Technical tips for EUS-guided embolization of varices and pseudoaneurysms

Backgrounds and Aims

EUS-guided vascular intervention has expanded the horizons of diagnostic as well as therapeutic interventions for vascular pathology. EUS-guided embolization is a commonly performed technique for the treatment of gastric varices. However, there is a lack of data on the standardization of the technique. Here, we review the techniques and difficulties encountered during EUS-guided embolization of varices and pseudoaneurysms.

Methods

This article and accompanying video describe the EUS-guided embolization techniques for various vascular lesions. EUS-guided embolization was achieved by combination therapy using coils and cyanoacrylate. Complete obliteration of the lesions was documented on follow-up. The existing literature of EUS-guided embolization therapy is also reviewed.

Results

Patients with various vascular lesions, including gastric varices, ectopic duodenal varices, and splenic artery pseudoaneurysms, were successfully treated with EUS-guided coil plus cyanoacrylate injection. Patients with gastric varices underwent treatment with 2 EUS-guided techniques: (1) direct puncture of the varix and embolization and (2) feeder vessel embolization. Following embolization, the absence of Doppler flow within the varix and pseudoaneurysm was documented.

Conclusions

Techniques of EUS-guided embolization of varices and pseudoaneurysms are demonstrated. Understanding the techniques and the challenges encountered during therapy is crucial to optimize outcomes and reduce adverse events.

The activation of HAMP promotes colorectal cancer cell proliferation through zinc-mediated upregulation of SMAD4 expression

Background

Colorectal cancer (CRC) poses a significant challenge in digestive system diseases, and emerging evidence underscores the critical role of zinc metabolism in its progression. This study aimed to investigate the clinical implications of genes at the intersection of zinc metabolism and CRC.

Methods

We downloaded CRC prognosis-related genes and zinc metabolism-related genes from public databases. Then, the overlapping genes were screened out, and bioinformatics analysis was performed to obtain the hub gene associated with CRC prognosis. Subsequently, in vitro assays were carried out to investigate the expression of this hub gene and its exact mechanism between zinc metabolism and CRC.

Results

HAMP was identified as the hub CRC prognostic gene from overlapping zinc metabolism-related and CRC prognostic genes. In vitro analysis showed HAMP was over-expressed in CRC, and its knockdown inhibited RKO and HCT-116 cell invasion and migration significantly. ZnSO4 induced HAMP up-regulation to promote cell proliferation, while TPEN decreased HAMP expression to inhibit cell proliferation. Importantly, we further found that ZnSO4 enhanced SMAD4 expression to augment HAMP promoter activity and promote cell proliferation in CRC.

Conclusions

HAMP stands out as an independent prognostic factor in CRC, representing a potential therapeutic target. Its intricate regulation by zinc, particularly through the modulation of SMAD4, unveils a novel avenue for understanding CRC biology. This study provides valuable insights into the interplay between zinc metabolism, HAMP, and CRC, offering promising clinical indicators for CRC patients. The findings present a compelling case for further exploration and development of targeted therapeutic strategies in CRC management.

Hepatic subcapsular hematoma: A rare complication post-ERCP; a case report

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used in gastroenterology wards for both diagnostic and therapeutic purposes. It doesn't however come free of complications. As a matter of fact, complications are reported in up to 10% of patients undergoing ERCP.

PATIENT CONCERNS

In this article, we report the case of a patient who underwent ERCP and sphincterotomy for choledocholithiasis. Twenty-four hours after the procedure, the patient developed sudden sharp abdominal pain and dropped her hemoglobin levels.

DIAGNOSIS

An emergent gastroscopy was done and it ruled out bleeding from the sphincterotomy. Computed tomography of the abdomen showed a large hepatic subcapsular hematoma.

INTERVENTIONS

Blood was urgently transfused and the patient was transferred to the intensive care unit for monitoring.

OUTCOMES

The patient's condition quickly deteriorated despite extensive resuscitative measures, and eventually passed away on day 4 post ERCP.

LESSONS

Hepatic subcapsular hematoma is a very rare but fatal complication after ERCP and should be ruled out in patients who underwent the procedure and develop sudden abdominal pain with hemodynamic and laboratory instability.

Feasibility and clinical value of linear endoscopic ultrasonography imaging in the lower gastrointestinal subepithelial lesions

Linear endoscopic ultrasonography (EUS) has been extensively utilized as a novel diagnostic and therapeutic modality across various fields. However, there have been relatively few studies focusing on lower gastrointestinal lesions. The aim of our study was to investigate the feasibility, safety and clinical value of linear EUS in the lower gastrointestinal subepithelial lesions. This was a retrospective study involving patients with lower gastrointestinal subepithelial lesions diagnosed by linear EUS from August 2019 to April 2023 at the Second Affiliated Hospital of Anhui Medical University. The data, including basic clinical information, linear EUS features, technical success rate, complications, and follow-up, were retrospectively collected and analyzed. A total of 69 patients with lower gastrointestinal subepithelial lesions underwent examination by linear EUS. Excluding the rectum, the technical success rate of linear EUS was 90.6% (29/32). Apart from the 7 patients whose diagnosis remained unknown, 3 patients with no abnormal EUS findings, and 3 patients failed the procedure, 56 patients were included in the final diagnostic performance analysis. The most common locations of the lesions were the rectum (37/56, 66.1%) and sigmoid colon (7/56, 12.5%). Based on endoscopy findings and pathological results, the most prevalent types of subepithelial lesions in the lower gastrointestinal tract were neuroendocrine tumor (NET) (12/56, 20.3%), lipoma (8/56, 13.6%) and extraluminal compression (8/56, 13.6%). The majority of lesions ranged in diameter from 1 to 3 cm (χ2 = 18.750, p < 0.001). After undergoing linear EUS examination, 36 patients received EUS-FNA (3/36), biopsy (5/36), endoscopic resection (25/36), or surgical excision (3/36) respectively. The pathological results of 29 patients were entirely consistent with the diagnosis made using linear EUS, with an 80.6% (29/36) diagnostic accuracy rate. Follow-up indicated that the lesions remained unchanged within 6-36 months. All patients tolerated the procedure well without any complications. In conclusion, linear EUS demonstrates technical feasibility, safety, and a high diagnostic accuracy for subepithelial lesions in the lower gastrointestinal tract.

Investigating the mortality trend of gastrointestinal cancers in Babol, North Iran (2013-2021)

BACKGROUND AND AIM

This study aims to examine the mortality rate and trend of gastrointestinal cancers, particularly gastric cancer, as the leading cause of death among cancers in northern Iran over a 9-year period. In light of the changing incidence and mortality rates of cancer in Iran and around the world, the importance of these diseases in people's lives, and the necessity of updating and monitoring the trend of cancer mortality, we have decided to report on the mortality trend of gastrointestinal cancers, based on crude and age-standardized rates.

METHOD

This study is a cross-sectional examination of deaths caused by gastrointestinal cancers in Babol city, Iran, between 2013 and 2021. Data was collected from the cause of death registration and classification system of Babol University of Medical Sciences. Population estimation was obtained from the latest census reports. The crude and age-standardized mortality rates and trends of the cancers were calculated.

RESULTS

Overall, there were 1345 deaths from gastrointestinal cancers with an average age of 69.11 ± 14.25 years. The crude and age-standardized rates of these cancers rose from 24.1 to 20.1 per hundred thousand people in 2012 to 29.5 and 25.5 per hundred thousand people, respectively. This trend became more prevalent significantly with the increase of each decade of age for both men (P-value Trend = 0.002) and women (P-value Trend = 0.012). An analysis of gastrointestinal cancers revealed a decreasing trend for cancers of the small intestine, an increasing trend for cancers of the colon, pancreas, and gallbladder, and a stable trend for the remaining cancers over the study period.

CONCLUSION

The age-standardized rate and the number of gastrointestinal cancers is rising, highlighting the importance of preventative measures such as screening, increasing public awareness, and appropriate diagnostic methods.

