Sounds of comfort: the impact of music therapy on labor pain and anxiety in primigravida women during vaginal delivery: a systematic review and meta-analysis

BACKGROUND

Music therapy has been widely used in medical practices, demonstrating positive effects on diverse medical procedures. In the context of labor pain management, evidence suggests that music can positively influence pain perception and overall well-being during labor, serving as a distraction and stress reducer. This systematic review and meta-analysis aim to comprehensively evaluate the impact of music therapy on labor pain in primigravida women during vaginal delivery.

METHODS

Following PRISMA guidelines, a thorough literature search was conducted in Google Scholar, PubMed, and Cochrane Central Register of Controlled Trials up to November 2023. Nine randomized control trials (RCTs) met the inclusion criteria, involving primigravida women undergoing vaginal delivery with music therapy intervention. Quality assessment was performed using the Cochrane Risk of Bias assessment tool.

RESULTS

A meta-analysis of the fixed effects was performed using mean differences (MD). Pooled analysis of Visual Analog Scale (VAS) scores revealed statistically significant reductions in pain intensity during latent (MD: - 0.73; 95% CI - 1.01; - 0.45); during the active phase (MD: - 0.56; 95% CI - 1.06; - 0.07) and the second stage (MD: - 0.69; 95% CI - 0.85; - 0.54). The findings indicated no statistically significant variances related to the integration of music therapy in addressing anxiety, both in the latent phase (MD: - 0.88; 95% CI - 1.86; -2.02) and the active phase of labor (MD: -0.30; 95% CI - 1.74; 1.13).

CONCLUSIONS

In conclusion, the collective evidence presented in this systematic review underscores the potential of music, especially for women giving for the first time. in mitigating labor pain and anxiety across different stages, offering a holistic approach to enhance the overall childbirth experience for women.

Novel non-curable resection prediction model for early colorectal cancer following endoscopic submucosal dissection based on inflammatory immune index

Backgrounds

Colorectal carcinoma represents one of the common malignant tumors of digestive tract in clinic. Systemic immune inflammation index (SII) has great potential in predicting prognosis of digestive tract tumors. We sought to explore the predictive ability of SII for non-curative resection of early colorectal cancer treated with ESD, and to establish a related predictive model.

Methods

A retrospective analysis was performed on data from patients with early-stage colorectal cancer who underwent ESD in our hospital between January 2019 and December 2022. To establish the optimal cut-off value for the SII, Receiver Operating Characteristic (ROC) curves were generated, correlating preoperative SII levels with postoperative resection outcomes. Patients were categorized into high SII and low SII groups, and their clinical characteristics were comparatively analyzed. Furthermore, patients were stratified according to the presence or absence of non-curative resection outcomes post-ESD, to identify independent risk factors associated with non-curative resection. A prognostic nomogram was subsequently developed to enhance predictive accuracy for non-curative resection, integrating identified risk variables.

Results

A total of 215 patients were enrolled in this study, all of whom successfully underwent ESD, achieving an en bloc resection rate of 96.7%. Based on surgical procedures and pathological resection characteristics, 181 cases were classified as curative resections, whereas 34 cases of non-curative resections. Postoperative complications occurred in 10 patients, resulting in a complication rate of 4.7%. The optimal cut-off value of SII was 629.2 × 10∧9/L (area under the curve: 0.762, P < 0.001), and the sensitivity and specificity was 64.7 and 85.6%, respectively. An optimal SII cut-off value for predicting non-curative resection was determined to be 1.56 (AUC: 0.571, 95% CI: 0.501-0.641). Multivariate analysis demonstrated that elevated SII (P = 0.002), a positive lifting sign (P = 0.003), increased tumor size (P = 0.034), and poor tumor differentiation (P < 0.001) were independent risk factors significantly associated with non-curative resection.

Conclusion

SII revealed well correlation in predicting non-curable resection in patients with early colorectal cancer treated by ESD. Meanwhile, the higher the patient's NLR, PLR, tumor diameter and infiltration depth, the more likely to occur postoperative non-curative resection.

Effect of proton pump inhibitors on occlusion of lumen-apposing metal stents and rate of endoscopic necrosectomies: a Europe-wide multicenter cohort study

BACKGROUND

 Lumen-apposing metal stents (LAMS) are widely used to drain walled-off necrosis (WON). LAMS occlusion is a significant clinical problem and identification of risk factors for LAMS occlusion could contribute to novel preventive strategies. A previous study suggested contradictory effects of proton pump inhibitors (PPIs) on occlusion and necrosectomy rates.

METHODS

 We conducted a Europe-wide multicenter retrospective cohort study assessing WONs drained by LAMS. The primary aims were to assess the strength of association between PPI intake and LAMS occlusion and necrosectomy rates, respectively. The secondary aim was to assess the strength of association between PPI intake and other LAMS-associated complications. Multiple mixed-effects models were used to control for possible confounding covariates.

RESULTS

 893 patients with 967 LAMS from 17 centers were included. After excluding incomplete datasets and patients who took PPIs intermittently, 768 LAMS remained. The overall occlusion rate was 28.0 %. Most occlusions occurred within 10 days. Most patients received PPIs continuously (n = 577 vs. no intake n = 191). In patients who did not use PPIs continuously, lower rates of LAMS occlusion (odds ratio [OR] 0.61, P = 0.04) and necrosectomies (incidence rate ratio 0.8, P = 0.006) were observed. A post hoc analysis exhibited a dose- and compound-dependent effect of PPI intake on necrosectomy rate. No increase in other complications in the non-PPI group, such as bleeding events (OR 1.14) were observed.

CONCLUSION

 PPI intake was associated with higher rates of LAMS occlusion and necrosectomy.

Interventional Endoscopic Ultrasonography: Advances in Application

Technological advances have greatly expanded the diagnostic and therapeutic capabilities of endoscopic ultrasound (EUS). The integration of cutting-edge imaging techniques, including tissue harmonic echo, contrast-enhanced harmonic EUS, elastography, and needle-based confocal laser endomicroscopy, have significantly enhanced lesion characterization and diagnostic accuracy. Additionally, developments in stent design and the introduction of new accessories have broadened the therapeutic applications of EUS. Ongoing innovations in clinical practice have transformed procedures such as drainage, tumor ablation, EUS-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP), the placement of fiducial markers, advancements in endohepatology, lesion characterization, and treatment. These developments continue to expand the role of EUS in delivering precise and effective therapeutic interventions.

Impact of Frailty on Care Burden of Hospitalized Older Adults Receiving Colonoscopy: A 2016-2020 Nationwide Inpatient Sample Analysis

BACKGROUND

Colonoscopy is a widely used diagnostic and therapeutic procedure. The impact of frailty on outcomes of hospitalized older patients undergoing colonoscopy is unclear. This study aims to evaluate associations between frailty and outcomes of hospitalized older adults undergoing colonoscopy.

METHODS

Data were extracted from the Nationwide Inpatient Sample (NIS), 2016-2020. Hospitalized patients ≥ 65 years old who underwent colonoscopy were included. Frailty was assessed using a modified frailty index (mFI), and frail was defined as mFI ≥ 0.27. The primary outcomes were in-hospital mortality, nonroutine discharge, prolonged length of stay (LOS) (≥ 75th percentile), postprocedural dysrhythmia, and other postprocedural complications.

RESULTS

A total of 142 257 hospitalized older adults were included, with 29 558 categorized as frail. The mean age was 77 years, and 54% were males. Frail patients had significantly higher in-hospital mortality (2.7% vs. 1.7%), nonroutine discharge (27.8% vs. 19.6%), prolonged LOS (33.9% vs. 24.2%), and postprocedural dysrhythmia (46.3% vs. 29.2%) compared to nonfrail patients (all, p < 0.001). After adjusting for covariates, frailty remained significantly associated with increased risks of in-hospital mortality (odds ratio [OR] = 1.60), nonroutine discharge (OR = 1.62), prolonged LOS (OR = 1.62), and postprocedural dysrhythmia (OR = 2.12). Stratified analyses by sex and age obtained the same results across all subgroups.

DISCUSSION

Frailty is significantly associated with adverse outcomes in hospitalized older adults undergoing colonoscopy. These findings highlight the importance of increased periprocedural care for frail patients to improve clinical outcomes and optimize resource utilization.

Synchronous neuroendocrine tumor and signet ring cell carcinoma in the stomach: a case report and review of literature

Synchronous neoplasms of the stomach are uncommon. Here we presented an unusual case with coexistence of neuroendocrine tumor and signet ring cell carcinoma in the stomach. Gastroscopic examination of a 66-year-old male patient showed a submucosal tumor-like mass with an ulcer on the surface located in the anterior wall of the lower segment of gastric body, confirmed by subsequent biopsy as a signet ring cell carcinoma. Moreover, we also found a slightly yellowish 6-mm protrusion simulating a polyp located in the lesser curvature of the upper segment of gastric body, and biopsy revealed it was a neuroendocrine tumor. The patient underwent a total gastrectomy with a standard D2 lymph node dissection. Pathohistological results led to the final diagnosis of synchronous neoplasms in the stomach, including a signet ring cell carcinoma and a neuroendocrine tumor.

