Venous air emboli during esophagoscopy confirmed by computed tomographic pulmonary angiography -a case report

BACKGROUND

Esophagogastroduodenoscopy (EGD) is vital for the diagnosis and treatment of various gastrointestinal conditions but carries a low risk of venous air embolism (VAE). We report a case of VAE during EGD, confirmed by computed tomographic pulmonary angiography (CTPA).

CASE

A 56-year-old male with a history of hypopharyngeal cancer underwent EGD for dysphagia-related esophageal dilation. Signs of VAE were noted, prompting swift interventions, including oxygen therapy, positional changes, and CTPA. CTPA revealed the Mercedes-Benz sign, pneumomediastinum, and a minimal pneumothorax. The patient's oxygen saturation improved within 30 min before undergoing CTPA, and he was discharged on postoperative day 4.

CONCLUSIONS

Timely recognition of VAE, resulting in appropriate interventions supported by CTPA, resulted in favorable patient outcomes.

Technical outcomes and postprocedural courses of mucosal incision-assisted biopsy for possible gastric gastrointestinal stromal tumors: A series of 48 cases (with video)

Objective

Mucosal incision-assisted biopsy (MIAB) has been introduced as an alternative to endoscopic ultrasound-guided fine needle aspiration for tissue sampling of subepithelial lesions. However, there have been few reports on MIAB, and the evidence is lacking, particularly in small lesions. In this case series, we investigated the technical outcomes and postprocedural influences of MIAB for gastric subepithelial lesions 10 mm or greater in size.

Methods

We retrospectively reviewed cases with the intraluminal growth type of possible gastrointestinal stromal tumors, in which MIAB was performed at a single institution between October 2020 and August 2022. Technical success, adverse events, and clinical courses following the procedure were evaluated.

Results

In 48 MIAB cases with a median tumor diameter of 16 mm, the success rate of tissue sampling and the diagnostic rate were 96% and 92%, respectively. Two biopsies were considered sufficient for making the definitive diagnosis. Postoperative bleeding occurred in one case (2%). In 24 cases, surgery has performed a median of two months after MIAB, and no unfavorable findings caused by MIAB were seen intraoperatively. Finally, 23 cases were histologically diagnosed as gastrointestinal stromal tumors, and no patients who underwent MIAB experienced recurrence or metastasis during a median observation period of 13 months.

Conclusions

The data indicated that MIAB appears feasible, safe, and useful for histological diagnosis of gastric intraluminal growth types of possible gastrointestinal stromal tumors, even those of a small size. Postprocedural clinical effects were considered negligible.

ERCP endoscopic minimally invasive treatment of acute suppurative obstructive cholangitis: A study of 47 patients

The primary objective of the present study was to investigate the efficacy and safety of endoscopic therapy for acute obstructive suppurative cholangitis (AOSC) in patients with different underlying conditions. The present study comprised 47 patients diagnosed with AOSC, with a mean age of 70±14 years. Minimally invasive endoscopic treatments, including endoscopic duodenal papillary sphincterotomy, endoscopic duodenal nasobiliary drainage and/or placement of an endobiliary duct stent drainage tube, were performed. Variations in the levels of the white blood cell count, liver function, procalcitonin (PCT) and carbohydrate antigen-199 (CA199) were examined, compared and evaluated both prior to and following endoscopic retrograde cholangiopancreatography (ERCP). Among the 47 patients, 45 had a high fever, although their body temperature returned to normal after 7 days of ERCP treatment. The infection was difficult to control completely in two cases, including one case of biliary anastomosis secondary tumor with stenosis and AOSC and another case of an elderly patient with multiple choledocholithiasis complicated with sepsis. Within 7 days following treatment, the abdominal pain was resolved in 27 patients and jaundice subsided in 29 patients. On the 7th day after endoscopic treatment, the blood leukocyte, liver function, PCT and CA-199 parameters of all patients were significantly improved compared with those at admission. A total of 35 bile cultures yielded positive results, with Escherichia coli accounting for 11 cases (31.4%), Klebsiella pneumoniae accounting for 7 cases (20%), Pseudomonas aeruginosa accounting for 5 cases (14.3%), Enterococcus faecus accounting for 4 cases (11.4%) and other strains making up the remaining 17 cases. No serious complications were encountered with these patients, such as perforation, bleeding, severe pancreatitis or mortality, following ERCP. In conclusion, ERCP has been shown to be a safe and effective minimally invasive treatment method for elderly patients with AOSC, yielding a high rate of success.

Standard of Care Versus Octreotide in Angiodysplasia-Related Bleeding (the OCEAN Study): A Multicenter Randomized Controlled Trial

BACKGROUND & AIMS

Gastrointestinal angiodysplasias are vascular anomalies that may result in transfusion-dependent anemia despite endoscopic therapy. An individual patient data meta-analysis of cohort studies suggests that octreotide decreases rebleeding rates, but component studies possessed a high risk of bias. We investigated the efficacy of octreotide in reducing the transfusion requirements of patients with angiodysplasia-related anemia in a clinical trial setting.

METHODS

The study was designed as a multicenter, open-label, randomized controlled trial. Patients with angiodysplasia bleeding were required to have had at least 4 red blood cell (RBC) units or parental iron infusions, or both, in the year preceding randomization. Patients were allocated (1:1) to 40-mg octreotide long-acting release intramuscular every 28 days or standard of care, including endoscopic therapy. The treatment duration was 1 year. The primary outcome was the mean difference in the number of transfusion units (RBC + parental iron) between the octreotide and standard of care groups. Patients who received at least 1 octreotide injection or followed standard of care for at least 1 month were included in the intention-to-treat analyses. Analyses of covariance were used to adjust for baseline transfusion requirements and incomplete follow-up.

RESULTS

We enrolled 62 patients (mean age, 72 years; 32 men) from 17 Dutch hospitals in the octreotide (n = 31) and standard of care (n = 31) groups. Patients required a mean number of 20.3 (standard deviation, 15.6) transfusion units and 2.4 (standard deviation, 2.0) endoscopic procedures in the year before enrollment. The total number of transfusions was lower with octreotide (11.0; 95% confidence interval [CI], 5.5-16.5) compared with standard of care (21.2; 95% CI, 15.7-26.7). Octreotide reduced the mean number of transfusion units by 10.2 (95% CI, 2.4-18.1; P = .012). Octreotide reduced the annual volume of endoscopic procedures by 0.9 (95% CI, 0.3-1.5).

CONCLUSIONS

Octreotide effectively reduces transfusion requirements and the need for endoscopic therapy in patients with angiodysplasia-related anemia.

CLINICALTRIALS

gov, NCT02384122.

Endoscopic ultrasound-guided hepaticogastrostomy versus choledochoduodenostomy for malignant biliary obstruction: A meta-analysis

Objectives

Endoscopic ultrasound (EUS)-guided biliary drainage encompasses techniques such as EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided choledochoduodenostomy (EUS-CDS). This meta-analysis compared the efficacy of EUS-CDS with that of EUS-HGS for the treatment of biliary obstruction.

Methods

A systematic meta-analysis of all relevant articles listed was performed by searching the Cochrane Library, PubMed, and Google Scholar databases. We used random effects or fixed effects models to compare success rates, adverse events, procedure times, and time to recurrent biliary obstruction after EUS-CDS and EUS-HGS.

Results

This meta-analysis included 18 eligible studies. There was no significant difference between EUS-CDS and EUS-HGS with respect to technical success rate (odds ratio [OR] 1.04; 95% confidence interval [CI] 0.62-1.73) and clinical success rate (OR 0.66; 95% CI 0.43-1.04), or with respect to total procedure-related adverse events (OR 1.39; 95% CI 1.00-1.93). Subgroup analysis of adverse events revealed that the rate of recurrent biliary obstruction (RBO) was significantly higher for EUS-HGS (OR 2.95; 95% CI 1.54-5.64). There was no significant difference between the two methods with respect to time to recurrent biliary obstruction (mean difference -11.93 days; 95% CI -47.77-23.91). However, the procedure time was longer for EUS-HGS (mean difference, 3.21 min; 95% CI 1.24-5.19).

Conclusion

EUS-CDS and EUS-HGS are comparable in terms of technical success, clinical success, and rate of adverse events; however, EUS-CDS is superior with respect to procedure time and preventing RBO.

