide on rates of retained gastric contents (RGC) visualized during esophagogastroduodenoscopy (EGD). Cases and controls were matched using multidimensional propensity score matching: age, gender, body mass index, and EGD indication. Pairs were analyzed using McNemar testing and Mann-Whitney non-parametric tests.

Results

Of the patients on GLP-1 therapy at time of EGD, 12.5% had RGC, compared with 1.3% in the control group (confidence interval [CI] 7.2% to 17.7%, P < 0.0001). Approximately 23% of patients prescribed GLP-1 therapy for weight loss had RGC at time of EGD compared with the control group (CI 13.4% to 32.6%, P < 0.0001). Only 2.6% of patients prescribed GLP-1 therapy for diabetes had RGC at time of EGD compared with the control group (CI -0.9% to 6.1%, P = 0.5). Patients receiving GLP-1 therapy with RGC at time of EGD did not differ from non-RGC patients in dosing of GLP-1 agonist ( P = 0.23) or duration of GLP-1 agonist use prior to EGD ( P = 0.98).

Conclusions

Semaglutide use appears to increase risk of having retained gastric contents visualized during endoscopy. Patients on semaglutide for weight loss appear to have a greater risk of RGC compared with patients on semaglutide for glycemic control. This observation may have clinical implications for management of GLP-1 agonist use prior to endoscopy.

Comparing the risk of gastroparesis following different modalities for treating obesity: semaglutide versus bupropion-naltrexone versus sleeve gastrectomy - a retrospective cohort study

OBJECTIVE

The use of glucagon-like peptide 1 receptor agonists has been associated with gastroparesis, but little is known about the risk of gastroparesis in those with obesity but without type 2 diabetes (T2D), and how that risk compares with other treatment modalities for obesity. This study aims to characterise the relationship between different treatment modalities for obesity and the risk of gastroparesis in a population without pre-existing T2D.

METHODS

A retrospective cohort study using Merative MarketScan Research Databases of individuals with obesity who underwent treatment with semaglutide, bupropion-naltrexone or sleeve gastrectomy from 1 January 2018 to 31 December 2022. The incidence of gastroparesis diagnosis was evaluated using International Classification of Diseases, Version 10 codes. The risk of gastroparesis was compared between three intervention groups using Cox proportional hazards regression models.

RESULTS

Of the 55 460 individuals included, 36 990 (66.7%) were treated with semaglutide, 7369 (13.3%) with bupropion-naltrexone and 11 101 (13.7%) with sleeve gastrectomy. Gastroparesis rates among those treated with semaglutide versus bupropion-naltrexone versus sleeve gastrectomy were 6.5 per 1000 person-years (PY) vs 2.1 per 1000 PY vs 1.1 per 1000 PY, respectively. After adjusting for baseline characteristics, individuals treated with semaglutide had a higher risk of gastroparesis than those treated with bupropion-naltrexone (adjusted HR 3.33, 95% CI 2.27, 4.98) and sleeve gastrectomy (adjusted HR 6.14, 95% CI 3.94, 9.57).

CONCLUSIONS

There is an increased incidence of gastroparesis among individuals with obesity without T2D who are using semaglutide as compared with bupropion-naltrexone and sleeve gastrectomy. Understanding these potential side effects, though rare, may help guide personalised treatment regimens.

[New cases of botulism after intragastric injection of botulinum toxin]

Two female patients presented to our clinic shortly after one another with visual disturbances, double vision, swallowing difficulties and shortness of breath, a few days after an intragastric injection of botulinum toxin in a clinic in Turkey.The physical examination was unremarkable except for signs of respiratory insufficiency with increased respiratory rate and shortness of breath, especially when lying down; no clear neurological symptoms were found. Imaging showed reduced diaphragmatic mobility. Blood gas analyses showed hypoxemic respiratory insufficiency.The patients were observed as inpatients for a few days without specific therapy and were discharged with regressing symptoms.In March 2023, the Robert Koch Institute, the European Centre for Disease Prevention and Control and the WHO published a report on 87 patients who had received intragastric injections of botulinum toxin in 2 Turkish hospitals with the aim of losing weight and subsequently have developed symptoms of botulism. The current cases presented here draw further attention to the problems of the procedure that is still being carried out and to the risks of botulism.

The origin of patient-derived cancer organoids from pathologically undiagnosed specimen in patients with pancreatobiliary cancers

PURPOSE

Tissue confirmation of pancreatobiliary cancer is often difficult because of the location of the tumor and structure of the surrounding blood vessels. Patient-derived cancer organoids (PDCOs) reflect the genomic characteristics of individual cancers. Although diverse attempts to construct PDCOs for various pancreatobiliary cancer models are ongoing, no research results have yet confirmed the possibility of performing a precise diagnosis on PDCOs derived from pathologically negative patient samples.

METHODS

We obtained a total of nine samples, including pathologically negative samples, from four patients (three patients with pancreatic cancer and one patient with gallbladder cancer) using different tissue acquisition methods to establish PDCOs (success rate 75%).

RESULTS

We successfully verified whether the constructed PDCOs could represent the tissues of patients with pancreatobiliary cancer at each multi-omics level using tumor panel sequencing, single-cell RNA sequencing, hematoxylin and eosin, and immunohistochemical staining. PDCOs from pathologically negative samples showed expression patterns of malignant ductal cell-related biomarkers similar to those of other pathologically positive samples. Furthermore, the expression patterns at the single-cell level in PDCO from patients ultimately diagnosed with gallbladder cancer after surgery were different from those in patients with pancreatic cancer.