Cap-assisted 5-cm diameter cold snare treatment for phytobezoars: A retrospective study

BACKGROUND AND AIMS

The current treatment options for phytobezoars include endoscopic therapy, chemical lysis, and surgical treatment. These methods are often less efficient or are associated with more adverse events in large-diameter phytobezoars. This study aimed to evaluate the feasibility, effectiveness, and safety of the cap-assisted 5-cm diameter cold snare technique for the treatment of huge phytobezoars.

METHODS

This retrospective study enrolled 24 patients with huge phytobezoars treated with the cap-assisted 5-cm diameter cold snare technique in the Department of Gastroenterology, Nanchong Central Hospital, between December 25, 2022, and October 1, 2023. Patients' clinical characteristics and bezoar features were evaluated, the procedure was recorded, and patients were reviewed and followed with gastroscopy 1 day and 1 month after the procedure.

RESULTS

Twenty-four patients with huge phytobezoars were treated with the cap-assisted 5-cm diameter cold snare technique during the study period. The median phytobezoar size, break-up time, and extraction time were 5 × 3 cm (range 4-10, 3-5), 10.08 minutes (range 3.31-31.48), and 9.63 minutes (range 6.5-35.71), respectively. All patients achieved satisfactory treatment results, with no residual phytobezoars or gastrointestinal injuries on gastroscopy review 1 day after the procedure, and no postoperative adverse events were found on gastroscopy follow-up 1 month after the procedure.

CONCLUSIONS

The results of this study indicated that the cap-assisted 5-cm diameter cold snare technique is safe, feasible, and effective for treating huge gastric bezoars, offering a new treatment method for this disease. Given the limitations inherent in the retrospective nature and relatively small sample size of this study, a prospective, multicenter, large-sample clinical trial is warranted to evaluate the efficacy and generalizability of this technique comprehensively.

Western Experience of Hepatolithiasis: Clinical Insights from a Case Series in a Tertiary Center

Background and Objectives: Hepatolithiasis (HL), or intrahepatic bile duct stone disease, shows regional variation and is a rare condition in Western countries. While cases from East Asia are often linked to chronic biliary infections and brown pigment stones, Western HL more frequently involves cholesterol or black pigment stones, typically in the context of prior cholecystectomy, biliary interventions, or congenital anomalies. The disease is generally associated with significant morbidity, including recurrent cholangitis, biliary strictures, and risk of cholangiocarcinoma. This study aimed to characterize HL disease in an Italian case series. Materials and Methods: We retrospectively reviewed 1450 patients with biliary stone disease treated between 2010 and 2024. HL was diagnosed in 14 patients (0.96%). Clinical records, imaging (ultrasound, CT, magnetic resonance cholangiopancreatography-MRCP, cholangiography), bile cultures, and stone composition (categorized as cholesterol, brown pigment, black pigment, or mixed using FTIR/XRD) were analyzed. Results: Among the 14 patients (mean age: 60.1 years; 64.3% female), 71.4% presented with recurrent cholangitis, while 28.6% were asymptomatic. Stones were left-sided in 57.1%, right-sided in 21.4%, and bilateral in 21.4%. Stone composition was cholesterol/mixed in 50%, brown pigment in 35.7%, and black pigment in 14.3%. Risk factors for bile stasis were present in 71.4% of cases. Bile cultures (available in nine cases) were positive in 77.8%. MRCP was highly effective for diagnosis. Hepatectomy achieved complete resolution in 35.7% of patients with unilobar disease; endoscopic/percutaneous therapy had a 44.4% recurrence rate. Interestingly, no cholangiocarcinoma was observed over a median follow-up of 4.8 years. Conclusions: Western HL is a rare, heterogeneous disease with distinct features. Cholesterol-predominant, infection-negative cases suggest a metabolic or surgical etiology. Hepatectomy offers durable outcomes in unilobar disease. Advanced imaging (MRCP, cholangioscopy) and personalized strategies are key to effective management.

The Application of Multifunctional Endoscope Transport Carts in Bedside Endoscopy in Intensive Care Unit Patients

Background

This study aimed to investigate whether the application of multifunctional endoscope transport carts, in bedside endoscopy in intensive care unit (ICU) patients, can improve the cleaning quality of the endoscopes.

Methods

A total of 175 endoscopes, used for bedside endoscopy in ICU patients in a hospital in China during November 2023 to January 2024, were randomly classified into the control group (n=88) and the experimental group (n=87). Multifunctional transport carts were used to deliver the endoscopes in the experimental group and traditionally used transport trolleys were used in the control group. Adenosine triphosphate (ATP) tests were performed to measure the relative light unit (RLU) values for the outer surfaces and forceps channels of the endoscopes, and a satisfaction survey was conducted with nurses who used the endoscope transport trolleys/carts and the endoscope cleaning staff.

Results

The ATP values for the outer surfaces and forceps channels of the endoscopes in the experimental group were 10.0 (6.0, 17.0) RLU and 7.0 (4.0, 11.0) RLU, respectively, lower than 33.5 (9.3, 77.0) RLU for outer surfaces and 14.0 (5.0, 39.8) RLU for forceps channels in the control group. The pass rates for cleaning quality of the outer surfaces and channels of the endoscopes in the experimental group were 98.9% and 100%, respectively, higher than 88.6% for outer surfaces and 93.2% for channels in the control group (P < 0.05). The satisfaction scores of the nurses who used the multifunctional endoscope transport carts and the endoscope cleaning staff in the experimental group were 39.7±1.87 and 18.45±1.41, respectively, higher than 19.83±2.08 for nurses and 9.08±1.71 for cleaning staff in the control group (P < 0.05).

Conclusion

The application of multifunctional endoscope transport carts in bedside endoscopy in ICU patients could improve the quality of endoscope cleaning.

Effects of the combined use of linaclotide and oral sulfate solution in bowel preparation for patients with chronic constipation undergoing colonoscopy: protocol of a prospective, randomised, controlled, single-blind clinical trial from a single centre in China

INTRODUCTION

Chronic constipation is an independent risk factor for inadequate bowel preparation. The objective of this study is to evaluate the effectiveness and safety of the combined use of linaclotide and oral sulfate solution (OSS) in patients with chronic constipation undergoing colonoscopy.

METHODS AND ANALYSIS

This is a prospective, randomised, controlled, single-blind (endoscopist) clinical trial that compares three bowel cleansing regimens for patients with chronic constipation undergoing colonoscopy. Regimen A consists of 2d-linaclotide and OSS, regimen B consists of 3d-linaclotide and OSS, and regimen C consists of OSS. All patients are required to consume a low-fibre diet for 3 days and then a clear fluid diet for 1 day before the colonoscopy. The primary outcome is adequate bowel preparation (defined as a Boston Bowel Preparation Scale (BBPS) score ≥2 for each segment and a total BBPS score ≥6). The secondary outcomes include defecation frequency, caecal intubation rate, adenoma detection rate and colonoscope insertion time and withdrawal time. The tertiary outcomes include complications of colonoscopy, adverse events and degree of comfort, which is evaluated via a self-designed questionnaire of comfort.

ETHICS AND DISSEMINATION

The research will be conducted according to Good Clinical Practice principles. Ethical approval has been obtained from the Ethics Committee of Beijing Shijitan Hospital, Capital Medical University (IIT2024-146-003). Study findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2500096394.

Risk factors for adverse reactions to nurse-administered propofol during outpatient endoscopy: a cross-sectional study

BACKGROUND

Endoscopic procedures are essential for diagnosing and managing gastrointestinal conditions, often requiring sedation for patient comfort. Propofol is a common choice for outpatient sedation due to its rapid onset and predictable recovery time. Although propofol has an established safety profile, adverse drug reactions (ADRs) can still occur. This study investigated the prevalence and risk factors associated with ADRs related to nurse-administered propofol sedation during outpatient endoscopic procedures at a private hospital in Peru.

METHOD

We conducted a retrospective study. The clinical records of 919 Peruvian patients who underwent endoscopic interventions under propofol sedation were reviewed. This study included patients between the ages of 18 and 69 years who had American Society of Anesthesiologists (ASA) physical status classification scores of I-III and who were hemodynamically stable with an oxygen saturation (SO2) > 90% before the procedure. Sedation was nurse-administered using standardized protocols. ADR data, including severity and causality assessment data, were collected. Data were collected and analyzed by SPSS, Inc., and the statistical significance was calculated at the p < 0.05 level.

RESULTS

A total of 693 patients were included in the study, 30.9% of whom experienced at least one ADR, predominantly cardiovascular or respiratory events such as hypotension and hypoxia, with causality scores classified as probable or definitive. Among the ADRs, 35.8% (n = 87) were moderately severe, and 64.2% (n = 143) were mildly severe. There were no reports of any serious adverse events. An ASA class III status (p = 0.048, PR adjusted (PRa) = 1.73, 95% CI: 1.01-2.99) and a procedure time of more than 20 min (p < 0.0001, PRa = 2.05, 95% CI: 1.53-2.73) were significant risk factors for ADR occurrence. Patients with ADRs had longer recovery times than did those without ADRs (22 min ± 22.5 vs. 14 min ± 8, respectively; p < 0.001).

CONCLUSION

In our work, moderate propofol sedation administered by trained nursing staff to outpatients undergoing interventional endoscopic procedures was generally safe but not free from risks. Vital parameters should be monitored regularly during long-term interventions and when patients are classified as ASA III.