Comparing clinical outcomes of peroral endoscopic myotomy for achalasia between Eastern and Western countries: a systematic review and meta-analysis

Peroral endoscopic myotomy (POEM) has revolutionized the therapeutic strategy for achalasia with promising results. We conducted this meta-analysis to compare clinical outcomes between Eastern and Western countries. A comprehensive literature search was conducted in PubMed, EMBASE, Web of Science and Cochrane Library databases to query for studies that assessed the efficacy of POEM for achalasia. All articles published from inception to December 31, 2021 were included. The primary outcome was the pooled clinical success rate. The secondary outcomes included the pooled technical success rate, incidence of adverse events, procedure time and hospital stay. Eighteen Eastern studies involving 5962 patients and 11 Western studies involving 1651 patients were included. The pooled clinical success rate and technical success rate for POEM was equal in the Eastern studies compared to Western studies. The pooled incidence of procedure adverse events for POEM was a little lower in the Eastern studies compared to Western studies (6.6% vs. 8.7%). Similarly, the incidence of reflux-related adverse events was lower in Eastern studies than that in Western studies. The pooled procedure time of POEM was shorter in Eastern studies compared to Western studies (61 minutes vs. 80 minutes), while the length of hospital stay was longer in Eastern studies compared to Western studies (5.8 days vs. 2.4 days). Overall, Eastern countries have the similar POEM outcomes compared to Western countries. However, Eastern countries still need to do more to reduce the length of hospital stay.

Surgical and per-oral endoscopic myotomy (POEM) for the treatment of primary esophageal motility disorders: A systematic analysis of current trends in Germany between 2011 and 2019

BACKGROUND/AIMS

While surgery remains a standard treatment for primary esophageal motility disorders (PEMDs), per-oral endoscopic myotomy (POEM) has recently evolved as an alternative. Systematic data on current trends of invasive procedures for PEMDs in Germany are missing.

METHODS

Hospital discharge data were used to evaluate trends and mortality of invasive treatment options for PEMDs in Germany between 2011 and 2019.

RESULTS

4543 cases of PEMDs (achalasia: n = 4349, dyskinesia of the esophagus: n = 194) receiving open surgery (n = 200), minimal invasive surgery (n = 2366), or POEM (n = 1977) were identified. The relative proportion of POEM significantly increased from 10.9% (2011) to 65.7% (2019). Hospital mortality was 0.2%. The median duration of mechanical ventilation was significantly lower in POEM patients (29.4 hours) compared to open (274.0 hours) or minimal invasive (91.9 hours) surgery. The duration of hospitalization was lowest among POEM patients (5.7 days) compared to surgical procedures (13.7 and 7.7 days).

CONCLUSION

While the low in-hospital mortality of all procedures combined confirms the solid safety profile of invasive procedures in general, our findings show that POEM has the lowest duration of mechanical ventilation and hospitalization compared to invasive surgical options.

Safety and efficacy of modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension

BACKGROUND

Gastric variceal hemorrhage is one of the primary manifestations of left-sided portal hypertension (LSPH). The hemorrhage is fatal and requires safe and effective interventions.

AIM

To evaluate the clinical safety and efficacy of modified endoscopic ultrasound (EUS)-guided selective N-butyl-2-cyanoacrylate (NBC) injections for gastric variceal hemorrhage in LSPH.

METHODS

A retrospective observational study of patients with LSPH-induced gastric variceal hemorrhage was conducted. Preoperative EUS evaluations were performed. Enrolled patients were divided into modified and conventional groups according to the NBC injection technique. The final selection of NBC injection technique depended on the patients' preferences and clinical status. The technical and clinical success rates, operation time, NBC doses, perioperative complications, postoperative hospital stay, and recurrent bleeding rates were analyzed, respectively.

RESULTS

A total of 27 patients were enrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. In comparison to patients in the conventional group, patients in the modified group demonstrated significantly reduced NBC doses (2.0 ± 0.6 mL vs 3.1 ± 1.0 mL; P = 0.004) and increased endoscopic operation time (71.9 ± 11.9 min vs 22.5 ± 6.7 min; P < 0.001). Meanwhile, the two groups had no significant difference in the technical and clinical success rates, perioperative complications, postoperative hospital stay, and recurrent bleeding rates.

CONCLUSION

Modified EUS-guided selective NBC injections demonstrated safety and efficacy for LSPH-induced gastric variceal hemorrhage, with advantages of reduced injection dose and no radiation risk. Drawbacks were time consumption and technical challenge.

Safety and efficacy of modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension

BACKGROUND

Gastric variceal hemorrhage is one of the primary manifestations of left-sided portal hypertension (LSPH). The hemorrhage is fatal and requires safe and effective interventions.

AIM

To evaluate the clinical safety and efficacy of modified endoscopic ultrasound (EUS)-guided selective N-butyl-2-cyanoacrylate (NBC) injections for gastric variceal hemorrhage in LSPH.

METHODS

A retrospective observational study of patients with LSPH-induced gastric variceal hemorrhage was conducted. Preoperative EUS evaluations were performed. Enrolled patients were divided into modified and conventional groups according to the NBC injection technique. The final selection of NBC injection technique depended on the patients' preferences and clinical status. The technical and clinical success rates, operation time, NBC doses, perioperative complications, postoperative hospital stay, and recurrent bleeding rates were analyzed, respectively.

RESULTS

A total of 27 patients were enrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. In comparison to patients in the conventional group, patients in the modified group demonstrated significantly reduced NBC doses (2.0 ± 0.6 mL vs 3.1 ± 1.0 mL; P = 0.004) and increased endoscopic operation time (71.9 ± 11.9 min vs 22.5 ± 6.7 min; P < 0.001). Meanwhile, the two groups had no significant difference in the technical and clinical success rates, perioperative complications, postoperative hospital stay, and recurrent bleeding rates.

CONCLUSION

Modified EUS-guided selective NBC injections demonstrated safety and efficacy for LSPH-induced gastric variceal hemorrhage, with advantages of reduced injection dose and no radiation risk. Drawbacks were time consumption and technical challenge.

Use of Artificial Intelligence in the Diagnosis of Colorectal Cancer

Colorectal cancer (CRC) is one of the most common forms of cancer. Therefore, diagnosing the condition early and accurately is critical for improved patient outcomes and effective treatment. Recently, artificial intelligence (AI) algorithms such as support vector machine (SVM) and convolutional neural network (CNN) have demonstrated promise in medical image analysis. This paper, conducted from a systematic review perspective, aimed to determine the effectiveness of AI integration in CRC diagnosis, emphasizing accuracy, sensitivity, and specificity. From a methodological perspective, articles that were included were those that had been conducted in the past decade. Also, the articles needed to have been documented in English, with databases such as Embase, PubMed, and Google Scholar used to obtain relevant research studies. Similarly, keywords were used to arrive at relevant articles. These keywords included AI, CRC, specificity, sensitivity, accuracy, efficacy, effectiveness, disease diagnosis, screening, machine learning, area under the curve (AUC), and deep learning. From the results, most scholarly studies contend that AI is superior in medical image analysis, the development of subtle patterns, and decision support. However, while deploying these algorithms, a key theme is that the collaboration between medical experts and AI systems needs to be seamless. In addition, the AI algorithms ought to be refined continuously in the current world of big data and ensure that they undergo rigorous validation to provide more informed decision-making for or against adopting those AI tools in clinical settings. In conclusion, therefore, balancing between human expertise and technological innovation is likely to pave the way for the realization of AI's full potential concerning its promising role in improving CRC diagnosis, upon which there might be significant patient outcome improvements, disease detection, and the achievement of a more effective healthcare system.

The impact of COVID-19 on hospitalizations that underwent endoscopic retrograde cholangiopancreatography in the United States

BACKGROUND/OBJECTIVES

COVID-19 impacts technical success of endoscopic retrograde cholangiopancreatography (ERCP). In this study, we aimed to assess the influence of COVID-19 on hospitalizations that underwent ERCP.