Efficacy and Rationale of Endoscopic Ultrasound-Guided Thrombin Injection in Visceral Artery Pseudoaneurysm Not Amenable to Angioembolization

BACKGROUND

Pseudoaneurysm usually occurs after vascular injuries or erosions such as in trauma or inflammation like pancreatitis and is associated with high morbidity and mortality.

AIM

The aim of study is to assess efficacy and safety of EUS-guided thrombin injection in pseudoaneurysm.

MATERIALS AND METHODS

Prospective data collection was done at SMS Hospital, Jaipur, from January 2015 to March 2023. All patients with pseudoaneurysm were consecutively enrolled.

RESULTS

Twenty patients (M/F, 18:2) with median age of 41 years (25-58 years), were studied. Underlying etiology of pseudoaneurysm was chronic pancreatitis in 75% of the patients, blunt trauma abdomen in 15% of the patients, recurrent acute pancreatitis in 5%, and idiopathic in 5% of the patients. At the time of admission, mean hemoglobin was 6.7 g/dL (3.4-8.2), with median blood transfusion requirement was 2 units (0-6 units). Hemoglobin values after 4-6 weeks showed a significant improvement ( t = 9.21, P < 0.05).Mean dose of human thrombin required for complete obliteration of pseudoaneurysm was 520 ± 188.6 IU per patient (300-800 IU). Amount of thrombin (IU) dose needed to achieve complete obliteration correlated well significantly with the dimension of pseudoaneurysm, P value less than 0.05 ( R = 0.80). Median follow-up duration in this study was 44 months (3-84 months), which was the longest follow-up period by far.

CONCLUSIONS

Endoscopic ultrasound-guided thrombin injection in visceral artery pseudoaneurysm is a safe and effective alternative for patients not amenable for digital subtraction angiography-guided angioembolization.

Comparison of Transumbilical Laparoscopy-Assisted Appendectomy with Conventional Three-Port Laparoscopic Appendectomy Performed by Pediatric Surgeons in Training for Appendicitis in Children

Background: Transumbilical laparoscopy-assisted appendectomy (TULAA) is the technique of choice for all types of appendicitis. However, the technique is challenging for trainees to learn in comparison with performing conventional three-port laparoscopic appendectomy (CTPLA) in children. We aimed to compare the surgical outcomes of children with appendicitis treated by TULAA versus CTPLA performed by pediatric surgeons in training (PSITs). Materials and Methods: This retrospective study analyzed pediatric patients with acute appendicitis treated with CTPLA or TULAA between April 2016 and December 2022. Operative time (OT: minutes), pneumoperitoneum time (PT: minutes), blood loss (milliliter), length of hospital stay (days), and surgical site infection rate were compared between the two groups. Operative outcomes were also analyzed according to type of appendicitis such as uncomplicated and complicated cases. Results: Two hundred twenty-five laparoscopic appendectomies were performed by CTPLA (n = 94) or TULAA (n = 131). All cases were performed by PSITs and there was no open conversion cases. TULAA had a shorter OT (67.0 ± 28.4 versus 78.3 ± 21.7; P < .01) and PT (26.1 ± 17.4 versus 52.5 ± 22.1 min; P < .01). The surgical site infection rate was slightly higher in the TULAA group, but the difference was not statistically significant. In uncomplicated appendicitis (n = 164), significant differences between the CTPLA and TULAA groups were observed in OT (CTPLA versus TULAA: 70.7 ± 14.9 versus 59.1 ± 21.6, P < .01) and PT (CTPLA versus TULAA: 43.6 ± 13.1 versus 20.4 ± 13.6, P < .01). With regard to postoperative complications, only surgical site infection was significantly different between the CTPLA and TULAA groups (CTPLA: 0.0% versus TULAA: 8.2%, P < .05). In complicated cases (n = 61), there were significant differences between the groups in PT (CTPLA versus TULAA: 73.4 ± 24.9 versus 42.3 ± 17.2, P < .01) and length of hospital stay (CTPLA versus TULAA: 7.0 ± 1.3 versus 8.9 ± 4.7, P < .05). Conclusions: TULAA had a shorter OT and PT than CTPLA. TULAA for PSITs shows similar safety and feasibility to CTPLA for not only uncomplicated cases but also complicated cases.

The Effects of Combined Use of Linaclotide and Polyethylene Glycol Electrolyte Powder in Colonoscopy Preparation for Patients With Chronic Constipation

OBJECTIVE

The purpose of this study is to evaluate the safety and efficacy of linaclotide and polyethylene glycol (PEG) electrolyte powder in patients with chronic constipation undergoing colonoscopy preparation.

PATIENTS AND METHODS

We included 260 patients with chronic constipation who were scheduled to undergo a colonoscopy. They were equally divided into 4 groups using a random number table: 4L PEG, 3L PEG, 3L PEG+L, and 2L PEG+L. The 4 groups were compared based on their scores on the Boston Bowel Preparation Scale (BBPS) and Ottawa Bowel Preparation Quality Scale (OBPQS), adverse reactions during the bowel preparation procedure, colonoscope insertion time, colonoscope withdrawal time, detection rate of adenomas, and their willingness to repeat bowel preparation.

RESULTS

In terms of the score of the right half of the colon, the score of the transverse colon, the total score using BBPS, and the total score using OBPQS, the 3L PEG (polyethylene glycol)+L group was superior to groups 3L PEG and 2L PEG+L ( P <0.05), but comparable to the 4L PEG group ( P >0.05). The incidence rate of vomiting was higher in the 4L PEG group than in the 2L PEG+L group ( P <0.05). There was no statistically significant difference in the insertion time of the colonoscope between the 4 groups. The colonoscope withdrawal time in the 3L PEG+L group was shorter than in groups 4L PEG and 3L PEG ( P <0.05) and comparable to that in the 4L PEG group ( P >0.05). There was no statistically significant difference in the rate of adenoma detection among the 4 groups ( P >0.05). The 4L PEG group was the least willing of the 4 groups to undergo repeated bowel preparation ( P <0.05).

CONCLUSION

The 3L PEG+L is optimal among the 4 procedures. It can facilitate high-quality bowel preparation, reduce the incidence of nausea during the bowel preparation procedure, and encourage patients to undertake repeated bowel preparation.

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 Impact of Radiofrequency Ablation on Survival Outcomes and Stent Patency in Patients with Unresectable Cholangiocarcinoma: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Endoluminal biliary radiofrequency ablation (RFA) has been proposed as a palliative treatment for patients with malignant biliary obstruction (MBO) in order to improve stent patency and survival. However, the existing data on patients with inoperable extrahepatic cholangiocarcinoma (eCCA) are conflicting. We performed a meta-analysis of randomized trials comparing RFA plus stenting versus stenting alone in patients with inoperable eCCA. We searched for trials published in the PubMed/MEDLINE, Scopus, and Cochrane databases up to November 2023. Data extraction was conducted from published studies, and a quality assessment was carried out in accordance with the guidelines recommended by the Cochrane Collaboration. Hazard ratios (HRs) with 95% CI were estimated from the trials. The primary endpoints of interest were overall survival and stent patency. Out of 275 results, 5 randomized trials and 370 patients were included. While overall survival was not different between the groups (HR 0.62; 95% CI 0.36-1.07; p = 0.09; I2 = 80%;), the subgroup analysis of studies employing plastic stents showed a trend toward better survival in the RFA-treated group (HR 0.42; 95% CI 0.22-0.80; p = 0.009; I2 = 72%). Stent patency was improved in patients receiving RFA (HR 0.64; 95% CI 0.45-0.90; p = 0.01; I2 = 23%). Adverse events were not different between the groups (OR 1.21; 95% CI 0.69-2.12; p = 0.50; I2 = 0%). Despite the promising results, high heterogeneity and potential biases in the included studies suggest the need for further high-quality randomized trials to explore the potential cumulative effects of RFA on CCA treatment outcomes.

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.