The role of computed tomography and endoscopy in caustic esophageal injury in adults: a systematic review

Caustic esophageal injury can cause severe morbidity and mortality. Despite the need for emergent treatment, individual experience in diagnosis and management can be limited. Computed tomography (CT) has emerged as a promising non-invasive modality for assessing injury severity, but the clinical utility of both CT and endoscopy should be investigated. A systematic review was conducted following PRISMA guidelines. A comprehensive search of the PubMed database identified relevant articles published from January 1, 2000 to December 31, 2023. Inclusion criteria encompassed studies investigating the use of CT and/or endoscopy in diagnosing and managing caustic esophageal injury. Twelve articles were selected from a pool of 931 studies. Findings suggested that CT was superior in diagnostic capability to endoscopy in high-grade injury and stricture formation, but less so for low grade injuries. Diagnostic algorithms incorporating imaging with laboratory studies have emerged in the literature, which are promising pending additional validation. CT can serve as a valuable, non-invasive tool in the initial evaluation of caustic esophageal injury and is postulated to accurately predict both the need for emergent surgery and the risk of stricture formation. However, CT should not replace but rather complement the use of endoscopy to comprehensively evaluate these potentially highly morbid situations.

Effects of anesthetic nasal masks on hypoxemia in overweight/obese patients undergoing gastroscopy: a randomized controlled trial

BACKGROUND

Overweight and obese patients are at a higher risk of hypoxemia during sedated gastroscopy due to impaired respiratory function. The aim of this study was to investigate whether an anesthetic nasal mask could have a positive outcome in preventing hypoxemia in such patients compared with a conventional nasal catheter.

METHODS

This prospective, randomized controlled trial enrolled 146 overweight/obese patients (BMI ≥ 25 kg/m2) who underwent sedated gastroscopy from February 15, 2022, to December 31, 2022. Patients were randomly assigned (1:1) to receive oxygen via nasal masks or nasal cannulas using a computer-generated randomization sequence. The sample size was calculated based on an expected reduction in hypoxemia incidence from 40 to 15%, with a significance level of 0.05 and a power of 90%. Statisticians responsible for data analysis were blinded to group assignments. Both groups received standardized oxygen delivery with initial flow rates (5 L/min) to minimize procedural variability. The primary outcome was the incidence of hypoxemia (SpO2 ≤ 90%). Secondary outcomes included the incidence of severe hypoxemia, rescue airway interventions, and adverse events.

RESULTS

Of the 146 patients, 73 were assigned to the nasal mask group and 73 to the nasal cannula group. The incidence of hypoxemia was significantly lower in the nasal mask group (13.7%) compared with the nasal cannula group (37.0%; absolute risk reduction [ARR] = 23.3%, 95% CI 9.7-36.9%%, p = 0.002; relative risk reduction [RRR] = 63.0%). In addition, the nasal mask group required fewer rescue airway interventions, such as jaw thrusts and noninvasive ventilation. No significant differences were observed in adverse events between the two groups.

CONCLUSIONS

Nasal masks significantly reduce hypoxemia (with a 63% relative risk reduction) and the need for airway interventions during sedated gastroscopy in overweight/obese patients, without increasing adverse events. These findings support the use of nasal masks as an effective and safe airway management strategy for this patient population. Clinical trial registration number ChiCTR2100053388.

Current status and trends in ERCP and post-ERCP pancreatitis in Japan: a nationwide observational study

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is indispensable for the management of biliary and pancreatic diseases but carries a high risk of post-ERCP pancreatitis (PEP). This study aimed to clarify the current status and temporal trends of ERCP and PEP in Japan, including preventive measures.

METHODS

We conducted a retrospective, population-based cohort study using the Diagnosis Procedure Combination database from April 1, 2016, to March 31, 2023. Trend analyses were performed for ERCP, PEP, nonsteroidal anti-inflammatory drugs (NSAIDs), and protease inhibitors. Additionally, factors associated with PEP and severe PEP were evaluated.

RESULTS

Among the 1,073,513 ERCP cases, PEP and severe PEP incidences were 85,212 (7.9%) and 4841 cases (0.5%), respectively. The mortality rate was 0.5% for severe PEP and 0.2% for non-severe cases. The number of ERCP procedures and the proportion of therapeutic ERCP increased over time. The incidence of PEP declined from 9.1% in the fiscal year 2016-2017 to 6.4% in the fiscal year 2022, while the incidence of severe PEP decreased from 0.5 to 0.33% over the same period. The usage rate of rectal NSAIDs increased from 16.4 to 27.6%, whereas that of protease inhibitors decreased from 70.5 to 53.5%. The administration of rectal NSAIDs at doses of 20-25 mg and 50 mg was associated with a reduced risk of severe PEP.

CONCLUSIONS

The number of ERCP procedures and the proportion of therapeutic ERCP have increased, whereas the incidences of PEP and severe PEP have decreased. Rectal NSAIDs may prevent the progression of PEP to severe disease.

Racial Differences in Colorectal Adenomas at Screening Colonoscopy in the United States

BACKGROUND

Black Americans experience a higher incidence of colorectal cancer than Whites despite undergoing prevention screenings similar to those of Whites since 2010. We compared the colorectal adenoma status of Black and White patients at screening colonoscopy, a measure of colorectal cancer risk.

METHODS

Using cross-sectional, observational data, we studied colorectal adenomas at first-time screening colonoscopy in average-risk patients aged 40 to 89 years, screened between September 2001 and July 2016 in South Carolina. We analyzed the age-adjusted odds of Black men and women (vs. White) having adenomas, advanced adenomas, ≥3 nonadvanced adenomas, and right hyperplastic polyps, and compared their total polyp burden (the sum of the diameters of all adenomas and right polyps detected).

RESULTS

Among 28,100 patients (58.4% Black and 53.8% women), we found that Black patients had lower age- and gender-adjusted odds than White patients of having adenoma (OR = 0.88, P < 0.01) and right hyperplastic polyp (OR = 0.74, P < 0.01), with a similar pattern within gender groups. Black and White patients were similar about advanced adenoma and 3+ nonadvanced adenoma. Among patients with lesions, mean polyp burden ranged from 8.5 mm (±7.2) for Black women aged 40 to 49 years to 12.3 mm (±7.4) for Black men aged more than 70 years. Age-adjusted polyp burden was 0.4 mm higher for Black men than for White men and 0.3 mm lower for Black women than for White women patient groups (P < 0.01).

CONCLUSIONS

In a large, racially balanced patient sample, Black and White patients showed similar polyp profiles.

IMPACT

Given similar adenoma status, other evidence-supported clinical factors associated with suboptimal polyp detection should be explored to understand the continuing colorectal cancer disparities affecting Black Americans.

Bowel Perforation Caused by Biliary Stent Migration After ERCP: A Systematic Review

GOALS

This systematic review aims to evaluate the risk factors, clinical features, and outcomes of bowel perforation caused by stent migration after endoscopic retrograde cholangiopancreatography (ERCP).

BACKGROUND

Distal migration of biliary stents can occur after ERCP. Upon migration, most stents pass through the intestine without adverse events; however, bowel perforation has been reported.

STUDY

A comprehensive literature search of PubMed, EMBASE, and Cochrane databases was conducted through October 2023 for articles that reported bowel perforation because of stent migration. Cases of incomplete stent migration and proximal stent migration were excluded. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify full-length articles in English reporting.

RESULTS

Of 2041 articles retrieved on the initial search, 92 met the inclusion criteria. A total of 132 cases of bowel perforation occurred due to stent migration after ERCP (56.1% female; average age: 66 y). The median time from initial ERCP to perforation was 44.5 days (IQR 12.5-125.5). Most cases of perforation occurred in the small bowel (64.4%) compared with the colon (34.8%). Stents were mostly plastic (87.1%) with a median diameter of 10 Fr (IQR 8.5-10) and median length of 10.3 cm (IQR 715). Surgical management was pursued in 52.3% and endoscopic management in 42.4%. Bowel resection was required for 25.8% of patients. The overall mortality rate was 17.4%.

CONCLUSION

In summary, this study demonstrates that bowel perforation after ERCP stent migration primarily occurs within 44.5 days and most frequently with a 10 Fr plastic biliary stent. The overall mortality rate was 17.4%. It is important for endoscopists to be mindful of this rare but serious adverse event.

Evolving therapeutic approaches in achalasia: a comprehensive review of peroral endoscopic myotomy (POEM) vs. Heller's myotomy

This comprehensive narrative review thoroughly explores the treatment landscape for achalasia, a rare esophageal motility disorder. Beginning with an introduction outlining the anatomical and clinical aspects of achalasia, the review delves into its historical perspective, tracing the evolution of treatment options from early nonsurgical methods to advanced surgical techniques such as Heller's myotomy and peroral endoscopic myotomy (POEM). Technical perspectives on surgical interventions, including key steps, clinical practice guidelines, and modifications to POEM techniques, are extensively discussed. A comparative analysis between POEM and Heller's myotomy elucidates their indications, contraindications, efficacy, outcomes, and interventions for persistent symptoms or complications. Furthermore, the review explores the adverse events associated with both procedures, highlighting their safety profiles and management strategies. Finally, from a financial perspective, considerations such as operative time, hospital stay length, readmission rates, and quality-adjusted life years are examined, emphasizing the implications for patient decision-making. This review underscores the importance of a multidimensional approach to understanding and managing achalasia, advocating for further research to enhance treatment efficacy and reduce adverse effects.