CONCLUSION

Therefore, our study implicated the potential of PDCOs as diagnostic and research tools, including for case involving limited tissue samples. Based on these results, we anticipate that this could be extended to more advanced studies, such as drug sensitivity testing, through large-scale trials in the near future.

Primary percutaneous metal stenting above the ampulla in resectable perihilar cholangiocarcinoma

INTRODUCTION

We present a case of a patient with resectable perihilar cholangiocarcinoma (pCCA) who underwent primary metal stenting above the ampulla, followed by a successful surgical resection. Biliary drainage is a crucial step in the preoperative management of pCCA, yet there is no consensus on the optimal approach. Traditional drainage methods involve passing through the ampulla and/or the skin barrier, thereby increasing the risk of bacterial contamination of the biliary tree and secondary cholangitis.

METHOD

A novel drainage technique was utilised in this case. A metal stent was percutaneously placed across the malignant hilar stenosis without external biliary drainage. During the procedure, both guidewires and stents were meticulously prevented from passing through the ampulla. Additionally, percutaneous access to the biliary tree was removed during the index procedure to minimise the risk of biliary colonisation and cholangitis.

RESULTS

Following the drainage, bilirubin levels rapidly normalised, and no clinical or biochemical signs of cholangitis were observed. This allowed for rapid and uncomplicated surgical resection.

CONCLUSION

This case illustrates the potential of a novel biliary drainage technique in patients with pCCA. By minimising the risk of biliary colonisation and cholangitis, this approach could potentially improve surgical outcomes.

Uncovered Self-Expandable Metallic Stent with an Ultra-Thin Delivery Sheath in Unresectable Malignant Hilar Biliary Obstruction: A Multicenter Prospective Observational Study

BACKGROUND

Although various self-expandable metallic stents (SEMSs) for malignant hilar biliary obstruction (MHBO) have been introduced, the optimal SEMS for MHBO has not yet been established.

PURPOSE

This study aimed to evaluate outcomes of the transpapillary placement of an uncovered laser-cut SEMS with an ultra-thin delivery sheath (YABUSAME) for MHBO.

METHODS

This multicenter, prospective study was conducted in 11 hospitals for 10 months (from March 2022 to December 2022). The primary outcome was the stent patency rate at 6 months. Key secondary outcomes were the technical success rate, clinical success rate, time to recurrent biliary obstruction (RBO), overall survival (OS), and adverse events.

RESULTS

Of 45 enrolled patients, 43 patients underwent biliary drainage, including 42 patients who underwent YABUSAME placement; 66.7% of patients received chemotherapy, and 60% had previously undergone biliary drainage. Drainage methods were partial stent-in-stent, side-by-side, and unilateral in 65.1%, 7.0%, and 27.9% of patients, respectively. Technical and clinical success rates were 93.2% (41/45) and 79.1% (34/45), respectively. The incidence rate of early postprocedural adverse events was 2.2%. The stent patency rate at 6 months was 55.3%. The median time to RBO was 231 days. The median OS was 125 days.

CONCLUSION

This study showed that the primary outcome, the 6-month stent patency rate, exceeded the expected rate of 55%, which indicates the efficacy of YABUSAME placement for MHBO.

Maximizing oral intake tolerance in malignant gastric outlet obstruction - a Markov decision tree analysis comparing duodenal stenting, endoscopic ultrasound-guided gastroenterostomy and surgical gastrojejunostomy based on a meta-analysis of randomized controlled trials

INTRODUCTION

Malignant gastric outlet obstruction (GOO) has a significant impact on quality of life. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has shown promising results. Traditional isolated outcome measures do not sufficiently address critical considerations for end-of-life patients like oral intake tolerance. This study aimed to determine via a probabilistic approach, the optimal management strategy for GOO patients that maximizes their oral intake tolerance.

METHODS

A Markov decision model was developed, with input variables based on a systematic review and meta-analysis of randomized controlled trials (RCT) comparing duodenal stenting (DS), EUS-GE and surgical gastrojejunostomy (GJ). A prospective cohort study with a comparator group was also included for EUS-GE model given the scarcity of RCTs. Model assumption was a patient with malignant GOO, with equal probabilities of being allocated to 1 of 3 treatment options. Each data point was evaluated using pooled probabilities from the meta-analysis of clinical outcomes. Primary outcome was successful oral intake tolerance at various time points of 1-6 months post-intervention.

RESULTS

Fifteen studies were included into the Markov model. Based on 10 000 simulations in each arm, at a survival of 1-month, DS and EUS-GE had the highest likelihood of oral intake (81.2% and 80.4%) compared to GJ (75.5%). However, at a survival of 6-month, EUS-GE and GJ were better at palliating GOO, with likelihood of oral intake at 23.8% and 25.2%, compared to 21.3% for DS.

CONCLUSION

For patients with a prognosis of more than 1-month, a surgical GJ, or EUS-GE if technical expertise is available, is preferred for GOO palliation.