Role of Palliative Care in the Supportive Management of AL Amyloidosis-A Review

Light chain amyloidosis is a plasma-cell disorder with a poor prognosis. It is a progressive condition, causing worsening pain, disability, and life-limiting complications involving multiple organ systems. The medical regimen can be complex, including chemotherapy or immunotherapy for the disease itself, as well as treatment for pain, gastrointestinal and cardiorespiratory symptoms, and various secondary symptoms. Patients and their families must have a realistic awareness of the illness and of the goals and limitations of treatments in making informed decisions about medical therapy, supportive management, and end-of-life planning. Palliative care services can thus improve patients' quality of life and may even reduce overall treatment costs. Light chain (AL) amyloidosis is a clonal plasma cell disorder characterized by the excessive secretion of light chains by an indolent plasma cell clone that gradually accumulates in vital organs as amyloid fibrils and leads to end-organ damage. With progressive disease, most patients develop diverse clinical symptoms and complications that negatively impact quality of life and increase mortality. Complications include cardiac problems including heart failure, hypotension, pleural effusions, renal involvement including nephrotic syndrome with peripheral edema, gastrointestinal symptoms leading to anorexia and cachexia, complex pain syndromes, and mood disorders. The prognosis of patients with advanced AL amyloidosis is dismal. With such a complex presentation, and high morbidity and mortality rates, there is a critical need for the establishment of a palliative care program in clinical management. This paper provides an evidence-based overview of the integration of palliative care in the clinical management of AL amyloidosis as a means of reducing ER visits, rehospitalizations, and in-hospital mortality. We also discuss potential future collaborative directions in various aspects of clinical care related to AL amyloidosis.

Endoscopic Management of Post-Sleeve Gastrectomy Complications

Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.

A meta-analysis on the efficacy of endoscopic ultrasonography for treatment of pancreatic cancer

OBJECTIVE

This study aimed to systematically evaluate the efficacy and safety of Endoscopic Ultrasonography (EUS) for the treatment of pancreatic cancer.

METHODS

The PubMed, Embase, Web of Science, and Google Scholar databases were searched from the inception of the databases to June 2022. RevMan 5.3.0 software was utilized for data analysis. In total, 13 self-descriptive studies, which enrolled 382 patients, were finally included.

RESULTS

It was revealed that EUS for the treatment of pancreatic cancer exhibited a lower incidence of adverse reactions (Relative Risk Ration [RR = 0.23], 95 % Confidence interval [95 % CI 0.23-0.23]), a higher success rate (RR = 0.90, 95 % CI 0.90-0.90), and a low failure rate (RR = 0.06, 95 % CI 0.06-0.06). Moreover, EUS-guided Celiac Plexus Neurolysis (EUS-CPN) not only significantly relieved pancreatic cancer patients' pain (RR = 0.83, 95 % CI 0.83-0.83), but also significantly eliminated pain in some patients (RR = 0.09, 95 % CI 0.09-0.09). The effects of EUS on pancreatic cancer treatment were satisfactory, and few adverse reactions were found.

CONCLUSION

Owing to the restricted sample size in this meta-analysis, primarily consisting of descriptive studies, it was imperative to conduct more rigorously designed, multi-center, long-term follow-up, larger sample, and Randomized Controlled Trials (RCTs) to validate the findings.

Recurrent Crohn's disease

Although surgical management of the ileocolic segment in pediatric Crohn's disease is not curative, the main goal of therapy is to allow for growth, adequate nutrition, and age-appropriate development. Recurrent disease at the site of anastomosis presents as a major morbidity. Several factors have been implicated in the development of surgical recurrence though data in the literature is scarce. This review explores the epidemiology of recurrent ileocolic disease following primary surgery, indications for surgical intervention, and techniques reported in the literature. Pediatric data is scarce, and therefore, much of it is extrapolated from adult literature.

A Self-Powered Lactate Sensor Based on the Piezoelectric Effect for Assessing Tumor Development

The build-up of lactate in solid tumors stands as a crucial and early occurrence in malignancy development, and the concentration of lactate in the tumor microenvironment may be a more sensitive indicator for analyzing primary tumors. In this study, we designed a self-powered lactate sensor for the rapid analysis of tumor samples, utilizing the coupling between the piezoelectric effect and enzymatic reaction. This lactate sensor is fabricated using a ZnO nanowire array modified with lactate oxidase (LOx). The sensing process does not require an external power source or batteries. The device can directly output electric signals containing lactate concentration information when subjected to external forces. The lactate concentration detection upper limit of the sensor is at least 27 mM, with a limit of detection (LOD) of approximately 1.3 mM and a response time of around 10 s. This study innovatively applied self-powered technology to the in situ detection of the tumor microenvironment and used the results to estimate the growth period of the primary tumor. The availability of this application has been confirmed through biological experiments. Furthermore, the sensor data generated by the device offer valuable insights for evaluating the likelihood of remote tumor metastasis. This study may expand the research scope of self-powered technology in the field of medical diagnosis and offer a novel perspective on cancer diagnosis.

Predicting short-term major postoperative complications in intestinal resection for Crohn's disease: A machine learning-based study

BACKGROUND

Due to the complexity and numerous comorbidities associated with Crohn's disease (CD), the incidence of postoperative complications is high, significantly impacting the recovery and prognosis of patients. Consequently, additional studies are required to precisely predict short-term major complications following intestinal resection (IR), aiding surgical decision-making and optimizing patient care.

AIM

To construct novel models based on machine learning (ML) to predict short-term major postoperative complications in patients with CD following IR.

METHODS

A retrospective analysis was performed on clinical data derived from a patient cohort that underwent IR for CD from January 2017 to December 2022. The study participants were randomly allocated to either a training cohort or a validation cohort. The logistic regression and random forest (RF) were applied to construct models in the training cohort, with model discrimination evaluated using the area under the curves (AUC). The validation cohort assessed the performance of the constructed models.

RESULTS

Out of the 259 patients encompassed in the study, 5.0% encountered major postoperative complications (Clavien-Dindo ≥ III) within 30 d following IR for CD. The AUC for the logistic model was 0.916, significantly lower than the AUC of 0.965 for the RF model. The logistic model incorporated a preoperative CD activity index (CDAI) of ≥ 220, a diminished preoperative serum albumin level, conversion to laparotomy surgery, and an extended operation time. A nomogram for the logistic model was plotted. Except for the surgical approach, the other three variables ranked among the top four important variables in the novel ML model.

CONCLUSION

Both the nomogram and RF exhibited good performance in predicting short-term major postoperative complications in patients with CD, with the RF model showing more superiority. A preoperative CDAI of ≥ 220, a diminished preoperative serum albumin level, and an extended operation time might be the most crucial variables. The findings of this study can assist clinicians in identifying patients at a higher risk for complications and offering personalized perioperative management to enhance patient outcomes.

Comparing surgical and endoscopic resection approaches for colorectal neuroendocrine tumors within the diameter range of 10-20mm: an inverse probability weighting analysis based on the SEER database

Background

Currently, the primary treatment modalities for colorectal neuroendocrine tumors (CRNET) with a diameter between 10mm and 20mm are surgical resection (SR) and endoscopic resection (ER). However, it remains unclear which surgical approach yields the greatest survival benefit for patients.

Methods

This study included data from patients diagnosed with CRNET with tumor diameters ranging from 10mm to 20mm between the years 2004 and 2019, obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were categorized into ER and SR groups based on the respective surgical approaches. Inverse probability weighting (IPTW) was employed to mitigate selection bias. Kaplan-Meier analysis and log-rank tests were utilized to estimate overall survival (OS) and cancer-specific survival (CSS). Cox regression analysis (univariate and multivariate) was performed to evaluate potential factors influencing survival.

Results

A total of 292 CRNET patients were included in this study (ER group: 108 individuals, SR group: 184 individuals). Prior to IPTW adjustment, Kaplan-Meier analysis and Cox proportional hazard regression analysis demonstrated that the OS and CSS of the SR group were inferior to those of the ER group. However, after IPTW adjustment, no statistically significant differences in prognosis were observed between the two groups. Subgroup analyses revealed that patients with muscular invasion, positive lymph nodes, or distant metastasis derived greater survival benefits from SR. Significant differences in OS and CSS between the two groups were also observed across different age groups.

Conclusion

For patients with mucosal-limited lesions and without local lymph node or distant metastasis, ER is the preferred surgical approach. However, for patients with muscular invasion or positive lymph nodes/distant metastasis, SR offers a better prognosis. The choice of surgical approach should be based on the specific clinical characteristics of patients within different subgroups.

Ecogastroenterology: cultivating sustainable clinical excellence in an environmentally conscious landscape

Gastrointestinal practices, especially endoscopy, have a substantial environmental impact, marked by notable greenhouse gas emissions and waste generation. As the world struggles with climate change, there emerges a pressing need to re-evaluate and reform the environmental footprint within gastrointestinal medicine. The challenge lies in finding a harmonious balance between ensuring clinical effectiveness and upholding environmental responsibility. This task involves recognising that the most significant reduction in the carbon footprint of endoscopy is achieved by avoiding unnecessary procedures; addressing the use of single-use endoscopes and accessories; and extending beyond the procedural suites to include clinics, virtual care, and conferences, among other aspects of gastrointestinal practice. The emerging digital realm in health care is crucial, given the potential environmental advantages of virtual gastroenterological care. Through an in-depth analysis, this review presents a path towards sustainable gastrointestinal practices, emphasising integrated strategies that prioritise both patient care and environmental stewardship.