Clinical and radiological features of gastric and small intestinal anisakiasis: comparison with gastric ulcers and crohn's disease

PURPOSE

To compare the clinical and radiological features of gastric and small intestinal anisakiasis with those of gastric ulcers and Crohn's disease.

MATERIALS AND METHODS

In this retrospective cohort study, 205 cases of anisakiasis (148 gastric; 53 small intestinal) were identified between July 2003 and February 2022. The control groups included 130 and 31 patients with gastric ulcers and Crohn's disease, respectively. Clinical and imaging findings were compared between the groups using the chi-square test, Fisher's exact test, Mann-Whitney U test, and t-test.

RESULTS

Patients with gastric anisakiasis were younger (median age, 40 [21-85] years; 87 men) than those with gastric ulcers (median age, 64.5 [29-90] years; 101 men). Abdominal pain was common in the gastric anisakiasis group, whereas bleeding symptoms were frequent in the gastric ulcer group. Patients with small intestinal anisakiasis were older (mean age, 51.2 [38.6-63.7] years; 44 men) than those with Crohn's disease (mean age, 35.9 [21.6-50.3] years; 22 men). Patients with gastric anisakiasis exhibited more edematous wall thickening, increased surrounding fat density, ascites, and thickening of other intestinal walls than those with gastric ulcers. Patients with small intestinal anisakiasis showed greater wall edema, perienteric fat stranding, proximal dilatation, clamp sign, and ascites than those with Crohn's disease. Interobserver agreement was moderate to excellent, except for esophageal findings.

CONCLUSION

Anisakiasis demonstrates clinical and radiological features distinct from those of gastric ulcers and Crohn's disease. Recognizing these differences may aid in the differential diagnosis of gastrointestinal disorders, particularly in regions with high levels of raw fish consumption. This retrospective study compared CT findings of gastric and small intestinal anisakiasis with gastric ulcers and Crohn's disease. Anisakiasis exhibited distinct features, including edematous wall thickening, increased surrounding fat density, and ascites. These findings can aid in differential diagnosis, particularly in regions where raw fish consumption is common.

Bright and Specific Targeting of Metastatic Lymph Nodes in Orthotopic Mouse Models of Gastric Cancer with a Fluorescent Anti-CEA Antibody

BACKGROUND

Gastric cancer poses a major diagnostic and therapeutic challenge. Improved visualization of tumor margins and lymph node metastases with tumor-specific fluorescent markers could improve outcomes.

METHODS

To establish orthotopic models of gastric cancer, one million cells of the human gastric cancer cell line, MKN45, were suspended in 50 μl of equal parts PBS and Matrigel and injected into the nude mouse stomach with a 29-gauge needle. Tumors were allowed to grow for 8-12 weeks before performing imaging studies. For tumor labeling, M5A (humanized anti-CEA mAb) and IgG as a control, were conjugated with the near-infrared dye IRDye800CW. Mice were randomized to receive 50 μg of M5A-IR800 (n = 14) or 50 μg of IgG-IR800 (n = 14) intravenously and were imaged 72 hours later. Fluorescence imaging was performed using the LI-COR Pearl Imaging System.

RESULTS

Forty-two lymph nodes were collected from 28 mice, of which 59.5% were found to contain metastatic gastric cancer cells on pathologic examination. In mice that received M5A-IR800, there was a statistically significant difference in the mean fluorescence signal for cancer-positive lymph nodes at 0.431 (SE ± 0.224) compared with 0.105 (SE ± 0.009) for cancer-negative nodes (p: 0.002). For IgG-IR800, there was no significant difference in the mean fluorescence signal for cancer-positive nodes (0.057) compared with cancer-negative nodes (0.064), p-value 0.677.

CONCLUSIONS

Humanized anti-CEA (M5A) antibodies conjugated to fluorescent dyes provide bright labeling of lymph nodes containing metastatic gastric cancer. This tumor-specific fluorescent antibody is a promising clinical tool for identifying lymph nodes containing metastatic gastric cancer.

Small Bowel Perforation in Roux-en-Y Gastric Bypass (RYGB) Secondary to Apolipoprotein A-IV (AApoA-IV) Type Amyloidosis

BACKGROUND

ApoA-IV amyloidosis is a rare disease that involves the deposition of ApoA-IV protein aggregates in tissues. It commonly presents as cardiac or renal disease, but can, in rare cases, cause small bowel perforation.

METHODS

This study describes a case of ApoA-IV type amyloidosis causing small bowel perforation after conversion of a sleeve gastrectomy (SG) into a RYGB in a Crohn's disease (CD) and rheumatoid arthritis (RA) patient. It also considers the indications for bariatric and anti-reflux surgery in the setting of co-morbid inflammatory bowel disease (IBD), gastro-oesophageal reflux disease (GORD), and obesity.

RESULTS

Obesity can reduce the efficacy of IBD medications and drives a pro-inflammatory state that may worsen IBD, however IBD patients present an operative challenge due to risk of more intestinal adhesions, potential intolerance to intestinal bypass, and risk of affecting options for future bowel resections if required. SG is often chosen over RYGB for CD patients due to limited short-term complications. However, when considering co-morbid GORD, the long-term risk of medication resistant GORD, erosive oesophagitis, and Barrett's oesophagus with SG is significant, especially given that SG is an irreversible procedure.

CONCLUSION

There is growing evidence that bariatric surgery in IBD patients is both safe and effective, however the decision to perform bariatric surgery in an IBD patient involves consideration of the intricate interplay between obesity and IBD.

A rare presentation of pleural pseudocyst in chronic calcific pancreatitis: A case report

Chronic calcific pancreatitis (CP) is a progressive inflammatory disorder that can lead to complications in multiple organ systems. Pleural pseudocysts, a rare thoracic manifestation of chronic pancreatitis, pose significant diagnostic and therapeutic challenges. This case report highlights the presentation, diagnostic approach, and management of a patient with pleural pseudocyst associated with chronic calcific pancreatitis. A 41-year-old male presented with a one-month history of abdominal pain and a persistent cough. Clinical evaluation and imaging revealed chronic calcific pancreatitis with multiple pseudocysts, left-sided hydropneumothorax, a right pleural pseudocyst, and massive ascites. Diagnostic imaging, including high-resolution computed tomography (HRCT) of the thorax and contrast-enhanced computed tomography (CECT) of the abdomen, confirmed the diagnosis. Biochemical analysis showed elevated amylase levels in pleural and ascitic fluids, consistent with pseudocyst rupture. The patient was managed conservatively with intercostal drain (ICD) insertion, pigtail catheterization, nasojejunal feeding, and broad-spectrum antibiotics. Despite stabilization, the patient declined further surgical interventions, including decortication and endoscopic retrograde cholangiopancreatography (ERCP). This case underscores the importance of a multidisciplinary approach in managing rare complications of chronic pancreatitis. Advanced imaging and biochemical analysis are pivotal for diagnosis, while nutritional optimization and minimally invasive interventions form the cornerstone of management. Definitive surgical or endoscopic procedures are often required but may be limited by patient preferences or resource constraints. Pleural pseudocyst is a rare but significant complication of chronic pancreatitis requiring prompt diagnosis and tailored management. This report emphasizes the role of a patient-centric approach in addressing complex clinical scenarios.

Bowel Blockage Without a Block: Amyloidosis Presenting as Chronic Intestinal Pseudo-Obstruction

We present the case of a 61-year-old man with a history of schizophrenia and non-ischemic cardiomyopathy who was admitted with chronic nausea, vomiting, and abdominal pain. His clinical course was marked by recurrent hospitalizations due to persistently dilated small bowel and multiple exploratory laparotomies, all failing to yield a definitive diagnosis, raising suspicion for chronic intestinal pseudo-obstruction. Extensive testing for vascular, paraneoplastic, infectious, and autoimmune causes was unremarkable. Given his unexplained cardiomyopathy and elevated serum light chains with a mild M spike, amyloidosis was suspected. A biopsy of the abdominal fat pad with Congo red staining confirmed amyloid deposition. His symptoms showed partial improvement with prucalopride, but he continues to require total parenteral nutrition and a venting gastrostomy tube for symptom management. Amyloid subtyping and a bone marrow biopsy are pending to determine the underlying etiology.

Digital single-operator cholangioscopy for difficult anastomotic biliary strictures in living donor liver transplant recipients after failure of standard ERCP: SPYPASS-2 study (with videos)

BACKGROUND AND AIMS

Liver transplantation (LT) is a curative treatment for end-stage liver disease. Anastomotic biliary strictures (ABSs) are more common in living donor LT (LDLT). However, the success rate of ERCP for ABSs remains unsatisfactory. In this study, we evaluated the efficacy of single-operator cholangioscopy (SOC) for ABS treatment in LDLT recipients where standard ERCP failed to access the stricture.

METHODS

This prospective study included 40 LDLT patients undergoing ERCP with SOC (SpyGlass DS II; Boston Scientific Corp, Natick, Mass, USA) to treat ABSs when guidewire placement across the ABS was difficult during conventional ERCP (cannulation time >10 minutes) between October 2021 and May 2023. Our primary endpoint was technical success, defined as successful guidewire placement across the ABS and/or subsequent treatment. Secondary endpoints were rates of clinical success, adverse events, and reintervention.