METHODS

We identified all adult COVID-19 and non-COVID-19 hospitalizations that underwent ERCP in the United States using the National Inpatient Sample for 2020. Hospitalization characteristics, clinical outcomes, and complications were compared between the two groups.

RESULTS

In 2020, 2015 COVID-19 and 203,094 non-COVID-19 hospitalizations underwent ERCP. The COVID-19 cohort had a higher mean age (60.3 vs 55.6 years, p < 0.001) and a higher proportion of Blacks and Hispanics compared to the non-COVID-19 cohort. After adjusting for confounders, the COVID-19 cohort had higher all-cause inpatient mortality (4.77 vs 1.45%, aOR 4.09, 95% CI 2.50-6.69, p < 0.001), mean length of stay (LOS) [10.19 vs 5.94 days, mean difference: 3.88, 95% CI 2.68-5.07, p < 0.001] and mean total hospital charges (THC) [$152,933 vs $96,398, mean difference: 46,367, 95% CI 21,776-70,957, p < 0.001] compared to the non-COVID-19 cohort. Increasing age, higher Charlson Comorbidity Index, and post-ERCP pancreatitis were identified to be independent predictors of inpatient mortality for COVID-19 hospitalizations that underwent ERCP. Furthermore, the COVID-19 cohort had higher odds of developing post-ERCP pancreatitis (PEP) (11.55 vs 7.05%, aOR 1.64, 95% CI 1.19-2.25, p = 0.002) compared to the non-COVID-19 cohort, after adjusting for confounders. However, there was no statistical difference in the rates of bowel perforations and post-ERCP hemorrhage between the two groups.

CONCLUSION

COVID-19 hospitalizations that underwent ERCP had higher inpatient mortality, mean LOS, mean THC, and odds of developing PEP compared to the non-COVID-19 cohort.

CLINICAL TRIAL REGISTRATION

This study is not a part of a clinical trial.

Determining the Risk Factors of Complications Due to Endoscopic Retrograde Cholangiopancreatography

Background and objective The effective use of endoscopic retrograde cholangiopancreatography (ERCP) has been on the rise in diagnosing and treating benign and malignant pathologies of the common bile duct and pancreas. ERCP, a complex procedure requiring high knowledge, skills, and practice, differs from other endoscopic applications as it involves the use of different techniques and equipment and the occurrence of more complications. The most commonly observed complications of ERCP are pancreatitis, bleeding, perforation, and infections. In this study, we aimed to assess the incidence of post-ERCP complications to identify the associated risk factors and indications. Methodology In this study, 181 ERCP procedures performed on 122 consecutive patients in the endoscopy unit of Istanbul Training Hospital were prospectively evaluated by using an observational method to determine the frequency of and risk factors for post-ERCP complications. The patients were followed up in the course of the ERCP procedure and for 30 days after the procedure; the complications and clinical developments were recorded. Results The mean age of the cohort was 59.7 ± 17.7 (19-97) years; 40.9% were female and 59.1% were male. The cannulation success was achieved in 77.3% of the ERCP procedure performed. Among the ERCP procedures applied, 89% were performed for therapeutic purposes, and choledocholithiasis (60.2%) was the most common indication for ERCP. Major complications were detected in 25.4% of the patients after ERCP. The most common major complication was cholangitis (9.9%), followed by pancreatitis (7.2%), cholecystitis (5.5%), bleeding (3.9%), and perforation (1.1%). It was observed that sphincterotomy was associated with an increase in all complications. The incidence of cholangitis decreased in the presence of dilated bile ducts unrelated to obstruction. The increased incidence of pancreatitis was associated with the female gender, the use of sphincterotomy and basket, inexperienced endoscopists, and inpatient admissions. The incidence of cholecystitis, on the other hand, was found to be linked with sphincterotomy and inexperienced endoscopists. Conclusions ERCP is a complex endoscopic procedure that requires high technical knowledge and skill and can cause serious complications. For endoscopists to perform clinically effective and accurate ERCP, it is important that they correctly determine the indications for the procedure, know its potential complications, and refrain from practices that will create complications and are unnecessary as much as possible.

Endoscopic ultrasound guided gastroenterostomy: Technical details updates, clinical outcomes, and adverse events

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has been transformed from an innovative technique, into a viable alternative to enteral stenting and surgical gastrointestinal anastomosis for patients with gastric outlet obstruction. Even EUS-GE guided ERCP and EUS-guided gastrointestinal anastomosis for the treatment of afferent loop syndrome have been performed, giving patients more less invasive options. However, EUS-GE is still a technically challenging procedure. In order to improve EUS-GE, several techniques have been reported to improve the technical details. With EUS-GE widely performed, more data about EUS-GE’s clinical outcomes have been reported. The aim of the current review is to describe technical details updates, clinical outcomes, and adverse events of EUS-GE.

Gastric varices

PURPOSE OF REVIEW

Gastric varices are a rare cause of gastrointestinal bleeding in patients with portal hypertension. There have been significantly advances within endoscopic ultrasound for treatment of gastric varices over the past 5 years in addition to the conventional endoscopic and endovascular therapies. In this review, we will review the latest literature on gastric varices with emphasis on changes to the conventional classification systems and comparisons among the different treatment options for gastric varices in terms of efficacy and safety.

RECENT FINDINGS

There have been new guidelines proposed by the American Gastrointestinal Association on a simpler classification system compared to the conventional Sarin classification. In addition, endoscopic ultrasound guided coil embolization, a novel treatment pioneered over the past 5 years for gastric varices, has shown increased efficacy and reduced adverse event profile compared to cyanoacrylate glue, the more traditional therapy for gastric variceal bleeding. Options for endovascular therapy overall have not significantly changed over the recent years.

SUMMARY

Based on our literature review, we recommend a step-up approach with initial medical and endoscopic management with consideration of endovascular therapies when initial therapies fail.

Artificial Intelligence and Lung Cancer: Impact on Improving Patient Outcomes

Lung cancer remains one of the leading causes of cancer-related deaths worldwide, emphasizing the need for improved diagnostic and treatment approaches. In recent years, the emergence of artificial intelligence (AI) has sparked considerable interest in its potential role in lung cancer. This review aims to provide an overview of the current state of AI applications in lung cancer screening, diagnosis, and treatment. AI algorithms like machine learning, deep learning, and radiomics have shown remarkable capabilities in the detection and characterization of lung nodules, thereby aiding in accurate lung cancer screening and diagnosis. These systems can analyze various imaging modalities, such as low-dose CT scans, PET-CT imaging, and even chest radiographs, accurately identifying suspicious nodules and facilitating timely intervention. AI models have exhibited promise in utilizing biomarkers and tumor markers as supplementary screening tools, effectively enhancing the specificity and accuracy of early detection. These models can accurately distinguish between benign and malignant lung nodules, assisting radiologists in making more accurate and informed diagnostic decisions. Additionally, AI algorithms hold the potential to integrate multiple imaging modalities and clinical data, providing a more comprehensive diagnostic assessment. By utilizing high-quality data, including patient demographics, clinical history, and genetic profiles, AI models can predict treatment responses and guide the selection of optimal therapies. Notably, these models have shown considerable success in predicting the likelihood of response and recurrence following targeted therapies and optimizing radiation therapy for lung cancer patients. Implementing these AI tools in clinical practice can aid in the early diagnosis and timely management of lung cancer and potentially improve outcomes, including the mortality and morbidity of the patients.

A Road Less Traveled: Endoscopic Retrograde Cholangiopancreatography in a Patient with Long-standing Achalasia and Sigmoid Esophagus

Endoscopic retrograde cholangiopancreatography in a patient with achalasia and sigmoid esophagus poses a unique technical challenge, as one must safely guide the side viewing duodenoscope across a severely distorted distal esophagus and non-relaxing lower esophageal sphincter. In such patients, the use of an overtube is a simple solution that allows the safe passage of a duodenoscope and the removal of common bile duct stones.