Elective peri-operative management of adults taking glucagon-like peptide-1 receptor agonists, glucose-dependent insulinotropic peptide agonists and sodium-glucose cotransporter-2 inhibitors: a multidisciplinary consensus statement: A consensus statement from the Association of Anaesthetists, Association of British Clinical Diabetologists, British Obesity and Metabolic Surgery Society, Centre for Perioperative Care, Joint British Diabetes Societies for Inpatient Care, Royal College of Anaesthetists, Society for Obesity and Bariatric Anaesthesia and UK Clinical Pharmacy Association

INTRODUCTION

Glucagon-like peptide-1 receptor agonists, dual glucose-dependent insulinotropic peptide receptor agonists and sodium-glucose cotransporter-2 inhibitors are used increasingly in patients receiving peri-operative care. These drugs may be associated with risks of peri-operative pulmonary aspiration or euglycaemic ketoacidosis. We produced a consensus statement for the peri-operative management of adults taking these drugs.

METHODS

This multidisciplinary consensus statement included surgeons, anaesthetists, physicians, pharmacists and people with lived experience relevant to these guidelines. Following the directed literature review, a three-round modified Delphi process was conducted to generate and ratify recommendations.

RESULTS

Patients taking glucagon-like peptide-1 receptor agonists and dual glucose-dependent insulinotropic peptide receptor agonists should: continue these drugs before surgery; have full risk assessment and stratification; and receive peri-operative techniques that may mitigate risk of pulmonary aspiration before, during and after sedation or general anaesthesia. Patients taking sodium-glucose cotransporter-2 inhibitors should omit them the day before and the day of a procedure. All patients should have risks and mitigation strategies discussed with a shared decision-making approach.

DISCUSSION

Until more evidence becomes available, this pragmatic, multidisciplinary consensus statement aims to support shared decision-making and improve safety for patients taking glucagon-like peptide-1 receptor agonists, dual glucose-dependent insulinotropic peptide receptor agonists and sodium-glucose cotransporter-2 inhibitors during the peri-operative period.

Artificial Intelligence Performance in Image-Based Cancer Identification: Umbrella Review of Systematic Reviews

BACKGROUND

Artificial intelligence (AI) has the potential to transform cancer diagnosis, ultimately leading to better patient outcomes.

OBJECTIVE

We performed an umbrella review to summarize and critically evaluate the evidence for the AI-based imaging diagnosis of cancers.

METHODS

PubMed, Embase, Web of Science, Cochrane, and IEEE databases were searched for relevant systematic reviews from inception to June 19, 2024. Two independent investigators abstracted data and assessed the quality of evidence, using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. We further assessed the quality of evidence in each meta-analysis by applying the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. Diagnostic performance data were synthesized narratively.

RESULTS

In a comprehensive analysis of 158 included studies evaluating the performance of AI algorithms in noninvasive imaging diagnosis across 8 major human system cancers, the accuracy of the classifiers for central nervous system cancers varied widely (ranging from 48% to 100%). Similarities were observed in the diagnostic performance for cancers of the head and neck, respiratory system, digestive system, urinary system, female-related systems, skin, and other sites. Most meta-analyses demonstrated positive summary performance. For instance, 9 reviews meta-analyzed sensitivity and specificity for esophageal cancer, showing ranges of 90%-95% and 80%-93.8%, respectively. In the case of breast cancer detection, 8 reviews calculated the pooled sensitivity and specificity within the ranges of 75.4%-92% and 83%-90.6%, respectively. Four meta-analyses reported the ranges of sensitivity and specificity in ovarian cancer, and both were 75%-94%. Notably, in lung cancer, the pooled specificity was relatively low, primarily distributed between 65% and 80%. Furthermore, 80.4% (127/158) of the included studies were of high quality according to the JBI Critical Appraisal Checklist, with the remaining studies classified as medium quality. The GRADE assessment indicated that the overall quality of the evidence was moderate to low.

CONCLUSIONS

Although AI shows great potential for achieving accelerated, accurate, and more objective diagnoses of multiple cancers, there are still hurdles to overcome before its implementation in clinical settings. The present findings highlight that a concerted effort from the research community, clinicians, and policymakers is required to overcome existing hurdles and translate this potential into improved patient outcomes and health care delivery.

TRIAL REGISTRATION

PROSPERO CRD42022364278; https://www.crd.york.ac.uk/PROSPERO/view/CRD42022364278.

Glucagon-like peptide-1 receptor agonist use and the risk of residual gastric contents and aspiration in patients undergoing GI endoscopy: a systematic review and a meta-analysis

BACKGROUND AND AIMS

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are used for type 2 diabetes mellitus and obesity, but safety concerns have been raised for users undergoing GI endoscopy because of retained food and aspiration events. We compared the risk of adverse events for GLP-1RA users and nonusers undergoing endoscopy.

METHODS

We conducted a systematic review and meta-analysis (PROSPERO registration: CRD42024556732). A systematic search in PubMed, Scopus, Web of Science, and Cochrane Central was performed from their inception until July 1, 2024 (EMBASE from 1974 to June 28, 2024). Double-arm adult human original studies (observational, randomized controlled trial) with a sample size of ≥20 undergoing EGD or endoscopy with no GLP-1RA use in the control arm were searched. Studies were excluded if they were single arm and had any use of GLP-1RA before the procedure in the control arm. Residual gastric contents (RGCs), aspiration pneumonia, and premature endoscopy termination were the main outcomes. The random-effects model was used to pool and get final effect estimates.