Case report: The diagnostic dilemma of indeterminate biliary strictures: report on two cases with a literature review

Background

It is still a challenging problem for clinicians to explore the nature of the indeterminate biliary strictures (IBSs). Approximately 20% of biliary strictures remain undetermined after a thorough preoperative assessment.

Case presentation

Here, we present two cases of indeterminate biliary strictures patients, whose cross- sectional imaging and endoscopic examination were nondiagnostic. The patients underwent exploratory laparotomy finally and were confirmed as malignancy. We also reviewed the recent reports in literatures regarding the evaluation of IBSs.

Conclusions

Given the majority of the biliary strictures are malignancy, preoperative differentiation between benign and malignant is critical for choosing the best therapeutic regimen. Thus, close follow-up, multiple multidisciplinary discussion, and prompt surgical exploration are necessary for some difficult diagnostic cases.

Endoscopic-ultrasound-guided biliary drainage with placement of electrocautery-enhanced lumen-apposing metal stent for palliation of malignant biliary obstruction: Updated meta-analysis

BACKGROUND

Endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced (ECE) delivery of lumen-apposing metal stent (LAMS) is gradually being recognized as a viable palliative technique for malignant biliary obstruction after endoscopic retrograde cholangiopancreatography (ERCP) failure. However, most of the studies that have assessed its efficacy and safety were small and heterogeneous. Prior meta-analyses of six or fewer studies that were published 2 years ago were therefore underpowered to yield convincing evidence.

AIM

To update the efficacy and safety of ECE-LAMS for treatment of biliary obstruction after ERCP failure.

METHODS

We searched PubMed, EMBASE, and Scopus databases from the inception of the ECE technique to May 13, 2022. Primary outcome measure was pooled technical success rate, and secondary outcomes were pooled rates of clinical success, reintervention, and adverse events. Meta-analysis was performed using a random-effects model following Freeman-Tukey double-arcsine transformation in R software (version 4.1.3).

RESULTS

Fourteen eligible studies involving 620 participants were ultimately included. The pooled rate of technical success was 96.7%, and clinical success was 91.0%. Adverse events were reported in 17.5% of patients. Overall reintervention rate was 7.3%. Subgroup analyses showed results were generally consistent.

CONCLUSION

ECE-LAMS has favorable success with acceptable adverse events in relieving biliary obstruction when ERCP is impossible. The consistency of results across most subgroups suggested that this is a generalizable approach.

Advanced postoperative tissue antiadhesive membranes enabled with electrospun nanofibers

Tissue adhesion is one of the most common postoperative complications, which is frequently accompanied by inflammation, pain, and even dyskinesia, significantly reducing the quality of life of patients. Thus, to prevent the formation of tissue adhesions, various strategies have been explored. Among these methods, placing anti-adhesion membranes over the injured site to separate the wound from surrounding tissues is a simple and prominently favored method. Recently, electrospun nanofibers have been the most frequently investigated antiadhesive membranes due to their tunable porous structure and high porosities. They not only can act as an essential barrier and functional carrier system but also allow for high permeability and nutrient transport, showing great potential for preventing tissue adhesion. Herein, we provide a short review of the most recent applications of electrospun nanofibrous antiadhesive membranes in tendons, the abdominal cavity, dural sac, pericardium, and meninges. Firstly, each section highlights the most representative examples and they are sorted based on the latest progress of related research. Moreover, the design principles, preparation strategies, overall performances, and existing problems are highlighted and evaluated. Finally, the current challenges and several future ways to develop electrospun nanofibrous antiadhesive membranes are proposed. The systematic discussion and proposed directions can shed light on ideas and guide the reasonable design of electrospun nanofibrous membranes, contributing to the development of exceptional tissue anti-adhesive materials in the foreseeable future.

Clinical characteristics of acute non-varicose upper gastrointestinal bleeding and the effect of endoscopic hemostasis

BACKGROUND

Acute non-variceal upper gastrointestinal bleeding (ANVUGIB) constitutes a prevalent emergency within Gastroenterology, encompassing 80%-90% of all gastrointestinal hemorrhage incidents. This condition is distinguished by its abrupt onset, swift progression, and notably elevated mortality rate.

AIM

To gather clinical data from patients with ANVUGIB at our hospital in order to elucidate the clinical characteristics specific to our institution and analyze the therapeutic effectiveness of endoscopic hemostasis.

METHODS

We retrospectively retrieved the records of 532 patients diagnosed with ANVUGIB by endoscopy at our hospital between March 2021 and March 2023, utilizing our medical record system. Data pertaining to general patient information, etiological factors, disease outcomes, and other relevant variables were meticulously collected and analyzed.

RESULTS

Among the 532 patients diagnosed with ANVUGIB, the male-to-female ratio was 2.91:1, with a higher prevalence among males. Notably, 43.6% of patients presented with black stool as their primary complaint, while 27.4% had hematemesis as their initial symptom. Upon admission, 17% of patients exhibited both hematemesis and black stool, while most ANVUGIB patients primarily complained of overt gastrointestinal bleeding. Urgent routine blood examinations at admission revealed that 75.8% of patients had anemia, with 63.4% experiencing moderate to severe anemia, and 1.5% having extremely severe anemia (hemoglobin < 30 g/L). With regard to etiology, 53.2% of patients experienced bleeding without a definitive trigger, 24.2% had a history of using gastric mucosa-irritating medications, 24.2% developed bleeding after alcohol consumption, 2.8% attributed it to improper diet, 1.7% to emotional excitement, and 2.3% to fatigue preceding the bleeding episode. Drug-induced ANVUGIB was more prevalent in the elderly than middle-aged and young individuals, while bleeding due to alcohol consumption showed the opposite trend. Additionally, diet-related bleeding was more common among the young age group compared to the middle-aged group. Gastrointestinal endoscopy identified peptic ulcers as the most frequent cause of ANVUGIB (73.3%), followed by gastrointestinal malignancies (10.9%), acute gastric mucous lesions (9.8%), and androgenic upper gastrointestinal bleeding (1.5%) among inpatients with ANVUGIB. Of the 532 patients with gastrointestinal bleeding, 68 underwent endoscopic hemostasis, resulting in an endoscopic treatment rate of 12.8%, with a high immediate hemostasis success rate of 94.1%.

CONCLUSION

ANVUGIB patients exhibit diverse characteristics across different age groups, and endoscopic hemostatic treatments have demonstrated remarkable efficacy.

Early Endoscopic Interventions for Pancreatic Necrosis: Indications, Technique, and Outcomes

Endoscopic transmural drainage is usually performed for symptomatic well-encapsulated walled-off necrosis (WON) that usually develops in the delayed phase (> 4 weeks after disease onset) of acute necrotising pancreatitis (ANP). Endoscopic drainage is usually not advocated in the early (< 4 weeks after disease onset) stage of illness because of the risk of complications due to an incompletely formed encapsulating wall and poor demarcation of viable from necrotic tissue. However, emerging data from expert tertiary care centres over the last few years shows that the early endoscopic transluminal drainage approach is effective and safe. The development of lumen-apposing metal stents and better accessories for endoscopic necrosectomy has fuelled the expansion of indications of endoscopic drainage of pancreatic necrosis. However, early endoscopic drainage is associated with higher rates of adverse events; therefore, careful patient selection is paramount. This article will review the current indications, techniques and outcomes of early endoscopic transluminal drainage in pancreatic necrotic collections.

Endoscopic Ultrasound-Guided vs Endoscopic Retrograde Cholangiopancreatography-Guided Biliary Drainage as Primary Approach to Malignant Distal Biliary Obstruction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an alternative to endoscopic retrograde cholangiopancreatography (ERCP)-guided transpapillary drainage in malignant distal biliary obstruction (MDBO). This meta-analysis of randomized controlled trials (RCTs) aims to compare the outcomes of these 2 approaches.

METHODS

Electronic databases from January 2005 through December 2023 were searched for RCTs comparing outcomes of EUS-BD and ERCP for treating MDBO. Pooled proportions, risk ratio (RR), and odds ratio were calculated using random-effects models.