Evaluating the Effectiveness of a Modified Colorectal Cancer Screening Program in Almaty, Kazakhstan

OBJECTIVE

This study aimed to evaluate the effectiveness of a modified colorectal cancer (CRC) screening program, incorporating culturally tailored strategies to increase screening uptake and compliance, in Almaty, Kazakhstan.

METHODS

A cross-sectional study was conducted in Almaty between 2019-2022, involving 5370 participants aged 50-70 from diverse settings. Participants were assigned to the main (modified method) and comparison (standard method) groups based on the parity of their ID number digits. Variables of interest included demographics, somatic comorbidities, disability degree, and CRC screening results. The modified screening emphasized healthcare prioritization, optimized nursing resources, enhanced accessibility, and preparedness for the second screening stage.

RESULTS

In the study 2702 patients in the main group (modified method), and 2668 patients in the comparison group (standard method). Comorbidity data showed that the majority of participants in both groups had between 1-10 comorbidities, with an average of 8.2 in the main group and 8.1 in the comparison group. Screening response rates at stage I were higher in the main group, with 82.6% of subjects undergoing screening, compared to 78.9% in the comparison group (χ2=12.12, p=0.001). The response rates were higher among females in both groups, and no significant differences were found across age groups. At stage II, the response rate was again higher in the main group (56.2%) than in the comparison group (47.2%) (χ2=4.217, p=0.040), with no significant differences noted in relation to sex or age. However, the main group showed a higher response rate at stage I among respondents with 6-10 comorbidities (87.1% vs 82.5%, χ2 =7.820, p=0.009).

CONCLUSION

The study demonstrates that the modified program significantly outperformed the traditional one, achieving higher response rates at both the initial and subsequent stages of screening. These findings emphasize the value of revisiting and refining current CRC screening methods to maximize early detection rates.

A comprehensive survey of intestine histopathological image analysis using machine vision approaches

Colorectal Cancer (CRC) is currently one of the most common and deadly cancers. CRC is the third most common malignancy and the fourth leading cause of cancer death worldwide. It ranks as the second most frequent cause of cancer-related deaths in the United States and other developed countries. Histopathological images contain sufficient phenotypic information, they play an indispensable role in the diagnosis and treatment of CRC. In order to improve the objectivity and diagnostic efficiency for image analysis of intestinal histopathology, Computer-aided Diagnosis (CAD) methods based on machine learning (ML) are widely applied in image analysis of intestinal histopathology. In this investigation, we conduct a comprehensive study on recent ML-based methods for image analysis of intestinal histopathology. First, we discuss commonly used datasets from basic research studies with knowledge of intestinal histopathology relevant to medicine. Second, we introduce traditional ML methods commonly used in intestinal histopathology, as well as deep learning (DL) methods. Then, we provide a comprehensive review of the recent developments in ML methods for segmentation, classification, detection, and recognition, among others, for histopathological images of the intestine. Finally, the existing methods have been studied, and the application prospects of these methods in this field are given.

Up-to-date literature review and issues of sedation during digestive endoscopy

Sedation is common during digestive endoscopy to provide comfort and pain relief for patients. However, the use of sedation in endoscopy also poses potential risks, and recent issues have been raised regarding its safety and administration. This literature review paper will discuss the most recent developments in the field of sedation in digestive endoscopy, including the adverse events that might be associated with sedation and how to manage it, the legal issues associated with administration, the impact of COVID-19 on sedation practices, and sedation in special situations. It will also touch upon the current guidelines and recommendations for sedation, including the importance of patient selection and monitoring and the need for training and certification for endoscopists administering sedation. The review will also analyse studies evaluating the safety and efficacy of various sedation techniques, including propofol, midazolam, and others. It will examine the benefits and drawbacks of these agents.

MM-GLCM-CNN: A multi-scale and multi-level based GLCM-CNN for polyp classification

Distinguishing malignant from benign lesions has significant clinical impacts on both early detection and optimal management of those early detections. Convolutional neural network (CNN) has shown great potential in medical imaging applications due to its powerful feature learning capability. However, it is very challenging to obtain pathological ground truth, addition to collected in vivo medical images, to construct objective training labels for feature learning, leading to the difficulty of performing lesion diagnosis. This is contrary to the requirement that CNN algorithms need a large number of datasets for the training. To explore the ability to learn features from small pathologically-proven datasets for differentiation of malignant from benign polyps, we propose a Multi-scale and Multi-level based Gray-level Co-occurrence Matrix CNN (MM-GLCM-CNN). Specifically, instead of inputting the lesions' medical images, the GLCM, which characterizes the lesion heterogeneity in terms of image texture characteristics, is fed into the MM-GLCN-CNN model for the training. This aims to improve feature extraction by introducing multi-scale and multi-level analysis into the construction of lesion texture characteristic descriptors (LTCDs). To learn and fuse multiple sets of LTCDs from small datasets for lesion diagnosis, we further propose an adaptive multi-input CNN learning framework. Furthermore, an Adaptive Weight Network is used to highlight important information and suppress redundant information after the fusion of the LTCDs. We evaluated the performance of MM-GLCM-CNN by the area under the receiver operating characteristic curve (AUC) merit on small private lesion datasets of colon polyps. The AUC score reaches 93.99% with a gain of 1.49% over current state-of-the-art lesion classification methods on the same dataset. This gain indicates the importance of incorporating lesion characteristic heterogeneity for the prediction of lesion malignancy using small pathologically-proven datasets.

A deep learning-based system for mediastinum station localization in linear EUS (with video)

Background and Objectives

EUS is a crucial diagnostic and therapeutic method for many anatomical regions, especially in the evaluation of mediastinal diseases and related pathologies. Rapidly finding the standard stations is the key to achieving efficient and complete mediastinal EUS imaging. However, it requires substantial technical skills and extensive knowledge of mediastinal anatomy. We constructed a system, named EUS-MPS (EUS-mediastinal position system), for real-time mediastinal EUS station recognition.

Methods

The standard scanning of mediastinum EUS was divided into 7 stations. There were 33 010 images in mediastinum EUS examination collected to construct a station classification model. Then, we used 151 videos clips for video validation and used 1212 EUS images from 2 other hospitals for external validation. An independent data set containing 230 EUS images was applied for the man-machine contest. We conducted a crossover study to evaluate the effectiveness of this system in reducing the difficulty of mediastinal ultrasound image interpretation.

Results

For station classification, the model achieved an accuracy of 90.49% in image validation and 83.80% in video validation. At external validation, the models achieved 89.85% accuracy. In the man-machine contest, the model achieved an accuracy of 84.78%, which was comparable to that of expert (83.91%). The accuracy of the trainees' station recognition was significantly improved in the crossover study, with an increase of 13.26% (95% confidence interval, 11.04%-15.48%; P < 0.05).

Conclusions

This deep learning-based system shows great performance in mediastinum station localization, having the potential to play an important role in shortening the learning curve and establishing standard mediastinal scanning in the future.

The Role of EUS in Advanced Endoscopic Procedures and Therapeutics-Advancing the Field to Greater Heights

Endoscopic ultrasound (EUS) provides high-resolution and real-time visualization of various layers of the gastrointestinal (GI) tract and beyond by combining ultrasound technology with endoscopic visualization [...].

Clinical Outcomes and Complications for Achalasia Patients Admitted After Per-Oral Endoscopic Myotomy

Background

Per-oral endoscopic myotomy (POEM) is a rapidly emerging minimally invasive procedure for management of achalasia. Same-day discharge after POEM is safe and feasible; however, some patients may need hospitalization. We aimed to identify characteristics and outcomes for achalasia patients requiring hospitalizations after POEM in the United States (US).

Methods

The US National Inpatient Sample was utilized to identify all adult achalasia patients who were admitted after POEM from 2016 to 2019. Hospitalization characteristics and clinical outcomes were highlighted.