RESULTS

Twenty-three observational studies were selected consisting of 262,018 patients. GLP-1RA users had a statistically significant increase in the risk of RGCs (odds ratio [OR], 4.54; 95% confidence interval [CI], 3.30-6.24; P < .00001, I2 = 68%) and premature endoscopy termination (OR, 4.54; 95% CI, 3.05-6.75; P < .00001, I2 = 0%). There was no significant difference in the risk of aspiration pneumonia (OR, .96; 95% CI, .53-1.75; P = .90, I2 = 70%). A significant reduction was seen in RGCs when EGD and colonoscopy (OR, .28; 95% CI, .22-.36; P < .00001, I2 = 0%) were done the same day versus EGD alone.

CONCLUSIONS

GLP-1RA use was associated with an increased risk of RGCs and premature endoscopy termination, but no significant difference was found in the risk of aspiration pneumonia in patients undergoing endoscopy.

Novel minimally invasive strategies for achieving source control in intra-abdominal infections

PURPOSE OF REVIEW

To provide an overview of recent advancements in minimally invasive intra-abdominal source control techniques.

RECENT FINDINGS

There have been multiple recent advances in minimally invasive techniques for managing intra-abdominal infection or sepsis. Endoscopic based interventions include stenting, suturing, clip placement, and endoscopic vacuum therapy. Robotic surgery is becoming progressively more popular in emergency general surgery and offers comparable results compared to laparoscopic surgery with lower rates of conversion to open.

SUMMARY

Endoscopic based interventions and minimally invasive surgery offer comparable outcomes to more invasive interventions with less morbidity for patients, though the ability to perform these techniques may not be limited to tertiary and quaternary health centers. Providers must use their clinical judgment to determine the best course of action.

Endoscopic management of obesity and metabolic diseases

Obesity has become a global pandemic that is associated with a range of metabolic disorders. Traditional treatment options, such as lifestyle modification and anti-obesity medications, often exhibit limited efficacy and can lead to long-term weight gain, especially upon discontinuation of the medication. Although bariatric surgery is effective, its accessibility is constrained, and only a small percentage of eligible patients receive this intervention. Over the past two decades, endoscopic bariatric and metabolic therapies (EBMTs) have emerged as minimally invasive and effective alternatives for managing obesity and its related comorbidities. This article reviews primary gastric and small bowel EBMTs, their mechanisms of action, key supporting literature, and the metabolic outcomes associated with each device and procedure.

SAFE anaesthesia for patients at risk of pulmonary aspiration: A nationwide survey

BACKGROUND

Clinical practice in patients at risk of pulmonary aspiration varies widely. However, data on actual management, decision-driving factors and controversial issues remain elusive.

OBJECTIVE

We aimed to comprehensively review the management of patients at risk of pulmonary aspiration and identify controversies among anaesthesia professionals.

DESIGN

National interprofessional survey.

SETTING

All anaesthesia departments in Switzerland.

PARTICIPANTS

The survey was distributed electronically to all members of the Swiss Society of Anaesthesiology and Perioperative Medicine, members of the Swiss Interest Group for Anaesthesia Nursing and all department heads in Switzerland.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Consensus and controversies in clinical practice and management of patients at risk of pulmonary aspiration.

RESULTS

A total of 684 respondents were included in the final analysis (59 department heads, 366 consultants, 99 registrars, 160 nurse anaesthetists). The response rate from physicians was 47%. Consensus (>80% agreement or disagreement) was reached on 9/12 (75%) questions regarding preparation for rapid sequence induction (RSI), 6/13 (46%) regarding RSI practice and 3/8 (38%) regarding management of aspiration incidents. Major controversies included high-flow pre-oxygenation (55% agreement), the validity of modified RSI in adults (52% agreement), the primary use of video-laryngoscope (76% agreement) and management of apparent regurgitation. Subjective factors such as clinical presentation were considered more important than objective factors such as medical history, comorbidities or gastric ultrasound.

CONCLUSION

Across a wide range of experience and professional groups, we found a strong consensus on the indication and performance of 'traditional' RSI. However, clinical decision-making still relies heavily on subjective impressions, while newer risk stratification and management techniques remain controversial.

Acceptable number of cholangioscopy-guided biopsies for diagnosing perihilar cholangiocarcinoma

INTRODUCTION

diagnosing perihilar cholangiocarcinoma can be challenging. Previous studies suggest that the sensitivity of taking three cholangioscopy-guided biopsies is approximately 70 %. We hypothesized that obtaining four or more biopsies might improve the sensitivity for diagnosing perihilar cholangiocarcinoma.

OBJECTIVE

to determine the acceptable number of cholangioscopy-guided biopsies to improve sensitivity for diagnosing perihilar cholangiocarcinoma.

METHODS

this retrospective study analyzed clinical records of adults with perihilar stenosis who underwent cholangioscopy-guided biopsies. Patients with gallbladder cancer or metastatic bile duct obstruction were excluded. Data were grouped based on the number of biopsies taken: group A (one to three biopsies), group B (four to six biopsies), and group C (seven to ten biopsies). Results from each group were compared against a composite standard, including clinical follow-up and/or biopsies performed by alternative methods.

RESULTS

the group that underwent 4-6 biopsies had a sensitivity of 77.4 %, while the group with 7-10 biopsies had a sensitivity of 70.8 %. The group with 1-3 biopsies had a sensitivity of 34.5 %. Statistically significant differences were observed between the groups, with comparisons showing improved sensitivity in the 4-6 biopsy group versus the 1-3 biopsy group (χ² = 14.42, p = 0.0001), and the 7-10 biopsy group versus the 1-3 biopsy group (χ² = 6.56, p = 0.010).