RESULTS

The mean patient age was 59.7 ± 7.2 years, and the mean time from LDLT to the occurrence of ABS was 212 ± 230 days. Technical and clinical success were achieved in 92.5% (37/40) and 82.5% (33/40) of patients, respectively. The rates of post-ERCP cholangitis, pancreatitis, and bleeding were 10.0%, 15.0%, and 2.5%, respectively. Intestinal perforation did not occur, and all adverse events were mild in severity. Early stent migration within 1 month occurred in 2 patients (5.4%), and 4 patients (10.8%) required reintervention within 1 month.

CONCLUSIONS

This study shows the efficacy and safety of SOC-facilitated management for difficult ABSs in LDLT patients after failure of standard ERCP. (Clinical trial registration number: NCT05065125.).

Minimally invasive treatment strategies for submucosal tumors of the upper gastrointestinal tract: Advances in innovative endoscopy-based therapies

The increasing detection of submucosal tumors (SMTs) in the upper gastrointestinal tract (UGI) is due to the increased clinical use of endoscopy and imaging technology. Some of these SMTs have malignant potential and may cause clinical symptoms. Thus, it is recommended in clinical guidelines to consider resection of these SMTs. Endoscopic techniques have become widely used in the diagnosis and treatment of SMT in the UGI as compared with traditional surgery due to their advantages of minimally invasive, quick recovery, and economical cost. Recently, new endoscopic techniques and instruments have been continuously implemented, leading to revolutionary innovation in endoscopic treatments. However, the safety and efficacy of these innovative techniques remain unclear. Therefore, we have comprehensively summarized the various techniques used in the treatment of UGI tumors in recent years, evaluated the indications and effects of each technique, and compared their benefits and disadvantages. We hope that this review will provide a more comprehensive reference for clinical and endoscopic practitioners, and help them develop more individualized treatment plans for different patients. This will ultimately expand the patient population that can benefit from these innovative technologies.

Surgical endoscopy a historical perspective for the future

BACKGROUND

Flexible endoscopy today is often assumed to be the exclusive domain of medical gastroenterologists. Surgeons however, have been, and continue to be, pioneers and practitioners of endoscopy, significantly advancing this minimally invasive field through their contributions.

METHODS

We present a historical review of the contributions surgeons have made in the creation and practice of flexible endoscopy - and offer our vision of the course of future collaborative development of the field.

RESULTS

Surgical endoscopists have and continue to have a tremendous impact on both the technology and techniques of flexible endoscopy. While the involvement of surgeons in flexible endoscopy varies from country to country, it remains a fundamental component of surgical training and an important part of the practice of many surgeons.

CONCLUSION

Flexible endoscopy has always been and continues to be an important patient care tool that is shared between medical gastroenterology and digestive surgery. "Turf war" efforts to restrict access to this important tool are unjustified and only serve to deprive patients of the dramatic benefits this tool offers.

A Predictive Model for Oral Intake Independence in Dysphagia Treatment

OBJECTIVE

One concern for patients suffering from dysphagia is whether their swallowing improves enough to allow oral intake. Predicting oral intake independence would be practical for deciding the treatment strategy, such as swallowing improvement surgeries, at an early stage. This study describes the prognostic factors and predictive method for achieving oral intake independence at discharge from acute care hospitals.

METHODS

A total of 128 patients managed by the dysphagia treatment team were retrospectively examined. They were divided into two groups: the independent oral intake group and the restricted oral intake group. The patients' age, sex, causes of dysphagia, calf circumference (CC), body mass index (BMI), Hyodo score obtained through flexible endoscopic evaluation, Food Intake Level Scale (FILS) score, and Dysphasia Severity Scale (DSS) score at the initial consultation were determined.

RESULTS

The independent group had 32 patients, whereas the restricted group had 96 patients. The independent group had higher CC, BMI, and number of dysphagia cases caused by stroke. This group also had lower Hyodo scores and higher DSS scores. Multiple logistic regression analysis revealed that the Hyodo score and CC were independent prognostic factors for oral intake independence. Moreover, the prediction model developed using both factors showed relatively high accuracy (sensitivity: 42.9%, specificity: 94.0%, predictive accuracy: 81.3%).

CONCLUSION

A lower Hyodo score and higher CC at the initial consultation may be positive prognostic factors for achieving oral intake independence. The predictive model exhibited high accuracy, indicating it may help in determining alternative treatment strategies for serious dysphagia patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:1661-1665, 2025.

Evaluating The Glasgow Blatchford Score for Upper Gastrointestinal Bleeding Risk Stratification in A Community Hospital: A Retrospective Study

INTRODUCTION

Upper gastrointestinal bleeding (UGIB) is the most common emergency in gastroenterology. The Glasgow Blatchford Score (GBS) is a validated tool used for risk stratification. The cutoff values for GBS to predict the need for clinical intervention, endoscopic treatment, and mortality, are not consistent. To determine the relationship between mean GBS score and the need for hemostatic intervention, and blood transfusion, and to evaluate quality of care and proper allocation of resources at our midwestern community hospital.

METHODS

In this cross-sectional study, we retrospectively extracted records for patients ≥18 years who were admitted for UGIB and underwent esophagogastroduodenoscopy between July 2018 and July 2020. GBS was calculated for each observation. Multivariate analysis and a logistic regression model were performed to predict the GBS score, and the odds ratio, associated with the need for hemostatic intervention and blood transfusion while controlling for confounding factors.

RESULTS

The GBS sample mean score was 11.17. Those who required hemostatic intervention and blood transfusion scored significantly higher GBS (13.18 versus 10.79) and (13.57 versus 9.21), respectively. A GBS of >10 was associated with higher odds at 21.84 (CI: 10.324,46.185, P<0.001) and 5.085 (CI: 1.864, 13.872, P=0.001) for receiving blood transfusion and hemostatic intervention, respectively. A cutoff of 10 was 22.41% sensitive and 95.41% specific for requiring hemostatic interventions and 66.67% sensitive and 89.91% specific for receiving blood transfusion.

CONCLUSION

There is a clinical role to using the GBS even at a score higher than 2 to further stratify the severity of UGIB and determine the need for intervention. The sensitivity of a score of 10 on the GBS in this dataset was low. A cutoff with higher sensitivity is needed to stratify a life-threatening condition such as UGIB.

Benign Tumors and Tumor-Like Conditions of Ampulla and Small Intestine: The PathologyOutlines.com Review

Small intestine and ampulla can be involved in a heterogeneous group of benign tumors and tumor-like diseases, potentially mimicking malignant neoplasms. In-depth knowledge of them is critical for practicing pathologists since they represent potential pitfalls in routine diagnostic activity. Such conditions include the following: (1) Brunner gland lesions, including Brunner gland hyperplasia and hamartoma; (2) polyps, such as adenoma, hyperplastic, hamartomatous, and inflammatory; (3) mesenchymal proliferations encompassing inflammatory fibroid polyp, inflammatory myofibroblastic tumor, leiomyomas, lipomas, and lipomatosis of the ileocecal valve; (4) fibrosis-associated diseases, such as idiopathic retroperitoneal fibrosis, reactive nodular fibrous pseudotumor, and sclerosing peritonitis; (5) disorders of lymphatic vessels, including lymphangiectasia and lymphangiomas; and (6) other rare conditions/miscellanea, such as enteritis cystica profunda, intussusception, ischemia, and pneumatosis cystoides intestinalis. This review, inspired by the content of the PathologyOutlines website (https://www.pathologyoutlines.com), aims to provide a reference point in this complex scenario, summarizing the essential histopathological features of all these entities for better addressing routine practice and differential diagnoses.

Long-term validation of intra-cystic biomarkers for pancreatic cysts

BACKGROUND

Pancreatic Cyst Lesions (PCLs) are frequently diagnosed in radiologic imaging tests and can be classified as benign, premalignant and malignant. Their correct stratification is essential and has significant implications for the patient. The objective of the study was to determine the clinical and analytical characteristics that can help in their differential diagnosis.

METHODS

This observational retrospective study included patients with PCLs diagnosed by endoscopic ultrasound from 2011 to 2023. Data collected included age, sex, personal history, treatments, toxic habits, family history of cancer, body mass index, and radiological and serological findings. The following intra-cyst levels were gathered: glucose, amylase, lipase, CEA and CA19.9.

RESULTS

271 patients with PCLs were included, 93 (35%) of them were benign, 55 (20%) were premalignant, and 123 (45%) malignant. Serous cystadenomas were the most common benign lesion in 71 (76%) patients. Within the premalignant group, intraductal papillary mucinous neoplasms (IPMNs) were the most common in 85% (47) patients. Cystic adenocarcinoma was the most prevalent malignant PCLs in 102 (83%) patients. Intra-cystic CEA value was the only parameter able to differentiate benign from malignant/premalignant lesions. Thirty (11%) patients underwent surgery with a final diagnosis of a malignant lesion in 13 (43%) patients, premalignant lesions in 5 (23%) (4 IPMNs and 1 mucinous cystadenoma) and benign cysts in 12 (40%). Five (38%) of the 13 malignant lesions were diagnosed at stages III/IV.

CONCLUSION

Intra-cyst CEA values can help us to classify premalignant PCNs. However, additional biomarkers and clinical parameters are required to better discriminate patients at the time of PCLs detection.