Results

From 2016 to 2019, we found that 1,885 achalasia patients were admitted after POEM. There was an increase in the total number of hospitalizations after POEM from 380 in 2016 to 490 in 2019. The mean age increased from 54.2 years in 2016 to 59.3 years in 2019. Most POEM-related hospitalizations were for the 65 - 79 age group (31.8%), females (50.4%), and Whites (68.4%). A majority (56.2%) of the study population had a Charlson Comorbidity Index of 0. The Northeast hospital region had the highest number of POEM-related hospitalizations. Most of these patients (88.3%) were eventually discharged home. There was no inpatient mortality. The mean length of stay decreased from 4 days in 2016 to 3.2 days in 2019, while the mean total healthcare charge increased from $52,057 in 2016 to $65,109 in 2019. Esophageal perforation was the most common complication seen in 1.3% of patients.

Conclusion

The number of achalasia patients needing hospitalization after POEM increased. There was no inpatient mortality conferring an excellent safety profile of this procedure.

Prevention of acute post-manipulation pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most informative and often in-demand methods for the detection and treatment of pathology of the biliary tract, its diagnostic value is 79-98%. A significant disadvantage of the method are side effects and various complications (acute pancreatitis, bleeding, retroduodenal perforation, cholangitis, acute cholecystitis, etc.). Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a common and severe complication of intraluminal endoscopic operations on the large duodenal papilla, its etiology is multifactorial, and the pathophysiology has not yet been fully studied. According to many randomized, controlled studies, the incidence of PEP ranges from 2.7 to 37%. Despite all the possibilities of modern medicine and the introduction of new methods, mortality with the development of PEP remains at a very high level: it reaches 7-15%, and with the development of destructive forms - 40-70%. The problems of prevention of PEP are still the subject of discussions and numerous studies by leading clinics around the world. In this paper, we conducted a review of the literature over the past decade using the sources of major medical libraries Medline, eLibrary, PubMed. The article discusses current modern pathogenetic mechanisms and the main risk factors for the development of PEP, related to both the characteristics of the patient and the procedure being performed, technical options for performing ERCP. The article also presents currently used and recommended by most authors methods of drug prevention of PEP and various technical solutions related to this complication. Thus, the not entirely satisfactory results of the proposed methods of prevention of PEP force the authors to search for safer and more effective solutions to this urgent problem at the present time.

Peroral Endoscopic Myotomy: What Nurses Need to Know to Provide Preeminent Perioperative Care

This article aims to explore details of research, evidence, and key concepts intended for nurses and other healthcare clinicians surrounding the paradigm shift in therapeutic endoscopy relating to the third-space endoscopic procedure, peroral endoscopic myotomy. Although many medical publications detail the procedure, there are no specific guidelines for nurses to reference when caring for the patient undergoing peroral endoscopic myotomy. With scant published resources available to direct nurses distinctly in the delivery of exceptional care to patients undergoing peroral endoscopic myotomy, there is an identified need for collated information to be accessible to all nurses providing perioperative teaching and care. As peroral endoscopic myotomy continues to transpire as a mainstream or preferred standard treatment for patients who suffer from achalasia, relevant education remains to be fully understood and assessed in the nursing arena. By examining nursing considerations for patient care, indications, techniques, and advancements regarding this ever-emergent breakthrough, readers will discover guidance in comprehensive care encompassing patients undergoing the peroral endoscopic myotomy procedure.

Risk factors of pancreatitis after endoscopic retrograde cholangiopancreatography in patients with biliary tract diseases

BACKGROUND

To investigate the risk factors of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in patients with biliary tract diseases.

METHODS

We retrospectively analyzed the clinical data of 480 patients who underwent ERCP for biliary tract diseases at the Affiliated Zhongshan Hospital of Dalian University from October 2011 to October 2016. The patients were divided into a study group (n = 75, with PEP) and a control group (n = 405, without PEP) based on whether they developed post-ERCP pancreatitis (PEP), and their clinical baseline data and intraoperative conditions were retrieved and compared. Then, factors associated with PEP were analyzed using logistic regression model, based on which a nomogram prediction model was constructed. The receiver operating characteristic (ROC) curve and calibration curve were used to evaluate the performance of the prediction model.

RESULTS

Significant differences in age, sex, history of pancreatitis, history of choledocholithiasis, pancreatic duct imaging, pancreatic sphincterotomy, difficult cannulation, multiple cannulation attempts and juxtapapillary duodenal diverticula were observed between the two groups. Multivariate logistic regression analysis showed that age less than 60 years (OR, 0.477; 95% CI, 0.26-0.855), female sex (OR, 2.162; 95% CI, 1.220-3.831), history of pancreatitis (OR, 2.567; 95% CI, 1.218-5.410), history of choledocholithiasis (OR, 2.062; 95% CI, 1.162-3.658), pancreatic sphincterotomy (OR, 2.387; 95% CI, 1.298-4.390), pancreatic duct imaging (OR, 4.429; 95% CI, 1.481-13.242), multiple cannulation attempts (OR, 2.327; 95% CI, 1.205-4.493), difficult cannulation (OR, 2.421; 95% CI, 1.143-5.128), and JPD (OR, 2.002; 95% CI, 1.125-3.564) were independent risk factors for PEP. The nomogram for predicting the occurrence of PEP demonstrated an area under the ROC curve (AUC) of 0.787, and the calibration curves of the model showed good consistency between the predicted and actual probability of PEP.

CONCLUSION

Our results showed that age less than 60 years, female sex, history of pancreatitis, history of choledocholithiasis, pancreatic sphincterotomy, pancreatic duct imaging, multiple cannulation attempts, difficult cannulation and juxtapapillary duodenal diverticula were independent risk factors for PEP. In addition, the established nomogram demonstrated promising clinical efficacy in predicting PEP risk in patients who underwent ERCP for biliary tract diseases.

Diagnosis and Management of Esophagogastric Varices

Acute variceal bleeding (AVB) is a potentially fatal complication of clinically significant portal hypertension and is one of the most common causes of acute upper gastrointestinal bleeding. Thus, esophagogastric varices represent a major economic and population health issue. Patients with advanced chronic liver disease typically undergo an upper endoscopy to screen for esophagogastric varices. However, upper endoscopy is not recommended for patients with liver stiffness < 20 KPa and platelet count > 150 × 109/L as there is a low probability of high-risk varices. Patients with high-risk varices should receive primary prophylaxis with either nonselective beta-blockers or endoscopic band ligation. In cases of AVB, patients should receive upper endoscopy within 12 h after resuscitation and hemodynamic stability, whereas endoscopy should be performed as soon as possible if patients are unstable. In cases of suspected variceal bleeding, starting vasoactive therapy as soon as possible in combination with endoscopic treatment is recommended. On the other hand, in cases of uncontrolled bleeding, balloon tamponade or self-expandable metal stents can be used as a bridge to more definitive therapy such as transjugular intrahepatic portosystemic shunt. This article aims to offer a comprehensive review of recommendations from international guidelines as well as recent updates on the management of esophagogastric varices.

Request for biliary drainage for IgG4-SC could be waived before steroid administration?

BACKGROUND

In IgG4-related sclerosing cholangitis (IgG4-SC), the necessity of biliary drainage (BD) is unclear. In this study, we aimed to retrospectively investigate the improvement of liver damage and jaundice in cases of IgG4-SC with and without BD, before starting steroids.

METHODS

A total of 52 patients with IgG4-SC were investigated in the study. The study endpoints were the normalization rate of alkaline phosphatase (ALP)/total bilirubin (T-Bil) after 8 weeks of steroids, with and without BD.

RESULTS

Propensity score matching was performed based on ALP and T-Bil, and 28 patients were included. There were 14 patients each in the BD and non-BD groups. Before initiation of steroids, the mean ALP in the BD group and the non-BD group was 378/461 (P = .541); the mean T-Bil was 2.5/1.8 (P = .401). Eight weeks after initiation of steroids, ALP improvement rate in the BD group/non-BD group was 69.2%/61.5% (P = 1.000), and T-Bil improvement rate was 100%/100% (P = Ns).