CONCLUSIONS

performing four to six cholangioscopy-guided biopsies significantly improves sensitivity for diagnosing perihilar cholangiocarcinoma compared to one to three biopsies. Further studies are needed to validate these findings.

Clinical Outcomes and Safety of Upper Endoscopy While on Glucagon-Like Peptide-1 Receptor Agonists

Glucose-like peptide-1-receptor agonists (GLP-1RAs) have become integral to the management of type 2 diabetes and obesity. GLP-1RAs work in part through delaying gastric emptying, raising concerns about retained gastric contents (RGC) during esophagogastroduodenoscopy (EGD).1 The American Society of Anesthesiologists currently recommends holding GLP-1RAs for 1 dosing cycle before elective procedures, however, the American Gastroenterological Association (AGA) advocates proceeding with endoscopy in asymptomatic patients adhering to standard perioperative protocols without medication withholding and suggests implementing a liquid diet the day before endoscopy in lieu of stopping the medication.2,3 This variability in recommendations stems largely from a lack of GLP-1RA outcomes data from which to draw evidence-based conclusions.

Role of Artificial Intelligence for Endoscopic Ultrasound

Endoscopic ultrasound (EUS) is widely used for the diagnosis of biliopancreatic and gastrointestinal tract diseases, but it is one of the most operator-dependent endoscopic techniques, requiring a long and complex learning curve. The role of artificial intelligence (AI) in EUS is growing as AI algorithms can assist in lesion detection and characterization by analyzing EUS images. Deep learning (DL) techniques, such as convolutional neural networks, have shown great potential for tumor identification; the application of AI models can increase the EUS diagnostic accuracy, provide faster diagnoses, and provide more information that can be helpful also for a training program.

Effects of Glucagon-Like Peptide-1 Receptor Agonists on Upper Gastrointestinal Endoscopy: A Meta-Analysis

BACKGROUND AND AIMS

Limited evidence exists regarding the impact of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on upper endoscopy. Therefore, a meta-analysis was conducted to comprehensively review the available evidence on this subject.

METHODS

A systematic bibliographic search was carried out until May 2024. Pooled estimates were analyzed using a random-effects model, with results presented as odds ratio (OR) and 95% confidence interval (CI). The primary outcome assessed was the rate of retained gastric content (RGC), while secondary outcomes included rates of aborted and repeated procedures, adverse event rate, and rates of aspiration.

RESULTS

This analysis included 13 studies involving a total of 84,065 patients. Patients receiving GLP-1RA therapy exhibited significantly higher rates of RGC (OR, 5.56; 95% CI, 3.35 to 9.23), a trend that was consistent among patients with diabetes (OR, 2.60; 95% CI, 2.23 to 3.02). Adjusted analysis, accounting for variables such as sex, age, body mass index, diabetes, and other therapies, confirmed the elevated rates of RGC in the GLP-1RA user group (adjusted OR, 4.20; 95% CI, 3.42 to 5.15). Furthermore, rates of aborted and repeated procedures were higher in the GLP-1RA user group (OR, 5.13; 95% CI, 3.01 to 8.75; and OR, 2.19; 95% CI, 1.43 to 3.35; respectively). However, no significant differences were found in AE and aspiration rates between the 2 groups (OR, 4.04; 95% CI, 0.63 to 26.03; and OR, 1.75; 95% CI, 0.64 to 4.77; respectively).

CONCLUSION

Use of GLP-1RAs is associated with increased retention of gastric contents and more frequent aborted procedures during upper endoscopy. However, the adverse event and aspiration rates do not seem different; therefore, adjusting fasting time instead of routinely withholding GLP-1RAs could be reasonable in these patients.

Aspiration risk and strategic approach for patients receiving GLP-1 receptor agonists undergoing elective surgery

Perioperative management of patients receiving a glucagon-like peptide-1 receptor agonist (GLP-1 RA) remains challenging for the anesthesiologist. Despite the approval of GLP-1 RAs 2 decades ago, the recent reports of aspiration and postoperative pulmonary complications drew attention to this group of medications and resulted in multiple societal guidelines that would provide recommendations for anesthesiologists and proceduralists on the appropriate perioperative management of GLP-1 RAs. However, despite these guidelines and proposed options, there was a lack of adequate evidence to support holding versus continuing the medication, as well as data related to the role of gastric ultrasound in that decision-making process. The release of multiple societal guidelines and studies evaluating the impact of GLP-1 RAs on perioperative outcomes resulted in more controversy and uncertainty for the clinician anesthesiologist to follow. The ultimate goal for perioperative management of these medications is to evaluate an individual patient's risk of aspiration, rather than assuming the risk is low when holding the medication appropriately or high if not holding it. Furthermore, it is unclear whether holding these types of medicines or unnecessary postponing of surgery may result in adverse outcomes. In this narrative review, we present a summary of the existing literature on the topic with a focus on the risk of aspiration and a recommendation for perioperative management to include the utilization of gastric ultrasound for surgery patients based on their risks.

Association of Perioperative Glucagon-like Peptide-1 Receptor Agonist Use and Postoperative Outcomes

OBJECTIVE

To assess rates of surgical complications and postoperative readmission in diabetic patients with and without active perioperative prescriptions for glucagon-like peptide-1 receptor agonist (GLP-1 RA) medications.