Surgical management of candy cane syndrome after Roux-en-Y bypass

BACKGROUND

Candy cane (CC) syndrome is a complication that occurs following Roux-en-Y bypass (RYGB), implicated as a long, small-bowel blind limb at gastrojejunostomy possibly caused using circular staplers.

OBJECTIVES

We aimed to report our experience with CC resection and improving outcomes following RYGB.

SETTING

University hospital.

METHODS

We performed a retrospective analysis of patients who underwent CC resection at our institution from 2017 to 2023. Patient's charts were then reviewed to evaluate for symptoms, operative, and weight data. Only patients with an afferent blind limb in the most direct outlet from the gastroesophageal junction (GJ) visualized in upper gastrointestinal (GI) study and endoscopy were included.

RESULTS

Twenty-nine patients had presented with symptoms of and underwent surgery of resection of the CC (83% female; 50.3 ± 12.9 years) within 11 ± 6 years after initial RYGB. In addition, 58.6% underwent a concomitant procedure (10 hiatal hernia repair, 4 revision gastrojejunostomy, and 3 internal hernia reduction and defect closure). The mean length of the CC was 7.5 ± 3.9 cm. Resection of CC was performed in 62.1% as stapling only, 34.5% as stapling and oversewing, and 3.4% as oversewing only. The 30-day hospital readmission rate was 7.4% (n = 2). At 8.5-month follow-up, there was a significant reduction (P < .005) of bloating, nausea or vomiting, and dysphagia; however, abdominal pain and diarrhea slightly decreased. The estimated weight loss percentage was 29.4% ± 5.6%, and body mass index decreased from 32.1 ± 7.3 kg/m2 to 29.1 ± 4.7 kg/m2.

CONCLUSIONS

Resection of blind afferent limb can be managed safely with excellent outcomes and resolution of symptoms, even if major procedures are performed concomitantly. Surgeons should resect excess Roux limb in the initial RYGB to decrease the likelihood of this syndrome.

Exploring intraprocedural performance in colonoscopy: Insights from a tertiary care center in Saudi Arabia

BACKGROUND

Colonoscopy is essential for diagnosing and managing colorectal conditions, and is recognized as the gold standard for early cancer detection and removal of precancerous lesions. The American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology have established benchmark indicators to minimize the risk of interval colorectal cancer. Despite their importance, research on these metrics in Saudi Arabia is limited. This study analyzes key intraprocedural indicators of colonoscopies at a tertiary care center to evaluate adherence to care standards.

METHODS

This retrospective study examined 3763 colonoscopies conducted by adult gastroenterologists at Johns Hopkins Aramco Healthcare from January 2021 to December 2022. Procedures were categorized as screening and non-screening, with demographic data collected alongside withdrawal time (WT), cecal intubation rate (CIR), polyp detection rate (PDR), adenoma detection rate (ADR), Boston Bowel Preparation Scale (BBPS), polyp retrieval rate, rectal retroflexion, and adverse events.

RESULTS

The mean age of participants was 54.13 years, with 81.56% of them Saudis and 44.6% female. The average WT was 10 min. The overall CIR was 93.6% (94.78% for screening), with a PDR of 33.9% and a retrieval rate of 96.6%. ADR for screening participants was 25.63%, and 88.94% of participants achieved a BBPS score of 6 or more. The adverse event rate was at 0.2%, primarily due to bleeding.

CONCLUSIONS

The study indicates that colonoscopy procedures adhere to care standards, with ADR among male screening patients approaching 30%. Further research is necessary to evaluate pre- and post-procedural indicators.

Assessment of Lubiprostone as an Adjunct Therapy for Bowel Preparation in Colonoscopy: A Meta-Analysis of Randomized Controlled Trials

Introduction

The quality of bowel preparation has a significant impact on the success of colonoscopy. Currently, osmotically balanced polyethylene glycol electrolyte (PEG-E) solutions are most commonly used for bowel preparation. Recently, lubiprostone (LBP) has been considered a potentially effective adjunct to PEG. We conducted a meta-analysis of randomized controlled trials (RCTs) to evaluate the safety and efficacy of LBP in bowel preparation for colonoscopy.

Methods

Following PRISMA guidelines, we systematically screened PubMed, Embase, Web of Science, and Cochrane Library for RCTs on LBP as an adjunct to PEG-E for improving bowel preparation quality for colonoscopy. Statistical analysis was performed on RevMan, using a random-effects model with the generic inverse variance method to address clinical heterogeneity; results were significant at p < 0.05. Outcomes were reported as relative risks and standard errors.

Results

This meta-analysis included seven RCTs with 1206 patients. Adding LBP did not increase the likelihood of an excellent bowel preparation [RR = 1.28, 95% CI: 0.94-1.74, p = 0.12] or contribute to poor preparation [RR = 0.61, 95% CI: 0.36-1.04; p = 0.07]. It also did not affect procedure time [MD = -0.74, 95% CI: -2.91-1.43; p = 0.50], polyp detection rate [RR = 1.07, 95% CI: 0.90-1.26; p = 0.45], or adenoma detection rate [RR = 1.09, 95% CI: 0.75-1.57; p = 0.66].

Conclusion

Our meta-analysis found that LBP, explored as an adjunct to PEG-E solutions for bowel preparation, offers no significant additive effect on preparation quality before colonoscopy.

Risk factors of stent migration in esophageal cancer patients who underwent fully-covered self-expanding metal stents for malignant dysphagia or tracheoesophageal fistula

BACKGROUND

More than 50% of esophageal cancer patients are diagnosed with advanced diseases and commonly experience dysphagia, some of whom even have tracheoesophageal fistula. Self-expandable metal stent (SEMS) is one of the recommended palliative methods, although complications such as chest pain and stent migration are not uncommon. The goal of this study was to examine the predictors of stent migration.

METHODS

We conducted a retrospective cohort study to include patients with esophageal cancer and dysphagia/tracheoesophageal fistula. Clinicopathological information, stent characteristics and patient outcomes were collected for analysis, while side-effects of SEMS were recorded, potential predictors were examined, and patients' nutritional outcomes were compared in the migration and non-migration groups.

RESULTS

A total of 54 patients with esophageal cancer who received fully covered SEMS between 2013 and 2022 were included. We found tumor across the esophagogastric junction (adjusted odds ratio (OR) = 32.64, P = 0.01) and the female sex (adjusted OR = 12.5, P = 0.02) were significant predictors for stent migration. There was a decreasing tendency in body mass index/body weight in migration and non-migration groups, but the former had a steeper downslope.

CONCLUSION

Fully covered SEMS is a safe and effective strategy to palliate dysphagia or fistula. Tumor across esophagogastric junction and the female sex were higher risk predictors of stent migration. A careful patient selection would optimize the effects of SEMS placement, especially in those with short-expected lifespan.

Endoscopic size measurement of colorectal polyps: a systematic review of techniques

Accurate size measurement of colorectal polyps is critical for clinical decision making and patient management. This systematic review aimed to evaluate the current techniques used for colonic polyp measurement to improve the reliability of size estimations in routine practice.A comprehensive literature search was conducted across PubMed, EMBASE, and MEDLINE to identify studies relevant to size measurement techniques published between 1980 and March 2024. The primary outcome was the accuracy of polyp sizing techniques used during colonoscopy.61 studies were included with 34 focusing on unassisted and assisted endoscopic visual estimation and 27 on computer-based tools. There was significant variability in visual size estimation among endoscopists. The most accurate techniques identified were computer-based systems, such as virtual scale endoscopes (VSE) and artificial intelligence (AI)-based systems. The least accurate techniques were visual or snare-based polyp size estimation. VSE assists endoscopists by providing an adaptive scale for real-time, direct, in vivo polyp measurements, while AI systems offer size measurements independent of the endoscopist's subjective judgment.This review highlights the need for standardized, accurate, and accessible techniques to optimize sizing accuracy during endoscopic procedures. There is no consensus on a gold standard for measuring polyps during colonoscopy. While biopsy forceps, snare, and graduated devices can improve the accuracy of visual size estimation, their clinical implementation is limited by practical, time, and cost challenges. Computer-based techniques will likely offer improved accuracy of polyp sizing in the near future.

Impact of atrial fibrillation on in-hospital outcomes following endoscopic retrograde cholangiopancreatography: a propensity score-matched analysis of the National Inpatient Sample (2016-2020)

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is a critical tool in managing hepatobiliary and pancreatic diseases. Atrial fibrillation (AF) has been associated with greater morbidity in patients undergoing ERCP. This study compared in-hospital ERCP outcomes in patients with and without AF.

Methods

This retrospective cohort study utilized data from the National Inpatient Sample (2016-2020). Patients who underwent ERCP during hospitalization were included. Patients with AF were matched 1:1 to those without AF, based on demographic and clinical variables. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included procedure-related and non-procedure-related complications, hospitalization cost and length of stay.

Results

The final matched sample consisted of 29,942 patients, with 14,971 in each group (AF and non-AF). Patients with AF demonstrated significantly higher in-hospital mortality compared to those without AF (3.6% vs. 1.9%; odds ratio [OR] 1.87, 95% confidence interval [CI] 1.62-2.17). The AF group had a significantly longer median length of stay (8.1 vs. 6.4 days; β 1.7; 95%CI 1.5-1.8) and incurred higher hospitalization costs ($111,000 vs. $87,255; β $23,745; 95%CI $20,783-26,708). In terms of complications, patients with AF had significantly higher rates of acute kidney injury (OR 1.33, 95%CI 1.27-1.40) and sepsis (OR 1.38, 95%CI 1.30-1.48). However, the rates of procedure-specific complications, including biliary perforation, post-ERCP pancreatitis and post-ERCP cholangitis, were similar between the 2 groups.