RESULTS

Five RCTs comprising 519 patients were included in the final analysis. The pooled RR for overall technical success with EUS-BD compared with ERCP was 1.05 (95% confidence interval [CI] = 0.96-1.16, P = 0.246, I2 = 61%) and for clinical success was 0.99 (95% CI = 0.95-1.04, P = 0.850, I2 = 0%). The pooled rate of procedure-related pancreatitis was 7.20% (95% CI = 3.60-13.80, I2 = 34%) in the ERCP group compared with zero in the EUS-BD group. The pooled RR for stent dysfunction with EUS-BD compared with ERCP was 0.48 (95% CI = 0.28-0.83, P = 0.008, I2 = 7%). The weighted mean procedure time was 13.43 (SD = 10.12) minutes for EUS-BD compared with 21.06 (SD = 6.64) minutes for ERCP. The mean stent patency was 194.11 (SD = 52.12) days in the EUS-BD group and 187 (SD = 60.70) days in the ERCP group.

DISCUSSION

EUS-BD is an efficient and safe alternative to ERCP in MDBO. An almost nonexistent risk of procedure-related pancreatitis, lower procedure time, and ease of use make this an attractive primary approach to biliary decompression in centers with expertise.

Endoscopic treatment for early duodenal papillary carcinoma: long-term outcomes

BACKGROUND AND AIM

This study aims to determine whether endoscopic papillectomy (EP) is a safe and effective treatment for early duodenal papillary carcinoma with long-term follow-up.

METHODS

From June 2012 to September 2022, 48 patients with early duodenal papilloma carcinoma who received endoscopic treatment were included. The histological types, percentage of complete resections, postoperative residuals, adverse events, and recurrences were evaluated.

RESULTS

EP was successful in all patients; 46 were lumped, and two were fragmented, with a 95.8% intact removal rate (46/48). The preoperative biopsy pathological positive rate was 70.8% (34/48). The incidence of early postoperative adverse events (within 1 month after EP) were 16.7% (8/48), including four cases of acute pancreatitis, three cases of delayed bleeding, and one case of acute cholangitis. In addition, 4.2% (2/48) of the late adverse events were bile duct stenosis. After 6 months, the postoperative residual rate was 0%. The median time to recurrence was 17.5 months, and the postoperative recurrence rate was 16.7% (8/48) in patients treated with radiofrequency ablation. The median progression-free survival was 18.6 months (95% CI, 12.1-25.1), and the median overall survival was 121.5 months (95% CI, 105.6-120.9).

CONCLUSIONS

EP is a safe and efficient alternative therapy for early duodenal papillary carcinoma. Endoscopic follow-up and treatment are essential because of the potential for recurrence.

Current interventional options for palliative care for patients with advanced-stage cholangiocarcinoma

Primary biliary tract tumors are malignancies that originate in the liver, bile ducts, or gallbladder. These tumors often present with jaundice of unknown etiology, leading to delayed diagnosis and advanced disease. Currently, several palliative treatment options are available for primary biliary tract tumors. They include percutaneous transhepatic biliary drainage (PTBD), biliary stenting, and surgical interventions such as biliary diversion. Systemic therapy is also commonly used for the palliative treatment of primary biliary tract tumors. It involves the administration of chemotherapy drugs, such as gemcitabine and cisplatin, which have shown promising results in improving overall survival in patients with advanced biliary tract tumors. PTBD is another palliative treatment option for patients with unresectable or inoperable malignant biliary obstruction. Biliary stenting can also be used as a palliative treatment option to alleviate symptoms in patients with unresectable or inoperable malignant biliary obstruction. Surgical interventions, such as biliary diversion, have traditionally been used as palliative options for primary biliary tract tumors. However, biliary diversion only provides temporary relief and does not remove the tumor. Primary biliary tract tumors often present in advanced stages, making palliative treatment the primary option for improving the quality of life of patients.

Verrucous gastritis-like lesion in intramucosal Helicobacter pylori-uninfected signet ring cell carcinoma with poorly differentiated adenocarcinoma

In Japan, accessible Helicobacter pylori (Hp) eradication therapy is associated with an increase in the prevalence of gastric cancers (GCs) in Hp uninfected stomachs. Signet ring cell carcinoma (SRCC) is the most common of these GCs. Intramucosal SRCC with poorly differentiated adenocarcinoma (PDA) occurring in Hp uninfected gastric mucosa is rare; furthermore, many Hp uninfected pure SRCCs exhibit discoloration and flat or slightly depressed lesions, and morphological elevation is relatively rare. We report a case of intramucosal SRCC with PDA with an elevated, verrucous gastritis-like lesion in a 57-year-old male patient. In the present case, the PDA area showed dense tumor cell growth and coexisting desmoplastic and fibrotic reactions. Histopathology and immunohistochemical staining identified extensive fibromuscular obliteration with smooth muscle bundles extending from the muscularis mucosa into the lamina propria. The patient underwent curative endoscopic submucosal dissection. The reporting and analysis of such rare cases may lead to a better understanding of the characteristics of advanced Hp uninfected GCs.

Impact of equipment technology on reference levels in fluoroscopy-guided gastrointestinal procedures

OBJECTIVES

To evaluate the effect of equipment technology on reference point air kerma (Ka,r), air kerma-area product (PKA), and fluoroscopic time for fluoroscopically-guided gastrointestinal endoscopic procedures and establish benchmark levels.

METHODS

This retrospective study included the consecutive patients who underwent fluoroscopically-guided gastrointestinal endoscopic procedures from May 2016 to August 2023 at a tertiary care hospital in the U.S. Fluoroscopic systems included (a) Omega CS-50 e-View, (b) GE Precision 500D, and (c) Siemens Cios Alpha. Radiation dose was analyzed for four procedure types of endoscopic retrograde biliary, pancreas, biliary and pancreas combined, and other guidance. Median and 75th percentile values were computed using software package R (version 4.0.5, R Foundation).

RESULTS

This large study analyzed 9,459 gastrointestinal endoscopic procedures. Among four procedure types, median Ka,r was 108.8-433.2 mGy (a), 70-272 mGy (b), and 22-55.1 mGy (c). Median PKA was 20.9-49.5 Gy∙cm2 (a), 13.4-39.7 Gy∙cm2 (b), and 8.91-20.9 Gy∙cm2 (c). Median fluoroscopic time was 2.8-8.1 min (a), 3.6-9.2 min (b), and 2.9-9.4 min (c). Their median value ratio (a:b:c) was 8.5:4.8:1 (Ka,r), 2.7:2.1:1 (PKA), and 1.0:1.1:1 (fluoroscopic time). Median value and 75th percentile are presented for Ka,r, PKA, and fluoroscopic time for each procedure type, which can function as benchmark for comparison for dose optimization studies.

CONCLUSION

This study shows manifold variation in doses (Ka,r and PKA) among three fluoroscopic equipment types and provides local reference levels (50th and 75th percentiles) for four gastrointestinal endoscopic procedure types. Besides procedure type, imaging technology should be considered for establishing diagnostic reference level.

SUMMARY

With manifold (2 to 12 times) variation in doses observed in this study among 3 machines, we recommend development of technology-based diagnostic reference levels for gastrointestinal endoscopic procedures.

Innovations to Improve Lung Isolation Training for Thoracic Anesthesia: A Narrative Review

A double-lumen tube or bronchial blocker positioning using flexible bronchoscopy for lung isolation and one-lung ventilation requires specific technical competencies. Training to acquire and retain such skills remains a challenge in thoracic anesthesia. Recent technological and innovative developments in the field of simulation have opened up exciting new horizons and possibilities. In this narrative review, we examine the latest development of existing training modalities while investigating, in particular, the use of emergent techniques such as virtual reality bronchoscopy simulation, virtual airway endoscopy, or the preoperative 3D printing of airways. The goal of this article is, therefore, to summarize the role of existing and future applications of training models/simulators and virtual reality simulators for training flexible bronchoscopy and lung isolation for thoracic anesthesia.

Balloon dilatation for congenital esophageal stenosis associated with esophageal atresia

PURPOSE

Congenital esophageal stenosis (CES) associated with esophageal atresia (EA) is rare, and no standard treatment has been established. We reviewed cases of EA-associated CES to assess the clinical characteristics and treatment outcomes, especially the feasibility of endoscopic dilatation.