BACKGROUND

With the rapid growth of GLP-1 RA use in the United States, it is important to understand the potential effect of these drugs on surgical outcomes broadly.

METHODS

In this retrospective, observational cohort analysis, patients with a diagnosis of type 1 or type 2 diabetes undergoing a surgical procedure at a multicenter quaternary-care health care system between February 2020 and July 2023 were included. Propensity score matching was performed between procedures in patients with and without an active GLP-1 RA prescription. The primary outcome was 30-day readmission, and secondary outcomes were documented dehiscence, infection, hematoma, and bleeding within 180 days after surgery.

RESULTS

Among 74,425 surgical procedures in 21,772 patients included in the analysis, 27.2% were performed in the setting of an active GLP-1 RA prescription. In 13,129 patients [48.0% men, 52.0% women; median (interquartile range) age, 67 (57, 75)], 35,020 procedures were propensity score matched. After matching, the active GLP-1 RA prescription group had a significantly reduced risk of 30-day readmission [relative risk (RR): 0.883; 95% CI: 0.789-0.987; P = 0.028; number needed to treat (NNT): 219; 95% CI: 191-257], postoperative wound dehiscence (RR: 0.711; 95% CI: 0.577-0.877; P = 0.001; NNT: 266; 95% CI: 202-391), and postoperative hematoma (RR: 0.440; 95% CI: 0.216-0.894; P = 0.023; NNT: 1786; 95% CI: 652-2416). No significant differences were seen in rates of infection and bleeding.

CONCLUSIONS

An active perioperative GLP-1 RA prescription in patients with diabetes was associated with significant reductions in risk-adjusted readmission, wound dehiscence, and hematoma, and no difference in infection and bleeding rates. Further study is warranted to elucidate any causal association.

Side-by-side versus stent-in-stent technique for stent deployment during systemic chemotherapy in biliary tract cancer patients with malignant hilar biliary obstruction

Objectives

With the improved prognosis of patients with biliary tract cancer (BTC) owing to advances in chemotherapy, long-term stent patency has become an important goal in patients undergoing biliary stent placement. We compared the duration of stent patency between unresectable BTC patients undergoing multi-stenting for malignant hilar biliary obstruction by the side-by-side (SBS) and stent-in-stent (SIS) techniques during systemic chemotherapy.

Methods

We retrospectively evaluated the data of 62 unresectable BTC patients who underwent multi-stenting before the first or second cycle of first-line chemotherapy. Stent deployment was performed by the SBS technique in 40 patients (SBS group) and by the SIS technique in 22 patients (SIS group).

Results

The median time-to-recurrent biliary obstruction was 147 days in the SBS group and 252 days in the SIS (p = 0.029), being longer in the SIS group. The rates of development of early adverse events were 28% and 9% (p = 0.09) and the rates of development of late adverse events were 26% and 14% in the SBS and SIS groups (p = 0.27). The median overall survival was 480 days in the SBS group and 563 days in the SIS group (p = 0.92).

Conclusion

The duration of stent patency was shorter in the SBS group than in the SIS group; thus, the SIS technique is preferable to the SBS technique for biliary stent deployment in unresectable BTC patients during systemic chemotherapy.

Exploring the lived experiences of adults using home enteral nutrition and their caregivers: A meta-aggregation qualitative systematic review

Home enteral nutrition (HEN) provides nutrition through a tube to individuals at home who cannot meet their needs by mouth. Systematic reviews have explored the experiences of HEN subpopulations, such as those with head and neck cancers. Given HEN services care for adults with various underlying conditions, a synthesis of the experiences of all adults using HEN and their caregivers is warranted. The purpose of this study is to summarize the experiences of HEN adult users and their caregivers regardless of underlying condition. Medline, PsychINFO, EmBase and CINAHL were systematically searched in January 2024. Studies with qualitative results and adult participants and focused on HEN were included. Studies with participants in nursing facilities, results using word counts, or not in English were excluded. Study quality was assessed using the Johanna Briggs Institute (JBI) qualitative checklist. Study design and participants' details were extracted. Themes were collated using the JBI meta-aggregative method. Forty studies (n = 732) were included. Three synthesized findings were identified: positive experiences (very low ConQual score), negative experiences (low ConQual score), and facilitators and coping mechanisms (moderate ConQual score). Although more negative than positive experiences were reported, users and caregivers who developed coping mechanisms or accessed supports viewed HEN as a worthwhile experience. Those with few supports or coping mechanisms did not. Based on this review, it is proposed that before starting HEN, users and caregivers should be made aware of the available supports and coping mechanisms. As negative experiences arise, healthcare providers should help users and caregivers access supports to improve their experiences.

Efficacy and safety of a novel polytetrafluoroethylene-coated self-expandable metal stent for distal malignant biliary obstruction

Background

Stent migration and sludge formation remain significant problems associated with covered self-expandable metal stents (CSEMSs). The EGIS biliary stent fully covered flare type (EGIS biliary stent), a new type of polytetrafluoroethylene-coated self-expandable metal stent with low axial force and an anti-migration system, was developed to overcome these disadvantages. We conducted this study to evaluate the efficacy and safety of this stent in comparison with conventional CSEMS (c-CSEMS).