Conclusion

Patients with AF undergoing ERCP have higher in-hospital mortality, longer stays, greater costs, and higher rates of acute kidney injury and sepsis, although procedure-specific complication rates remain unaffected.

Simulation of gastroscopy and endoscopic retrograde cholangiopancreatography for medical student education

BACKGROUND

Simulation training has become part of medical student education, however endoscopy simulators have mostly been reserved for speciality training. Evidence suggests that simulation training has the potential to educate future doctors about endoscopy procedures and improve their communication with patients. Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic procedure that is technically challenging and poorly understood by medical students. This study aimed to investigate whether simulating gastroscopy and ERCP using an anatomical model of the upper gastrointestinal tract improves procedural knowledge, confidence, and performance in medical students.

METHODS

Students completed three attempts at gastroscopy and one attempt at ERCP using the model. Participants rated knowledge and confidence relating to endoscopic procedures before and after completing the simulation. Students also reported their attitudes towards endoscopic simulation training after their participation.

RESULTS

There was a significant increase in self-perceived knowledge of the purpose of and steps involved in endoscopy (P < 0.001), gastrointestinal anatomy (P = 0.003), and biliary system anatomy (P = 0.002) after using the simulator. Participants also reported significantly increased skills confidence in performing gastroscopy and duodenoscopy (P < 0.001), including in their ability to explain endoscopic procedures to a patient (P < 0.001). All participants agreed (5%) or strongly agreed (95%) that simulation training is a useful addition to their learning, and that they would like more simulation training in the medical curriculum.

CONCLUSION

Simulation training is an effective and engaging method of promoting procedural awareness and understanding of basic endoscopic procedures in medical students, with the potential to improve doctor-patient interactions in early clinical practice.

Characteristics of Clinically Significant Hyperplastic Polyps: Distinctions Between Microvesicular and Goblet Cell-Rich Types

BACKGROUND

Clinically significant serrated polyps (CSSPs) are defined as sessile serrated lesions (SSLs), SSLs with dysplasia, traditional serrated adenomas (TSAs), hyperplastic polyps (HPs) ≥ 10 mm, and HPs ≥ 6 mm in the proximal colon. HPs are further classified as microvesicular HPs (MVHPs) and goblet cell-rich HPs (GCHPs). Among CSSPs, HPs were categorized into clinically significant MVHPs (CS-MVHPs) and clinically significant GCHPs (CS-GCHPs). This study compares the characteristics of CS-MVHPs, CS-GCHPs, and SSLs.

METHODS

This study included patients who underwent colonoscopy at the Toyoshima Endoscopy Clinic between March 2021 and April 2024. Lesions diagnosed as adenomas or CSSPs were removed. Age, sex, number of polyps, detection rate, and polyp size were compared among CS-MVHPs, CS-GCHPs, and SSLs.

RESULTS

In total, 14 065 patients were enrolled. The detection rates for CS-MVHPs, CS-GCHPs, and SSLs were 5.24%, 1.22%, and 6.36%, respectively. Patients with CS-MVHPs or SSLs were significantly younger and more often female than those with CS-GCHPs. The mean sizes of CS-MVHPs and SSLs were significantly larger than that of CS-GCHPs. The detection rate of CS-GCHPs increased with age, whereas the detection rates of CS-MVHPs and SSLs did not show a similar trend.

CONCLUSIONS

Compared with CS-GCHPs, CS-MVHPs were larger, more frequent, and more likely to be found in younger patients and females. The characteristics of CS-MVHPs are similar to those of SSLs, supporting the hypothesis that CS-MVHPs are precursors of SSLs.

Quantitative measurement of tympanic membrane structure and symmetry with optical coherence tomography in normal human subjects

Significance

Early detection of ear pathology is essential for preventing hearing loss, yet the sensitivity of otoscopic examinations by primary care providers during annual physicals remains low. Optical coherence tomography (OCT) offers a promising alternative for detailed imaging of the tympanic membrane (TM) and middle ear (ME), providing the potential for early identification of ear disease.

Aim

We aim to develop a quantitative method for assessing symmetry between the right and left ears and to establish a baseline for this approach in normal subjects.

Approach

Volumetric OCT images were acquired from 12 normal subjects using a custom hand-held OCT otoscope. A volume registration and fusion method was applied to expand the TM field of view, followed by TM thickness measurement and generation of 3D thickness maps. The symmetry between left and right TMs was quantitatively analyzed using the Dice similarity coefficient.

Results

The average TM thickness was measured as 73.89 ± 14.79    μ m for left ears and 70.72 ± 11.58    μ m for right ears, with no statistically significant difference at the 0.05 level. The symmetry analysis revealed a mean similarity coefficient of 0.79 ± 0.02 between left and right ears among the 12 normal subjects.

Conclusions

OCT imaging enables quantitative assessment of TM thickness and symmetry, offering a baseline for identifying early ear pathologies.

Navigating the Complexities of Common Variable Immunodeficiency Enteropathy: From Established Therapies to Emerging Interventions

Common Variable Immunodeficiency (CVID) is a prevalent primary immunodeficiency in adults, marked by low immunoglobulin levels and recurrent infections. This review examines the gastrointestinal complications of CVID, including both infectious and non-infectious manifestations. It highlights therapeutic strategies, from antimicrobials to novel biologics, and the role of immune modulation. The review also explores the impact of gut microbiota dysbiosis on CVID pathogenesis and emphasizes the need for personalized treatment approaches and routine cancer screening due to the elevated risk of gastrointestinal malignancy in CVID patients.

The Third Pillar of Precision Medicine - Precision Delivery

Precision Medicine is thought of as having two main pillars: Precision Diagnosis and Precision Therapy. However, for Precision Medicine to reach its full potential, a third pillar is needed that we propose to call Precision Delivery. In the laboratory, many therapies show great efficacy when tested directly with target cells. However, upon clinical translation, they are often given via intravenous or oral administration, resulting in their systemic distribution. To ensure therapies reach target sites at the correct therapeutic levels, they are often given at higher concentrations. However, this can be associated with off-target effects, side-effects, and unwanted interactions. Delivery strategies can help mitigate this by "spatially re-coupling" therapies in vivo with target cells. This review explains the concept of Precision Delivery, which can be thought of as three interconnected, but independent, modules: targeted delivery, microenvironment modulation, and cellular interactions. While locoregional approaches directly deliver therapies into target tissues through endovascular, endoluminal, percutaneous, and implantation techniques, microenvironment modulation technologies facilitate the movement of therapies across biological barriers and through tissue matrices, so optimized therapies can reach and interact with target cells. We highlight new innovations driving advances in Precision Delivery, while also discussing the considerations and challenges that Precision Delivery faces as it becomes increasingly integrated into treatment workflows.

A New Drying Method of Thermolabile Flexible Endoscope Channels by Laminar and Turbulent Airflow: A Prospective, Randomized-Controlled, Single-Center, Proof-of-Concept Trial

INTRODUCTION

International guidelines suggest different possibilities for drying of endoscopes during reprocessing. Clinical results of these available drying methods are not satisfactory. The aim of this study was to compare the drying cycle of a standard endoscope washer-disinfector (EWD) (standard drying method [SD]) with a shortened mandatory drying by the EWD followed by a special drying device using laminar and turbulent air flow (novel drying method [ND]).

METHODS

Sixty endoscopes (duodenoscopes, colonoscocopes, and gastroscopes) from 3 different manufacturers underwent high-level disinfection and drying depending on the randomization group. Operational time of drying was measured for both groups. Residual fluid in the channels was measured using a laboratory scale. After a 14-day storage period, a sample of the endoscope channels was obtained to determine bacterial contamination.

RESULTS

ND had significantly fewer residual water in endoscope channels (SD: 90% vs ND: 0%; P < 0.001) after high-level disinfection and drying and less bacterial contamination after storage for 14 days (SD: 47% vs ND: 20%; P = 0.028). Time consumed for drying in ND was also significantly shorter (SD: 16 minutes 4 seconds vs ND: 5 minutes 59 seconds; P < 0.001).

DISCUSSION

Drying with a special automatic drying device was superior compared with an EWD's drying program as evidenced by no measurable residual water, reduced microbiological contamination, and a more than 2-fold decrease in operational time. Thus, drying by laminar and turbulent airflow may represent an attractive alternative to the currently used standard approach in the reprocessing process of flexible endoscopes.

Outcomes of lung transplantation for scleroderma versus other indications: Insigts from a single center

Background

Scleroderma is an autoimmune disease affecting the skin and internal organs, with pulmonary disease being the leading cause of mortality. Lung transplantation is a potential therapy, but its indication has been limited by concerns about complications, such as esophageal dysmotility.

Methods

A retrospective analysis was performed on 959 lung transplant patients from 2011 to 2023, including 77 with scleroderma-related lung disease. Survival rates, post-transplant complications, such as chronic lung allograft dysfunction, and acute cellular rejection rates.