METHODS

We retrospectively examined patients with EA-associated CES. We also compared treatment outcomes of EA-associated CES with those of EA patients without CES who developed postoperative anastomotic stricture.

RESULTS

Among 44 patients with EA, ten had CES (23%). Postoperative complications were not significantly different between EA patients with CES and those without CES but with anastomotic stricture. All CES patients underwent balloon dilatation as initial treatment. Eight of nine patients (89%) were successfully treated by dilatation only, and one patient underwent surgical resection. The median number of balloon dilatations for CES was five (2-17), which was higher than that for anastomotic stricture in patients without CES (p = 0.012). Esophageal perforation occurred in five patients with CES (5/9, 56%) after dilatation, but all perforations were successfully managed conservatively with an uneventful post-dilatation course.

CONCLUSIONS

Twenty-three percent of patients with EA had CES. Although balloon dilatation for EA-associated CES required multiple treatments and carried a risk of perforation, balloon dilatation showed an 89% success rate and all perforations could be managed conservatively.

Minimal endoscopic sphincterotomy followed by papillary balloon dilation to relieve choledocholithiasis in a 6-year-old girl with hereditary spherocytosis

A 6-year-old girl previously diagnosed with hereditary spherocytosis was admitted to our hospital with gallstones and cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, and fluoroscopy revealed a dilated common bile duct (CBD) without evident stones, possibly due to spontaneous excretion through the papilla of Vater. A 7-French plastic stent was inserted into the CBD. After the procedure, a marked increase in pancreatic enzyme levels was observed, and she was diagnosed with post-ERCP pancreatitis (PEP). Stent placement could have been a cause of pancreatitis; therefore, we removed the stent. Subsequently, recovery from pancreatitis was confirmed, although she suddenly complained of abdominal pain and was diagnosed with choledocholithiasis recurrence. ERCP was repeated, and fluoroscopy revealed a dilated CBD with a stone. A minimal endoscopic sphincterotomy (EST) was performed to reduce the risk of PEP, and a biliary dilation balloon placed across the papilla was gradually inflated until the waist of the balloon disappeared. Stones were extracted using a retrieval balloon catheter. The abdominal pain resolved immediately, and the patient recovered without developing PEP. To our knowledge, this is the first case report of a pediatric patient treated with minimal EST followed by papillary balloon dilation for choledocholithiasis.

Availability and utilization of endoscopic retrograde cholangiopancreatography at children's hospitals

OBJECTIVES

No study has explored whether availability of endoscopic retrograde cholangiopancreatography (ERCP) is adequate and equitable across US children's hospitals. We hypothesized that ERCP availability and utilization differs by geography and patient factors.

METHODS

Healthcare encounter data from 2009 to 2019 on children with pancreatic and biliary diseases from the Pediatric Health Information System were analyzed. ERCP availability was defined as treatment at a hospital that performed pediatric ERCP during the year of service.

RESULTS

From 2009 to 2019, 37,946 children (88,420 encounters) had a potential pancreatic or biliary indication for ERCP; 7066 ERCPs were performed. The commonest pancreatic diagnoses leading to ERCP were chronic (47.2%) and acute pancreatitis (43.2%); biliary diagnoses were calculus (68.3%) and obstruction (14.8%). No ERCP was available for 25.0% of pancreatic encounters and 8.1% of biliary encounters. In multivariable analysis, children with public insurance, rural residence, or of Black race were less likely to have pancreatic ERCP availability; those with rural residence or Asian race were less likely to have biliary ERCP availability. Black children or those with public insurance were less likely to undergo pancreatic ERCP where available. Among encounters for calculus or obstruction, those of Black race or admitted to hospitals in the West were less likely to undergo ERCP when available.

CONCLUSIONS

One-in-four children with pancreatic disorders and one-in-12 with biliary disorders may have limited access to ERCP. We identified racial and geographic disparities in availability and utilization of ERCP. Further studies are needed to understand these differences to ensure equitable care.

Colonic intussusception after endoscopic mucosal resection successfully managed by endoscopic procedure

Adult-onset intussusception, particularly associated with colonoscopy, is extremely rare. A 78-year-old man, referred to our hospital for colonic endoscopic mucosal resection (EMR), experienced subsequent dull abdominal pain, as well as elevated peripheral blood leukocytosis and C-reactive protein levels. Abdominal computed tomography (CT) revealed a colocolonic intussusception at the hepatic flexure. Emergency colonoscopy revealed ball-like swollen mucosa distal to the EMR site of the ascending colon. The mucosa was intact without necrosis. The endoscopic approach was able to temporarily release the intussusception. A transanal drainage tube was inserted through the endoscope to prevent relapse. Both CT and colonoscopy showed release of the intussusception. Our case underscores the importance of considering colocolonic intussusception in post-colonoscopy abdominal pain, advocating for endoscopic management after excluding mucosal necrosis.

Stenting as bridge to surgery versus upfront emergency resection for non-metastatic left sided obstructing colorectal cancer: risk of peritoneal recurrence and long-term outcomes

BACKGROUND

Oncological outcomes of stenting as a bridge to surgery (SBTS) remain a major concern, despite perioperative benefits it offers. This study aims to evaluate the differences in recurrence patterns and survival in patients with non-metastatic, obstructing left sided colon cancers treated by SBTS versus upfront emergency surgery (ES).

METHODS

This is a retrospective, single-centre cohort study of 227 consecutive patients with non-metastatic, obstructing left sided colon cancer between 2007 and 2016. Primary outcomes were pattern of recurrence, and survival. Univariate, bivariate and multivariate logistic regression were done to determine relationships between factors and recurrence. Kaplan Meier curves and log rank tests were used to analyse survival outcomes.

RESULTS

Of the 227 patients included, 62 underwent SBTS and 165 underwent upfront ES. There was a higher rate of peritoneal recurrence in SBTS group (27.4 vs 15.2% p = 0.034), with no difference observed in overall, liver or lung recurrences. No significant difference in overall survival (p = 0.11), cancer specific survival (p = 0.35), or recurrence free survival (p = 0.107) was observed. Univariate analysis showed that SBTS (OR 2.12, p = 0.036), diabetes mellitus (DM) (OR 2.58, p = 0.013), T4 (OR 2.81, p = 0.001), N + (OR 4.02, p = 0.001), lymphovascular invasion (OR 2.43, p = 0.011) contributed to a higher rate of peritoneal recurrence. Bivariate analysis showed synergistic relationship between T4 tumors and SBTS: in T4 tumors that underwent SBTS, the odds of having peritoneal recurrence was 6.8 times higher when compared to ES (p = 0.004); whilst in T2/3 tumors there was no significant difference observed (OR 1.33, p = 0.55). Multivariable analysis showed SBTS (OR 2.60, p = 0.04), DM (OR 2.88, p = 0.012), N + (OR 2.97, p = 0.026) were significant predictors for peritoneal recurrence.

CONCLUSIONS

There are concerns over oncological safety of SBTS even with low rates of stent-related perforation. Higher rates of peritoneal recurrence are seen especially with T4 colon cancers treated with SBTS. SBTS, DM and nodal stage were significant predictors for peritoneal recurrence.

Acute pericarditis as the presenting symptom of a case of oesophageal carcinoma

Oesophageal carcinoma is a globally prevalent form of cancer. Patients with advanced disease often experience progressive dysphagia and weight loss as initial symptoms, but pericarditis is an uncommon presentation. This study describes a young man who presented with pericarditis and was diagnosed with oesophageal squamous cell carcinoma. The patient's diagnosis came after presenting with intermittent chest pain. His diagnostic tests included an ECG showing ST elevation, echocardiography showing pericardial effusion and elevated inflammatory markers. His imaging tests revealed a neoplastic lesion in the lower oesophagus with metastases. He was initially treated as a case of pericarditis, followed by palliative chemotherapy for his cancer. Pericarditis, as the initial presentation of oesophageal carcinoma, is rare. There have only been 19 cases reported and published in the literature. Treatment depends on the stage of the disease. This case emphasises the importance of considering malignancy in unusual presentations of pericarditis, especially in young patients.