Methods

We retrospectively analyzed consecutive patients with unresectable pancreatic cancer who received initial CSEMS for distal malignant biliary obstruction. The primary outcome was time to recurrent biliary obstruction (RBO). Secondary outcomes included technical success rate, functional success rate, stent-related adverse events, causes of RBO, and re-intervention.

Results

A total of 40 patients were included (EGIS group: 20; c-CSEMS group: 20). The technical and functional success rates were similar between the two groups. Stent-related adverse event rates (20% vs. 15%, p > 0.99) and overall RBO rates (56% vs. 50%, p > 0.99) were not significantly different between the two groups. Stent migration was the most common cause of RBO in the EGIS group, while stent occlusion was in the c-CSEMS group. The median time to RBO (102 vs. 434 days, p = 0.10) was not significantly different between the two groups. Endoscopic transpapillary re-intervention was successful in most patients in both groups.

Conclusions

The EGIS biliary stent was not associated with a longer time to RBO compared to c-CSEMS. Further improvements, especially against stent migration, are needed to improve its efficacy.

Glucagon-Like Peptide-1 Receptor Agonists Do Not Increase Aspiration During Upper Endoscopy in Patients With Diabetes

BACKGROUND & AIMS

Glucagon-like peptide-1-receptor agonists (GLP1-RAs) have been associated with greater retention of gastric contents, however, there is minimal controlled, population-based data evaluating the potential adverse effects of GLP1-RA in the periprocedural setting. We aimed to determine if there is increased risk of aspiration and aspiration-related complications after upper endoscopy in patients using GLP1-RAs.

METHODS

We used a nationwide commercial administrative claims database to conduct a retrospective cohort study of patients aged 18 to 64 with type 2 diabetes who underwent outpatient upper endoscopy from 2005 to 2021. We identified 6,806,046 unique upper endoscopy procedures. We compared claims for aspiration and associated pulmonary adverse events in the 14 days after upper endoscopy between users of GLP1-RAs, dipeptidyl peptidase 4 inhibitors (DPP4is), and chronic opioids. We adjusted for age, sex, Charlson Comorbidity score, underlying respiratory disease, and gastroparesis.

RESULTS

We found that pulmonary adverse events after upper endoscopy are rare, ranging from 6 to 25 events per 10,000 procedures. When comparing GLP1-RAs with DPP4i, crude relative risks of aspiration (0.67; 95% CI, 0.25-1.75), aspiration pneumonia (0.95; 95% CI, 0.40-2.29), pneumonia (1.07; 95% CI, 0.62-1.86), or respiratory failure (0.75; 95% CI, 0.38-1.48) were not higher in patients prescribed a GLP1-RA. When comparing GLP1-RAs with opioids, crude relative risks were 0.42 (95% CI, 0.15-1.16) for aspiration, 0.60 (95% CI, 0.24-1.52) for aspiration pneumonia, 0.30 (95% CI, 0.19-0.49) for pneumonia, and 0.24 (95% CI, 0.13-0.45) for respiratory failure. These results were consistent across several sensitivity analyses.

CONCLUSIONS

GLP1-RA use is not associated with an increased risk of pulmonary complications after upper endoscopy compared with DPP4i use in patients with type 2 diabetes.

Endoscopic ultrasonography guided gallbladder drainage: "how and when"

INTRODUCTION

EUS-guided gallbladder drainage (EUS-GBD) is recognized as an effective minimally invasive alternative technique mainly in managing patients with acute cholecystitis not eligible for cholecystectomy and, more recently, for jaundice relief in inoperable patients with distant malignant biliary obstruction.

AREAS COVERED

This review provides an extensive guide to the actual role of EUS-GBD. A comprehensive search was conducted, including articles pertinent to this review's aims. It explored technical aspects and discussed clinical scenarios most suitable for this procedure compared to other traditional drainage methods (percutaneous or endoscopic transpapillary gallbladder drainage). Moreover, the introduction of lumen-apposing metal stents (LAMS) has enhanced EUS-GBD by adding the possibility of direct gallbladder inspection and treatment of stones. The indications for performing EUS-GBD have become wider, and several robust studies described the high technical and clinical success rate with an optimal safety profile.

EXPERT OPINION

For optimal EUS-GBD outcomes, a standardized technique and an accurate selection of patients are crucial and should benefit from a multidisciplinary team decision. Still, future efforts are required for more prospective studies to standardize clinical indications, clarify post-procedural management, and acquire new data on long-term follow-up.

Efficacy of Intragastric Balloon Treatment: Outcomes and Patient Satisfaction 6 Months After Removal