CONCLUSIONS

Steroids for IgG4-SC could prove effective in improving liver damage and jaundice, regardless of the presence or absence of BD. BD for IgG4-SC aimed to improve jaundice may not be necessary.

Role of vitamin C and rectal indomethacin in preventing and alleviating post-endoscopic retrograde cholangiopancreatography pancreatitis: a clinical study

BACKGROUND/AIMS

This study aimed to determine whether vitamin C in addition to indomethacin decreases the occurrence and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) occurrence and severity.

METHODS

This randomized clinical trial included patients undergoing ERCP. The participants were administered either rectal indomethacin (100 mg) plus an injection of vitamin C (500 mg) or rectal indomethacin (100 mg) alone just before ERCP. The primary outcomes were PEP occurrence and severity. The secondary amylase and lipase levels were determined after 24 hours.

RESULTS

A total of 344 patients completed the study. Based on intention-to-treat analysis, the PEP rates were 9.9% for indomethacin plus vitamin C plus indomethacin and 15.7% for indomethacin alone. Regarding the per-protocol analysis, the PEP rates were 9.7% and 15.7% in the combination and indomethacin arms, respectively. There was a remarkable difference between the two arms in PEP occurrence and severity on intention-to-treat and per-protocol analyses (p=0.034 and p=0.031, respectively). The post-ERCP lipase and amylase concentrations were lower in the combination arm than in the indomethacin alone arm (p=0.034 and p=0.029, respectively).

CONCLUSION

Vitamin C injection in addition to rectal indomethacin reduced PEP occurrence and severity.

Outcomes of endoscopic retrograde cholangiopancreatography-guided gallbladder drainage compared to percutaneous cholecystostomy in acute cholecystitis

Backgrounds/Aims

Endoscopic retrograde cholangiopancreatography-guided gallbladder drainage (ERGD) is an alternative to percutaneous cholecystostomy (PTC) for hospitalized acute cholecystitis (AC) patients.

Methods

We retrospectively analyzed propensity score matched (PSM) AC hospitalizations using the National Inpatient Sample database between 2016 and 2019 to compare the outcomes of ERGD and PTC.

Results

After PSM, there were 3,360 AC hospitalizations, with 48.8% undergoing PTC and 51.2% undergoing ERGD. There was no difference in median length of stay between the PTC and ERGD cohorts (p = 0.110). There was a higher median hospitalization cost in the ERGD cohort, $62,562 (interquartile range [IQR] $40,707-97,978) compared to PTC, $40,413 (IQR $25,244-65,608; p < 0.001). The 30-day inpatient mortality was significantly lower in hospitalizations with ERGD compared to PTC (adjusted hazard ratio 0.16, 95% confidence interval [CI]: 0.1-0.41; p < 0.001). There was no difference in association with blood transfusions, acute renal failure, ileus, small bowel obstruction, and open cholecystectomy conversion (p > 0.05) between hospitalizations with ERGD and PTC. There was lower association of acute hypoxic respiratory failure (adjusted ratio [AOR] 0.46, 95% CI: 0.29-0.72; p = 0.001), hypovolemia (AOR 0.66, 95% CI: 0.49-0.82; p = 0.009) and higher association of lower gastrointestinal bleed (AOR 1.94, 95% CI: 1.48-2.54; p < 0.001) with ERGD compared to PTC.

Conclusions

ERGD is a safer alternative to PTC in patients with AC. The risk complications are lower in ERGD compared to PTC but no difference exists based on mortality or conversion to open cholecystectomy.

Through-the-scope suture closure of peroral endoscopic myotomy mucosal incision sites

BACKGROUND : Peroral endoscopic myotomy (POEM) is now widely used for esophageal motility disorders including achalasia. Closure of the mucosal incision site is a critical step of the procedure. We evaluated the use of a novel through-the-scope (TTS) suture system for closure of POEM mucosal incision sites. METHODS : We retrospectively reviewed consecutive patients who underwent POEM with TTS suture closure at our institution between February and July 2021. Technical success was defined as complete mucosal incision site closure using TTS suturing, without the need for adjunctive devices. Continuous variables are presented as median (interquartile range [IQR]) or mean (SD). RESULTS : 35 consecutive patients (median age 58 years [IQR 46.5-72]; 54.3 % female) underwent POEM with attempted mucosal closure by TTS suturing. Technical success was achieved in 32 patients (91.4 %) with a mean closure time of 12.4 (SD 6.9) minutes. The median mucosal incision length at time of closure was 2.5 cm (IQR 2-2.5). Overall, 17 patients (53.1 %) required ≥ 2 TTS suture systems and 3 patients (8.6 %) required additional TTS clips to achieve secure mucosal closure. No adverse events were encountered. CONCLUSIONS : TTS suturing was effective and safe for POEM mucosotomy closure. However, prospective comparative trials and cost-effectiveness analyses are warranted before routine adoption.

Successful Design and Implementation of a POEM Program for Achalasia in an Integrated Healthcare System

BACKGROUND

Per Oral Endoscopic Myotomy (POEM) is a minimally invasive treatment for achalasia with results comparable to laparoscopic Heller myotomy (LHM). Studies have described the development of proficiency for endoscopists learning to perform POEM, and societies have defined educational and technical objectives for advanced endoscopy fellows in training. However, there is limited guidance on the organizational strategy and educational plan necessary to develop an achalasia service with POEM expertise.

AIMS

We aim to outline the steps for design and implementation of a successful POEM program.

METHODS

We reported our experience developing a multi-disciplinary clinical program for POEM and the steps taken to achieve procedural proficiency. We also reported our technical success (successful tunneling into the gastric cardia and myotomy of LES muscle fibers) and clinical success (post-procedure Eckardt score ≤ 3) at 3-6 months and 12 months post-procedure. Adverse events were classified per the ASGE lexicon for endoscopic adverse events.

RESULTS

After creating a multi-disciplinary clinical program for achalasia and completing procedural proficiency for POEM, our technical success rate was 100% and clinical success rate 90% for the first 41 patients. One adverse event (2.4%) occurred, moderate in severity per the American Society of Gastrointestinal Endoscopy (ASGE) lexicon for adverse endoscopic events.

CONCLUSION

In this study, we outlined the steps involved to establish a POEM service in a large integrated healthcare system. Prior competency in interventional endoscopy, procedural training models, POEM observation and education, proctorship, and interdisciplinary patient care are recommended.

Highlighting the Undetectable - Fluorescence Molecular Imaging in Gastrointestinal Endoscopy

Flexible high-definition white-light endoscopy is the current gold standard in screening for cancer and its precursor lesions in the gastrointestinal tract. However, miss rates are high, especially in populations at high risk for developing gastrointestinal cancer (e.g., inflammatory bowel disease, Lynch syndrome, or Barrett's esophagus) where lesions tend to be flat and subtle. Fluorescence molecular endoscopy (FME) enables intraluminal visualization of (pre)malignant lesions based on specific biomolecular features rather than morphology by using fluorescently labeled molecular probes that bind to specific molecular targets. This strategy has the potential to serve as a valuable tool for the clinician to improve endoscopic lesion detection and real-time clinical decision-making. This narrative review presents an overview of recent advances in FME, focusing on probe development, techniques, and clinical evidence. Future perspectives will also be addressed, such as the use of FME in patient stratification for targeted therapies and potential alliances with artificial intelligence. KEY MESSAGES: • Fluorescence molecular endoscopy is a relatively new technology that enables safe and real-time endoscopic lesion visualization based on specific molecular features rather than on morphology, thereby adding a layer of information to endoscopy, like in PET-CT imaging. • Recently the transition from preclinical to clinical studies has been made, with promising results regarding enhancing detection of flat and subtle lesions in the colon and esophagus. However, clinical evidence needs to be strengthened by larger patient studies with stratified study designs. • In the future fluorescence molecular endoscopy could serve as a valuable tool in clinical workflows to improve detection in high-risk populations like patients with Barrett's esophagus, Lynch syndrome, and inflammatory bowel syndrome, where flat and subtle lesions tend to be malignant up to five times more often. • Fluorescence molecular endoscopy has the potential to assess therapy responsiveness in vivo for targeted therapies, thereby playing a role in personalizing medicine. • To further reduce high miss rates due to human and technical factors, joint application of artificial intelligence and fluorescence molecular endoscopy are likely to generate added value.