Celiac disease diagnosis from endoscopic images based on multi-scale adaptive hybrid architecture model

Objective. Celiac disease (CD) has emerged as a significant global public health concern, exhibiting an estimated worldwide prevalence of approximately 1%. However, existing research pertaining to domestic occurrences of CD is confined mainly to case reports and limited case analyses. Furthermore, there is a substantial population of undiagnosed patients in the Xinjiang region. This study endeavors to create a novel, high-performance, lightweight deep learning model utilizing endoscopic images from CD patients in Xinjiang as a dataset, with the intention of enhancing the accuracy of CD diagnosis.Approach. In this study, we propose a novel CNN-Transformer hybrid architecture for deep learning, tailored to the diagnosis of CD using endoscopic images. Within this architecture, a multi-scale spatial adaptive selective kernel convolution feature attention module demonstrates remarkable efficacy in diagnosing CD. Within this module, we dynamically capture salient features within the local channel feature map that correspond to distinct manifestations of endoscopic image lesions in the CD-affected areas such as the duodenal bulb, duodenal descending segment, and terminal ileum. This process serves to extract and fortify the spatial information specific to different lesions. This strategic approach facilitates not only the extraction of diverse lesion characteristics but also the attentive consideration of their spatial distribution. Additionally, we integrate the global representation of the feature map obtained from the Transformer with the locally extracted information via convolutional layers. This integration achieves a harmonious synergy that optimizes the diagnostic prowess of the model.Main results. Overall, the accuracy, specificity, F1-Score, and precision in the experimental results were 98.38%, 99.04%, 98.66% and 99.38%, respectively.Significance. This study introduces a deep learning network equipped with both global feature response and local feature extraction capabilities. This innovative architecture holds significant promise for the accurate diagnosis of CD by leveraging endoscopic images captured from diverse anatomical sites.

Solid pseudopapillary neoplasm (SPN) of the pancreas: current understanding on its malignant potential and management

Solid pseudopapillary neoplasms (SPN) of the pancreas are presently recognized as low-grade malignant tumors that are frequently observed in young females. This tumor has a low incidence and is associated with an excellent prognosis following surgical resection. Typical SPNs primarily affect the pancreas and tend to have moderate or asymptomatic manifestations. Based on retrospective research, it is anticipated that patients with SPN can achieve disease-free survival, even in cases when metastasis is detected during inspection. However, the incidence of malignant SPN has been consistently underestimated, as evidenced by recent research findings. Malignancy of SPN primarily encompasses invasion and infiltration, metastasis, and recurrence after R0 resection. Imaging technologies such as Ultrasound, Computed Tomography, Magnetic Resonance Imaging, and Position Emission Tomography are capable of preliminarily identifying malignant SPN, which is primarily based on its invasive clinical features. Research on risk factors of malignant SPN revealed that larger tumor size, Ki-67 index, and several other parameters had significant correlations with invasive tumor behavior. Pathologic features of malignant SPNs overlay other pancreatic tumors, nevertheless they can provide valuable assistance in the process of diagnosis. Several confirmed specific pathologic biomarkers are related to its cellular origin, characteristic gene mutation, and cell proliferation. Considering the invasiveness of malignant SPN, it is imperative to enhance the comprehensiveness of its therapy. Tumor resection remains a suggested course of action in line with typical SPN, and additional lymph node dissection is seen as reasonable. Compared to benign SPNs, malignant SPNs have worse prognosis, underscoring the necessity of early identification and treatment in comprehensive medical centers to get improved clinical outcomes.

Computed tomography for prediction of esophageal variceal bleeding

This letter to the editor relates to the study entitled “The role of computed tomography for the prediction of esophageal variceal bleeding: Current status and future perspectives”. Esophageal variceal bleeding (EVB) is one of the most common and severe complications related to portal hypertension (PH). Despite marked advances in its management during the last three decades, EVB is still associated with significant morbidity and mortality. The risk of first EVB is related to the severity of both PH and liver disease, and to the size and endoscopic appearance of esophageal varices. Indeed, hepatic venous pressure gradient (HVPG) and esophagogastroduodenoscopy (EGD) are currently recognized as the “gold standard” and the diagnostic reference standard for the prediction of EVB, respectively. However, HVPG is an invasive, expensive, and technically complex procedure, not widely available in clinical practice, whereas EGD is mainly limited by its invasive nature. In this scenario, computed tomography (CT) has been recently proposed as a promising modality for the non-invasive prediction of EVB. While CT serves solely as a diagnostic tool and cannot replace EGD or HVPG for delivering therapeutic and physiological information, it has the potential to enhance the prediction of EVB more effectively when combined with liver disease scores, HVPG, and EGD. However, to date, evidence concerning the role of CT in this setting is still lacking, therefore we aim to summarize and discuss the current evidence concerning the role of CT in predicting the risk of EVB.

Future directions of noninvasive prediction of esophageal variceal bleeding: No worry about the present computed tomography inefficiency

In this editorial, we comment on the minireview by Martino A, published in the recent issue of World Journal of Gastrointestinal Endoscopy 2023; 15 (12): 681-689. We focused mainly on the possibility of replacing the hepatic venous pressure gradient (HVPG) and endoscopy with noninvasive methods for predicting esophageal variceal bleeding. The risk factors for bleeding were the size of the varices, the red sign and the Child-Pugh score. The intrinsic core factor that drove these changes was the HVPG. Therefore, the present studies investigating noninvasive methods, including computed tomography, magnetic resonance imaging, elastography, and laboratory tests, are working on correlating imaging or serum marker data with intravenous pressure and clinical outcomes, such as bleeding. A single parameter is usually not enough to construct an efficient model. Therefore, multiple factors were used in most of the studies to construct predictive models. Encouraging results have been obtained, in which bleeding prediction was partly reached. However, these methods are not satisfactory enough to replace invasive methods, due to the many drawbacks of different studies. There is still plenty of room for future improvement. Prediction of the precise timing of bleeding using various models, and extracting the texture of variceal walls using high-definition imaging modalities to predict the red sign are interesting directions to lay investment on.

Could near focus endoscopy, narrow-band imaging, and acetic acid improve the visualization of microscopic features of stomach mucosa?

BACKGROUND

Conventional magnifying endoscopy with narrow-band imaging (NBI) observation of the gastric body mucosa shows dominant patterns in relation to the regular arrangement of collecting venules, subepithelial capillary network, and gastric pits.

AIM

To evaluate the effectiveness of a new one-dual (near) focus, NBI mode in the assessment of the microscopic features of gastric body mucosa compared to conventional magnification.

METHODS

During 2021 and 2022, 68 patients underwent proximal gastrointestinal endoscopy using magnification endoscopic modalities subsequently applying acetic acid (AA). The GIF-190HQ series NBI system with dual focus capability was used for the investigation of gastric mucosa. At the time of the endoscopy, the gastric body mucosa of all enrolled patients was photographed using the white light endoscopy (WLE), near focus (NF), NF-NBI, AA-NF, and AA-NF-NBI modes.

RESULTS

The WLE, NF and NF-NBI endoscopic modes for all patients (204 images) were classified in the same order into three groups. Two images from each patient for the AA-NF and AA-NF-NBI endoscopic modes were classified in the same order. According to all three observers who completed the work independently, NF magnification was significantly superior to WLE (P < 0.01), and the NF-NBI mode was significantly superior to NF magnification (P < 0.01). After applying AA, the three observers confirmed that AA-NF-NBI was significantly superior to AA-NF (P < 0.01). Interobserver kappa values for WLE were 0.609, 0.704, and 0.598, respectively and were 0.600, 0.721, and 0.637, respectively, for NF magnification. For the NF-NBI mode, the values were 0.378, 0.471, and 0.553, respectively. For AA-NF, they were 0.453, 0.603, and 0.480, respectively, and for AA-NF-NBI, they were 0.643, 0.506, and 0.354, respectively.

CONCLUSION

When investigating gastric mucosa in microscopic detail, NF-NBI was the most powerful endoscopic mode for assessing regular arrangement of collecting venules, subepithelial capillary network, and gastric pits among the five endoscopic modalities investigated in this study. AA-NF-NBI was the most powerful endoscopic mode for analyzing crypt opening and intervening part.

Precision in detecting colon lesions: A key to effective screening policy but will it improve overall outcomes?

Colonoscopy is the gold standard for the screening and diagnosis of colorectal cancer, resulting in a decrease in the incidence and mortality of colon cancer. However, it has a 21% rate of missed polyps. Several strategies have been devised to increase polyp detection rates and improve their characterization and delimitation. These include chromoendoscopy (CE), the use of other devices such as Endo cuffs, and major advances in endoscopic equipment [high definition, magnification, narrow band imaging, i-scan, flexible spectral imaging color enhancement, texture and color enhancement imaging (TXI), etc.]. In the retrospective study by Hiramatsu et al, they compared white-light imaging with CE, TXI, and CE + TXI to determine which of these strategies allows for better definition and delimitation of polyps. They concluded that employing CE associated with TXI stands out as the most effective method to utilize. It remains to be demonstrated whether these results are extrapolatable to other types of virtual CE. Additionally, further investigation is needed in order to ascertain whether this strategy could lead to a reduction in the recurrence of excised lesions and potentially lower the occurrence of interval cancer.