Background and Objectives: This study aimed to investigate the weight loss, changes in eating habits, and satisfaction with the intragastric balloon (IGB) procedure in patients undergoing treatment for obesity, with follow-up until 6 months after IGB removal. Materials and Methods: This study included patients who underwent the IGB procedure between January 2020 and September 2024 at our clinic and were followed-up for 6 months after IGB removal. Patient records were retrieved from the endoscopy database. Parameters before IGB and during IGB removal were obtained from these records. Upon obtaining verbal consent from patients contacted via their registered phone numbers, their self-reported weights 6 months after IGB removal were recorded, and their body mass index (BMI) was calculated. During the same interview, patients were asked about their eating habits before IGB and 6 months after IGB removal, as well as their satisfaction with the procedure, based on questionnaires used in previous studies. The data collected included patients' age, sex, weight, BMI, percentages of weight and BMI loss at IGB removal and 6 months after IGB removal, duration of IGB placement, maximum weight lost during IGB placement, time to achieve maximum weight lost, changes in eating habits, and satisfaction levels. Results: The mean age of the 62 patients who were included in this study was 33.24 ± 8.71 years, with 37 (59.67%) women and 25 (40.32%) men. The mean weight of the patients before IGB was 91.58 ± 7.04 kg, and the mean BMI was 32.00 ± 4.25 kg/m2. The mean duration of IGB placement was 5.83 ± 0.41 months, with a mean maximum weight loss of 14.22 ± 4.70 kg and a mean time to achieve weight loss of 3.91 ± 0.91 months. There was a statistically significant difference between the weight before the IGB and the weight at IGB removal (p < 0.001). A significant difference was also noted in the weight before the IGB and 6 months after IGB removal (p < 0.001). The comparison of satisfaction levels showed no statistically significant difference in eating habits before the IGB (p = 0.384), whereas a significant difference was found in eating habits 6 months after IGB removal (p < 0.001). The weight loss differences between the satisfied and dissatisfied patients were significant at IGB removal and 6 months after, although no statistical difference was found in the pre-IGB weights between the satisfied and dissatisfied patients (p < 0.001). Conclusions: Patients undergoing the IGB procedure for obesity should correct their poor eating habits to maintain successful mid-term weight loss results.

A narrative review of glucagon-like peptide-1 receptor agonists prior to deep sedation or general anesthesia

Glucagon-like peptide-1 receptor agonists are a class of drugs that mimic a natural incretin hormone released by the intestine after meals, and they are well-suited for treating type 2 diabetes. Glucagon-like peptide-1 receptor agonists also lead to satiety and appetite reduction through action on the brain's appetite regulation centers, leading to weight loss in obese patients. However, because glucagon-like peptide-1 receptor agonists work to slow gastric emptying, a safety concern has been raised in patients undergoing deep sedation or general anesthesia regarding gastric aspiration, and considering their long half-life in the blood, they are difficult to manage in the perioperative period. The purpose of this review is (i) to explore the present knowledge about the risk of aspiration before anesthesia; (ii) to describe the method for evaluating the presence of liquid and food in the stomach before surgery; and (iii) to balance the actual warning with the opportunity for future discovery about their benefits.

The effects of endoscopic vacuum therapy for non-operative treatment of anastomotic leakage on oncological outcomes in rectal cancer patients

PURPOSE

Rectal resection has remained the cornerstone in curative treatment of rectal cancer. This however, implies the risk of anastomotic leakage leading to morbidity, mortality and potentially disease progression. Endoscopic vacuum therapy (EVT) has emerged as a promising tool in leakage therapy in order to avoid reoperation and Hartman resection. However, its clinical efficacy and its potential effect on oncological outcomes still requires further research.

METHODS

In this retrospective single-centre cohort study, we analysed all consecutive patients undergoing rectal resection for rectal cancer during 2012-2021. The incidence and management of anastomotic leakage and its effects on long-term oncological outcomes were analysed.

RESULTS

A total of 334 patients underwent rectal resection of whom 47 patients (14.1%) developed postoperative anastomotic leakage. Non-operative leakage treatment (NOLT) was successful in in 76.9% of which EVT was the most efficient (90.0% success) while reoperation was successful in 52.4% (p = 0.073). The more frequent application of EVT increased the NOLT rate from 48.3 to 66.7% during the observation period (p = 0.176). Concerning long-term outcomes, no differences in disease-free survival (p = 0.657) nor patient survival (p = 0.295) could be determined.

CONCLUSION

EVT is an effective treatment option for anastomotic leakage after rectal resection. EVT enables NOLT in the majority of cases. However, there might be no impact on oncological outcomes.

Efficacy of water infusion combined with defoamers in colonoscopy

BACKGROUND

Currently, colonoscopy still needs continuous optimization and exploration of novel alternative approaches to enhance the experience of patients during colonoscopy.

AIM

To analyze the efficacy of water infusion combined with defoamers in colonoscopy.

METHODS

This study included 97 patients undergoing colonoscopy from January 2024 to June 2024. The participants were categorized into two groups, namely, the control group (n = 47), who underwent conventional colonoscopy, and the experimental group (n = 50), who received colonoscopy using water injection combined with defoamers. A comparative analysis was then conducted on the disease detection rate (colonic polyps, colonorrhagia, colonic ulcers, colonic mucosal lesions, and others), colonoscopy duration, abdominal pain [visual analog scale (VAS)], Boston bowel preparation scale (BBPS), self-rating anxiety scale (SAS), bowel preparation comfort, complications (intestinal perforation, bleeding, nausea and vomiting, abdominal pain, and abdominal distension), and patient satisfaction.

RESULTS

The experimental group demonstrated a significantly higher total disease detection rate, BBPS scores, and patient satisfaction compared with the control group. Further, the research group exhibited shorter colonoscopy duration, lower VAS and SAS scores and total complication rate, and better patient comfort and satisfaction.

CONCLUSION

These results indicate that the combination of water injection and defoamers exhibited an overall better therapeutic effect than conventional colonoscopy, mainly reflected in higher disease detection rate, faster examination efficiency, lower abdominal pain, anxiety, and complication incidences, and significantly better bowel preparation, comfort, and patient satisfaction.