Periprocedural safety profile of peroral endoscopic myotomy (POEM)-a retrospective analysis of adverse events according to two different classifications

BACKGROUND

Peroral endoscopic myotomy (POEM) is nowadays a standard method for treatment of achalasia; nevertheless, it remains an invasive intervention with corresponding risk of adverse events (AEs). The classification and grading of AEs are still a matter of discussion. The aim of our retrospective study was to assess the occurrence of all "undesirable" events and "true" adverse events in patients undergoing POEM and to compare the outcomes when either Clavien-Dindo classification (CDC) or American Society of Gastrointestinal Endoscopy (ASGE) lexicon classification applied.

METHODS

This was a retrospective analysis of prospectively managed database of all patients who had undergone POEM between December 2012 and August 2018. We assessed the pre-, peri-, and early-postoperative (up to patient's discharge) undesirable events (including those not fulfilling criteria for AEs) and "true" AEs according the definition in either of the classifications.

RESULTS

A total of 231 patients have successfully undergone 244 POEM procedures (13 × re-POEM). Twenty-nine procedures (11.9%) passed uneventfully, while in 215 procedures (88.1%), a total of 440 undesirable events occurred. The CDC identified 27 AEs (17 minor, 10 major) occurring in 23/244 (9.4%) procedures. The ASGE lexicon identified identical 27 AEs (21 mild or moderate, 6 severe or fatal) resulting in the severity distribution of AEs being the only difference between the two classifications. Only the absence of previous treatment was found to be a risk factor [p = 0.047, OR with 95% CI: 4.55 (1.02; 20.25)] in the combined logistic regression model.

CONCLUSION

Undesirable events are common in patients undergoing POEM but the incidence of true AEs is low according to both classifications. Severe adverse events are infrequent irrespective of the classification applied. CDC may be more appropriate than ASGE lexicon for classifying POEM-related AEs given a surgical nature of this procedure.

Effect of Adding Intravenous Somatostatin to Rectal Indomethacin on Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis in High-risk Patients: A Double-blind Randomized Placebo-controlled Clinical Trial

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) has an important role in the treatment of pancreaticobiliary disorders.

GOALS

Considering the high prevalence and importance of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) and the controversial findings, we aimed to determine the effect of adding intravenous somatostatin to rectal indomethacin on the incidence of PEP in high-risk patients.

STUDY

In this prospective study, 530 patients underwent ERCP during March 2018 and February 2019. Patients were randomized into 2 groups. The intervention group received a bolus injection of 250 μg somatostatin followed by an infusion of 500 μg of somatostatin for 2 hours. In both groups, 100 mg of pre-ERCP suppository indomethacin was administrated. All patients were screened for PEP symptoms and signs for 24 hours after ERCP (Iranian Registry of Clinical Trials code: IRCT20080921001264N11).

RESULTS

A total of 376 patients were finally analyzed. PEP was the most common adverse event with 50 (13.2%) episodes, including 21 (5.5%) mild, 23 (6.1%) moderate, and 6 (1.2%) severe. The rate of PEP was 15.2% in the control group and 11.4% in the intervention group ( P =0.666). The incidence of post-ERCP hyperamylasemia was 21.7% in the control group and 18.2% in the intervention group ( P =0.395). No death occurred.

CONCLUSIONS

In this study administration of somatostatin plus indomethacin could safely reduce the rate of post-ERCP hyperamylasemia and PEP in the intervention group compared with the control group, but the differences were not significant. Further studies with larger sample sizes are required.

H. pylori Related Atrophic Gastritis Detection Using Enhanced Convolution Neural Network (CNN) Learner

Atrophic gastritis (AG) is commonly caused by the infection of the Helicobacter pylori (H. pylori) bacteria. If untreated, AG may develop into a chronic condition leading to gastric cancer, which is deemed to be the third primary cause of cancer-related deaths worldwide. Precursory detection of AG is crucial to avoid such cases. This work focuses on H. pylori-associated infection located at the gastric antrum, where the classification is of binary classes of normal versus atrophic gastritis. Existing work developed the Deep Convolution Neural Network (DCNN) of GoogLeNet with 22 layers of the pre-trained model. Another study employed GoogLeNet based on the Inception Module, fast and robust fuzzy C-means (FRFCM), and simple linear iterative clustering (SLIC) superpixel algorithms to identify gastric disease. GoogLeNet with Caffe framework and ResNet-50 are machine learners that detect H. pylori infection. Nonetheless, the accuracy may become abundant as the network depth increases. An upgrade to the current standards method is highly anticipated to avoid untreated and inaccurate diagnoses that may lead to chronic AG. The proposed work incorporates improved techniques revolving within DCNN with pooling as pre-trained models and channel shuffle to assist streams of information across feature channels to ease the training of networks for deeper CNN. In addition, Canonical Correlation Analysis (CCA) feature fusion method and ReliefF feature selection approaches are intended to revamp the combined techniques. CCA models the relationship between the two data sets of significant features generated by pre-trained ShuffleNet. ReliefF reduces and selects essential features from CCA and is classified using the Generalized Additive Model (GAM). It is believed the extended work is justified with a 98.2% testing accuracy reading, thus providing an accurate diagnosis of normal versus atrophic gastritis.

Artificial intelligence in improving the outcome of surgical treatment in colorectal cancer

BACKGROUND

A considerable number of recent research have used artificial intelligence (AI) in the area of colorectal cancer (CRC). Surgical treatment of CRC still remains the most important curative component. Artificial intelligence in CRC surgery is not nearly as advanced as it is in screening (colonoscopy), diagnosis and prognosis, especially due to the increased complexity and variability of structures and elements in all fields of view, as well as a general shortage of annotated video banks for utilization.

METHODS

A literature search was made and relevant studies were included in the minireview.

RESULTS

The intraoperative steps which, at this moment, can benefit from AI in CRC are: phase and action recognition, excision plane navigation, endoscopy control, real-time circulation analysis, knot tying, automatic optical biopsy and hyperspectral imaging. This minireview also analyses the current advances in robotic treatment of CRC as well as the present possibility of automated CRC robotic surgery.

CONCLUSIONS

The use of AI in CRC surgery is still at its beginnings. The development of AI models capable of reproducing a colorectal expert surgeon's skill, the creation of large and complex datasets and the standardization of surgical colorectal procedures will contribute to the widespread use of AI in CRC surgical treatment.

The value of artificial intelligence techniques in predicting pancreatic ductal adenocarcinoma with EUS images: A meta-analysis and systematic review

Conventional EUS plays an important role in identifying pancreatic cancer. However, the accuracy of EUS is strongly influenced by the operator's experience in performing EUS. Artificial intelligence (AI) is increasingly being used in various clinical diagnoses, especially in terms of image classification. This study aimed to evaluate the diagnostic test accuracy of AI for the prediction of pancreatic cancer using EUS images. We searched the Embase, PubMed, and Cochrane Library databases to identify studies that used endoscopic ultrasound images of pancreatic cancer and AI to predict the diagnostic accuracy of pancreatic cancer. Two reviewers extracted the data independently. The risk of bias of eligible studies was assessed using a Deek funnel plot. The quality of the included studies was measured by the QUDAS-2 tool. Seven studies involving 1110 participants were included: 634 participants with pancreatic cancer and 476 participants with nonpancreatic cancer. The accuracy of the AI for the prediction of pancreatic cancer (area under the curve) was 0.95 (95% confidence interval [CI], 0.93-0.97), with a corresponding pooled sensitivity of 93% (95% CI, 0.90-0.95), specificity of 90% (95% CI, 0.8-0.95), positive likelihood ratio 9.1 (95% CI 4.4-18.6), negative likelihood ratio 0.08 (95% CI 0.06-0.11), and diagnostic odds ratio 114 (95% CI 56-236). The methodological quality in each study was found to be the source of heterogeneity in the meta-regression combined model, which was statistically significant (P = 0.01). There was no evidence of publication bias. The accuracy of AI in diagnosing pancreatic cancer appears to be reliable. Further research and investment in AI could lead to substantial improvements in screening and early diagnosis.