Computed tomography for the prediction of oesophageal variceal bleeding: A surrogate or complementary to the gold standard?

In this editorial we comment on the in-press article in the World Journal of Gastrointestinal endoscopy about the role of computed tomography (CT) for the prediction of esophageal variceal bleeding. The mortality and morbidity are much increased in patients with chronic liver diseases when complicated with variceal bleeding. Predicting the patient at a risk of bleeding is extremely important and receives a great deal of attention, paving the way for primary prophylaxis either using medical treatment including carvedilol or propranolol, or endoscopic band ligation. Endoscopic examination and the hepatic venous pressure gradient are the gold standards in the diagnosis and prediction of variceal bleeding. Several non-invasive laboratory and radiological examinations are used for the prediction of variceal bleeding. The contrast-enhanced multislice CT is a widely used non-invasive, radiological examination that has many advantages. In this editorial we briefly comment on the current research regarding the use of CT as a non-invasive tool in predicting the variceal bleeding.

The Effect of Tegoprazan on the Treatment of Endoscopic Resection-Induced Artificial Ulcers: A Multicenter, Randomized, Active-Controlled Study

Background/Aims

: Tegoprazan is a novel potassium-competitive acid blocker that has beneficial effects on acid-related disorders such as gastroesophageal reflux and peptic ulcer diseases. This study aimed to validate the effect of tegoprazan on endoscopic submucosal dissection (ESD)-induced artificial ulcers.

Methods

: Patients from 16 centers in Korea who underwent ESD for gastric neoplasia were enrolled. After ESD, pantoprazole was administered intravenously for 48 hours. The patients were randomly allocated to either the tegoprazan or esomeprazole group. Tegoprazan 50 mg or esomeprazole 40 mg were administered for 4 weeks, after which gastroscopic evaluation was performed. If the artificial ulcer had not healed, the same dose of tegoprazan or esomeprazole was administered for an additional 4 weeks, and a gastroscopic evaluation was performed.

Results

: One hundred sixty patients were enrolled in this study. The healing rates of artificial ulcers at 4 weeks were 30.3% (23/76) and 22.1% (15/68) in the tegoprazan and esomeprazole groups, respectively (p=0.006). At 8 weeks after ESD, the cumulative ulcer healing rates were 73.7% (56/76) and 77.9% (53/68) in the tegoprazan and esomeprazole groups, respectively (p=0.210). Delayed bleeding occurred in two patients in the tegoprazan group (2.6%) and in one patient in the esomeprazole group (1.5%). Other adverse events were negligible in both groups.

Conclusions

: Tegoprazan showed similar effects on post-ESD artificial ulcer healing in comparison with esomeprazole.

Management of obstructed colorectal carcinoma in an emergency setting: An update

Colorectal carcinoma is common, particularly on the left side. In 20% of patients, obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced (stage II, III or even IV). Diagnosis is based on clinical presentation, plain abdominal radiogram, computed tomography (CT), CT colonography and positron emission tomography/CT. The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes remains unknown. For the most common left-sided obstruction, the first choice should be either emergency surgery or endoscopic decompression by self-expendable metal stents or tubes. The operative plan should be either one-stage or two-stage resection. One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma (colostomy or ileostomy). Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity. Two-stage resection (Hartmann's procedure) is safer and the most widely used despite temporally affecting quality of life. Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing. For the less common right-sided obstruction, one-stage surgical resection is more beneficial than endoscopic decompression. The role of minimally invasive surgery (laparoscopic or robotic) is a subject of debate. Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rupture and subsequent septic complications. The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates. Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes. Management plans are crucial and must be individualized to better fit each case.

Comparison of vonoprazan and proton pump inhibitors for the treatment of gastric endoscopic submucosal dissection-induced ulcer: an updated systematic review and meta-analysis

BACKGROUND

Both vonoprazan and proton pump inhibitors (PPIs) are currently used to treat artificial ulcers after gastric endoscopic submucosal dissection. However, evidence-based medicine proving the efficacy of vonoprazan is still lacking. Therefore, this meta-analysis aimed to compare the efficacy of vonoprazan and PPIs for the treatment of artificial ulcers after gastric endoscopic submucosal dissection.

METHODS

The PubMed, EMBASE and Cochrane Library databases were searched up to September 2023 for related randomized controlled trials (RCTs). RCTs that compared the efficacy of vonoprazan and PPIs in treating artificial gastric ulcers after gastric endoscopic submucosal dissection were included. Two independent reviewers screened the included studies, extracted the data and assessed the risk of bias. The following outcomes were extracted for comparison: ulcer healing rate, ulcer shrinkage rate, delayed postoperative bleeding rate, and ulcer perforation rate.

RESULTS

Nine randomized controlled trials involving 926 patients were included. The pooled results showed that vonoprazan had a significantly lower rate of delayed postoperative bleeding than did PPIs (RR = 0.46; 95% CI = 0.23-0.91; P = 0.03). No significant differences were found in terms of ulcer healing, shrinkage rates, or ulcer perforation rates between vonoprazan and PPIs.

CONCLUSIONS

Compared with PPIs, vonoprazan is superior at reducing delayed postoperative bleeding after endoscopic submucosal dissection. However, further studies are needed to prove the efficacy of vonoprazan.

SYSTEMATIC REVIEW REGISTRATION

Identifier CRD42024509227.

Unraveling the enigma: A comprehensive review of solid pseudopapillary tumor of the pancreas

Solid pseudopapillary tumor of the pancreas (SPTP) is a rare neoplasm predominantly observed in young females. Pathologically, CTNNB1 mutations, β-catenin nuclear accumulation, and subsequent Wnt-signaling pathway activation are the leading molecular features. Accurate preoperative diagnosis often relies on imaging techniques and endoscopic biopsies. Surgical resection remains the mainstay treatment. Risk models, such as the Fudan Prognostic Index, show promise as predictive tools for assessing the prognosis of SPTP. Establishing three types of metachronous liver metastasis can be beneficial in tailoring individualized treatment and follow-up strategies. Despite advancements, challenges persist in understanding its etiology, establishing standardized treatments for unresectable or metastatic diseases, and developing a widely recognized grading system. This comprehensive review aims to elucidate the enigma by consolidating current knowledge on the epidemiology, clinical presentation, pathology, molecular characteristics, diagnostic methods, treatment options, and prognostic factors.

Circulatory resistin levels in inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

Inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), is a chronic relapsing-remitting systemic disease of the gastrointestinal tract with rising incidence. Studies have shown that adipocytes play a crucial role in patients with IBD by actively participating in systemic immune responses. The present study was designed to investigate the correlation between the circulatory levels of resistin, as an adipokine, and active and remission phases of IBD in comparison with healthy controls.

METHODS

Relevant articles were retrieved from PubMed, Embase, the Web of Science, and Scopus from inception until June 2023. Estimation of the standardized mean difference (SMD) and 95% confidence interval (CI) for comparison of plasma/serum resistin levels between IBD patients, patients in remission, and healthy controls were conducted through random-effect meta-analysis.

RESULTS

A total of 19 studies were included, assessing 1836 cases. Meta-analysis indicated that generally, serum/plasma resistin levels were higher in IBD patients in comparison with healthy controls (SMD 1.33, 95% CI 0.58 to 2.08, p-value < 0.01). This was true for each of the UC and CD separate analyses, as well. Moreover, it was shown that higher serum/plasma resistin levels were detected in the active phase of IBD than in the remission phase (SMD 1.04, 95% CI 0.65 to 1.42, p-value = 0.01). Finally, higher serum/plasma resistin levels were found in the remission phase compared to healthy controls (SMD 0.60, 95% CI 0.15 to 1.06, p-value < 0.01).

CONCLUSION

The results of this systematic review and meta-analysis support the conclusion that circulating resistin levels are increased in IBD (both UC and CD). Also, higher resistin levels were recorded in the remission phase of IBD in comparison with healthy controls. This indicates that further studies may provide valuable insights into the role of resistin in the pathogenesis of IBD.