Racial disparities in endoscopic retrograde cholangiopancreatography (ERCP) utilization in the United States: are we getting better?

BACKGROUND

We identified trends of inpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the United States (US), focusing on outcomes related to specific patient demographics.

METHODS

The National Inpatient Sample was utilized to identify all adult inpatient ERCP in the US between 2007-2018. Trends of utilization and adverse outcomes were highlighted. P-values ≤ 0.05 were considered statistically significant.

RESULTS

We noted a rising trend for total inpatient ERCP in the US from 126,921 in 2007 to 165,555 in 2018 (p = 0.0004), with a significant increase in utilization for Blacks, Hispanics, and Asians. Despite an increasing comorbidity burden [Charlson Comorbidity Index (CCI) score ≥ 2], the overall inpatient mortality declined from 1.56% [2007] to 1.46% [2018] without a statistically significant trend (p = 0.14). Moreover, there was a rising trend of inpatient mortality for Black and Hispanic populations, while a decline was noted for Asians. After a comparative analysis, we noted higher rates of inpatient mortality for Blacks (2.4% vs 1.82%, p = 0.0112) and Hispanics (1.17% vs 0.83%, p = 0.0052) at urban teaching hospitals between July toand September compared to the October to June study period; however, we did not find a statistically significant difference for the Asian cohort (1.9% vs 2.10%, p = 0.56). The mean length of stay (LOS) decreased from 7 days in 2007 to 6 days in 2018 (p < 0.0001), while the mean total hospital charge (THC) increased from $48,883 in 2007 to $85,909 in 2018 (p < 0.0001) for inpatient ERCPs. Compared to the 2015-2018 study period, we noted higher rates of post-ERCP pancreatitis (27.76% vs 17.25%, p < 0.0001) from 2007-2014.

CONCLUSION

Therapeutic ERCP utilization and inpatient mortality were on the rise for a subset of the American minority population, including Black and Hispanics.

Artificial Intelligence and Precision Medicine: A New Frontier for the Treatment of Brain Tumors

Brain tumors are a widespread and serious neurological phenomenon that can be life- threatening. The computing field has allowed for the development of artificial intelligence (AI), which can mimic the neural network of the human brain. One use of this technology has been to help researchers capture hidden, high-dimensional images of brain tumors. These images can provide new insights into the nature of brain tumors and help to improve treatment options. AI and precision medicine (PM) are converging to revolutionize healthcare. AI has the potential to improve cancer imaging interpretation in several ways, including more accurate tumor genotyping, more precise delineation of tumor volume, and better prediction of clinical outcomes. AI-assisted brain surgery can be an effective and safe option for treating brain tumors. This review discusses various AI and PM techniques that can be used in brain tumor treatment. These new techniques for the treatment of brain tumors, i.e., genomic profiling, microRNA panels, quantitative imaging, and radiomics, hold great promise for the future. However, there are challenges that must be overcome for these technologies to reach their full potential and improve healthcare.

Endoscopic ultrasound-guided diagnosis and treatment of gastric varices

Gastric varices (GV) represent a common and severe complication in patients with portal hypertension, commonly seen in patients with cirrhosis and severe pancreatic disease. Endoscopic ultrasonography is a safe and efficacious approach that can perform real-time ultrasonic scanning and intervention for the gastrointestinal submucosa, portal vein and its tributaries, and collateral circulations during direct endoscopic observation. Recently, various studies have been published about endoscopic ultrasound (EUS)-guided management of GV, mainly including diagnosis, treatment, and prognostic analysis. This article reviews published articles and guidelines to present the development process and current management of EUS-guided GV procedures.

Endoscopic ultrasound-guided diagnosis and treatment of gastric varices

Gastric varices (GV) represent a common and severe complication in patients with portal hypertension, commonly seen in patients with cirrhosis and severe pancreatic disease. Endoscopic ultrasonography is a safe and efficacious approach that can perform real-time ultrasonic scanning and intervention for the gastrointestinal submucosa, portal vein and its tributaries, and collateral circulations during direct endoscopic observation. Recently, various studies have been published about endoscopic ultrasound (EUS)-guided management of GV, mainly including diagnosis, treatment, and prognostic analysis. This article reviews published articles and guidelines to present the development process and current management of EUS-guided GV procedures.

Outcomes following common bile duct exploration versus endoscopic stone extraction before, during and after laparoscopic cholecystectomy for patients with common bile duct stones

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. The best method for CBD stone removal is debatable. The aim of this study was to compare outcomes following LCBDE and/or ERCP, including laparoscopic cholecystectomy.

METHODS

Data were collected retrospectively for patients undergoing LCBDE and/or ERCP at a single centre from 2008 to 2018. Patients were grouped by intention-to-treat (single-stage LCBDE, pre-operative-, intra-operative-, or post-operative ERCP) and eventual plan (surgical or endoscopic). Outcomes included complication rates (minor Clavien-Dindo 1/2, major Clavien-Dindo 3/4, non-biliary complications) and mortality.

RESULTS

Of 671 patients, 578 patients received LCBDE and 93 patients received ERCP as primary care. Endoscopic clearance had significantly higher complications and mortality compared to surgical clearance. On an intention-to-treat basis LCBDE had the lowest minor-, major- and non-biliary complications, and mortality (5.2%, 6.1%, 2.9% and 0.5%, respectively), whilst pre-operative ERCP the worst (39.6%, 27.1%, 29.2% and 8.3%, respectively) (p=<0.001). LCBDE and postERCP had similar major complications and mortality.

CONCLUSION

Surgical clearance of CBD stones was potentially safer than endoscopic clearance. Pre-operative ERCP had the worst outcomes. LCBDE and postERCP are likely to have similar short-term patient outcomes.

The scientific progress and prospects of artificial intelligence in digestive endoscopy: A comprehensive bibliometric analysis

Artificial intelligence (AI) has been used for diagnosis and outcome prediction in clinical practice. Furthermore, AI in digestive endoscopy has attracted much attention and shown promising and stimulating results. This study aimed to determine the development trends and research hotspots of AI in digestive endoscopy by visualizing articles. Publications on AI in digestive endoscopy research were retrieved from the Web of Science Core Collection on April 25, 2022. VOSviewer and CiteSpace were used to assess and plot the research outputs. This analytical research was based on original articles and reviews. A total of 524 records of AI research in digestive endoscopy, published between 2005 and 2022, were retrieved. The number of articles has increased 27-fold from 2017 to 2021. Fifty-one countries and 994 institutions contributed to all publications. Asian countries had the highest number of publications. China, the USA, and Japan were consistently the leading driving forces and mainly contributed (26%, 21%, and 14.31%, respectively). With a solid academic reputation in this area, Japan has the highest number of citations per article. Tada Tomohiro published the most articles and received the most citations.. Gastrointestinal endoscopy published the largest number of publications, and 4 of the top 10 cited papers were published in this journal. "The Classification," "ulcerative colitis," "capsule endoscopy," "polyp detection," and "early gastric cancer" were the leading research hotspots. Our study provides systematic elaboration for researchers to better understand the development of AI in gastrointestinal endoscopy.