Results

Scleroderma patients had higher mean pulmonary arterial pressure (32 vs. 24 mmHg, p < 0.001) and increased esophageal dysmotility (85% vs. 27%, p < 0.001). Double lung transplantation was more common (99% vs. 87%, p = 0.003). Scleroderma patients experienced higher rates of delayed chest closure (44% vs. 25%, p < 0.001), severe primary graft dysfunction at 72 hours (30% vs. 17%, p = 0.006), and longer mechanical ventilation (median 7 vs. 4 days, p = 0.002). They also required more gastrojejunostomy tubes (79% vs. 20%, p < 0.001) and had longer ICU stays (median 12 vs. 8 days, p = 0.007). However, adjusted competing risks regression showed no significant association between scleroderma and chronic lung allograft dysfunction (HR 0.69 [0.33 - 1.46], p = 0.31) or survival (HR 0.90 [0.56 - 1.45], p = 0.68).

Conclusions

Our findings suggest that lung transplantation might be an important therapeutic option for patients with scleroderma, showing outcomes similar to those of patients with different underlying conditions.

Non-interventional outcomes of adult foreign body ingestions

INTRODUCTION

Foreign body ingestions are a common problem in the emergency department. Patients often undergo invasive interventions that require significant resources. Current recommendations based on limited studies, are to attempt endoscopic removal of objects that are sharp or greater than 2.5 cm at or above the proximal duodenum. We hypothesized that many small and sharp objects will pass spontaneously without complication.

METHODS

We performed a retrospective study of all foreign bodies ingested by adults that were not removed initially by endoscopy over five years. We recorded foreign body size, shape and location, radiographic results, interventions performed, and demographic data. Regression analysis was used to determine any significant associations with the outcome of late intervention.

RESULTS

117 patients with 171 encounters met inclusion criteria with an average age of 33 years. 74 % of patients had a known psychiatric history. The most common foreign body was a razorblade. Fifteen patients had late intervention with twelve endoscopies and three exploratory laparotomies. 87 % of these late interventions were for failure to progress determined by the treatment team. There were no small bowel obstructions. One patient had a recto-sigmoid perforation from a pencil. Analysis indicates that size and sharpness were not significant risk factors for later intervention.

CONCLUSION

Our study indicates that small objects, even sharp foreign bodies including razorblades, can pass spontaneously without intervention. If larger, future studies show the same conclusion, there should be a reconsideration of current guidelines.

Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025

At a population level, the European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter and Microbiota Study Group (EHMSG), and the European Society of Pathology (ESP) suggest endoscopic screening for gastric cancer (and precancerous conditions) in high-risk regions (age-standardized rate [ASR] > 20 per 100 000 person-years) every 2 to 3 years or, if cost-effectiveness has been proven, in intermediate risk regions (ASR 10-20 per 100 000 person-years) every 5 years, but not in low-risk regions (ASR < 10).ESGE/EHMSG/ESP recommend that irrespective of country of origin, individual gastric risk assessment and stratification of precancerous conditions is recommended for first-time gastroscopy. ESGE/EHMSG/ESP suggest that gastric cancer screening or surveillance in asymptomatic individuals over 80 should be discontinued or not started, and that patients' comorbidities should be considered when treatment of superficial lesions is planned.ESGE/EHMSG/ESP recommend that a high quality endoscopy including the use of virtual chromoendoscopy (VCE), after proper training, is performed for screening, diagnosis, and staging of precancerous conditions (atrophy and intestinal metaplasia) and lesions (dysplasia or cancer), as well as after endoscopic therapy. VCE should be used to guide the sampling site for biopsies in the case of suspected neoplastic lesions as well as to guide biopsies for diagnosis and staging of gastric precancerous conditions, with random biopsies to be taken in the absence of endoscopically suspected changes. When there is a suspected early gastric neoplastic lesion, it should be properly described (location, size, Paris classification, vascular and mucosal pattern), photodocumented, and two targeted biopsies taken.ESGE/EHMSG/ESP do not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection unless there are signs of deep submucosal invasion or if the lesion is not considered suitable for endoscopic resection.ESGE/EHMSG/ESP recommend endoscopic submucosal dissection (ESD) for differentiated gastric lesions clinically staged as dysplastic (low grade and high grade) or as intramucosal carcinoma (of any size if not ulcerated or ≤ 30 mm if ulcerated), with EMR being an alternative for Paris 0-IIa lesions of size ≤ 10 mm with low likelihood of malignancy.ESGE/EHMSG/ESP suggest that a decision about ESD can be considered for malignant lesions clinically staged as having minimal submucosal invasion if differentiated and ≤ 30 mm; or for malignant lesions clinically staged as intramucosal, undifferentiated and ≤ 20 mm; and in both cases with no ulcerative findings.ESGE/EHMSG/ESP recommends patient management based on the following histological risk after endoscopic resection: Curative/very low-risk resection (lymph node metastasis [LNM] risk < 0.5 %-1 %): en bloc R0 resection; dysplastic/pT1a, differentiated lesion, no lymphovascular invasion, independent of size if no ulceration and ≤ 30 mm if ulcerated. No further staging procedure or treatment is recommended.Curative/low-risk resection (LNM risk < 3 %): en bloc R0 resection; lesion with no lymphovascular invasion and: a) pT1b, invasion ≤ 500 µm, differentiated, size ≤ 30 mm; or b) pT1a, undifferentiated, size ≤ 20 mm and no ulceration. Staging should be completed, and further treatment is generally not necessary, but a multidisciplinary discussion is required. Local-risk resection (very low risk of LNM but increased risk of local persistence/recurrence): Piecemeal resection or tumor-positive horizontal margin of a lesion otherwise meeting curative/very low-risk criteria (or meeting low-risk criteria provided that there is no submucosal invasive tumor at the resection margin in the case of piecemeal resection or tumor-positive horizontal margin for pT1b lesions [invasion ≤ 500 µm; well-differentiated; size ≤ 30 mm, and VM0]). Endoscopic surveillance/re-treatment is recommended rather than other additional treatment. High-risk resection (noncurative): Any lesion with any of the following: (a) a positive vertical margin (if carcinoma) or lymphovascular invasion or deep submucosal invasion (> 500 µm from the muscularis mucosae); (b) poorly differentiated lesions if ulceration or size > 20 mm; (c) pT1b differentiated lesions with submucosal invasion ≤ 500 µm with size > 30 mm; or (d) intramucosal ulcerative lesion with size > 30 mm. Complete staging and strong consideration for additional treatments (surgery) in multidisciplinary discussion.ESGE/EHMSG/ESP suggest the use of validated endoscopic classifications of atrophy (e. g. Kimura-Takemoto) or intestinal metaplasia (e. g. endoscopic grading of gastric intestinal metaplasia [EGGIM]) to endoscopically stage precancerous conditions and stratify the risk for gastric cancer.ESGE/EHMSG/ESP recommend that biopsies should be taken from at least two topographic sites (2 biopsies from the antrum/incisura and 2 from the corpus, guided by VCE) in two separate, clearly labeled vials. Additional biopsy from the incisura is optional.ESGE/EHMSG/ESP recommend that patients with extensive endoscopic changes (Kimura C3 + or EGGIM 5 +) or advanced histological stages of atrophic gastritis (severe atrophic changes or intestinal metaplasia, or changes in both antrum and corpus, operative link on gastritis assessment/operative link on gastric intestinal metaplasia [OLGA/OLGIM] III/IV) should be followed up with high quality endoscopy every 3 years, irrespective of the individual's country of origin.ESGE/EHMSG/ESP recommend that no surveillance is proposed for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history, incomplete intestinal metaplasia, persistent H. pylori infection). This group constitutes most individuals found in clinical practice.ESGE/EHMSG/ESP recommend H. pylori eradication for patients with precancerous conditions and after endoscopic or surgical therapy.ESGE/EHMSG/ESP recommend that patients should be advised to stop smoking and low-dose daily aspirin use may be considered for the prevention of gastric cancer in selected individuals with high risk for cardiovascular events.

Identification of risk factors associated with post-ERCP pancreatitis in patients with easy cannulation: a prospective multicenter observational study (with videos)

BACKGROUND AND AIMS

Difficult biliary cannulation is an independent risk factor for post-ERCP pancreatitis (PEP); however, there is a noticeable lack of studies focusing on the incidence and risk factors of PEP among patients undergoing easy cannulation. Therefore, we systematically investigated the risk factors for PEP in patients who underwent easy cannulation.

METHODS

We prospectively enrolled patients with naive major papillae who underwent diagnostic or therapeutic ERCP between June 2018 and June 2023. The primary endpoint was to determine the incidence of PEP in patients with easy cannulation; secondary endpoints were identifying PEP risk factors and evaluating procedure-related adverse events (AEs).

RESULTS

Overall, 1930 patients were included, with 1061 (54.9%) undergoing easy cannulation. Within this cohort, PEP incidence was 3.0%, whereas 2.9% experienced procedure-related AEs, excluding PEP. A history of acute pancreatitis (odds ratio [OR], 6.75; 95% confidence interval [CI], 1.83-20.14; P = .001) and acute cholangitis on admission (OR, 2.25; 95% CI, 1.07-5.08; P = .039) were identified as independent risk factors for PEP in patients with easy cannulation. Endoscopic sphincterotomy and biliary stent placement were independent factors for procedure-related AEs.

CONCLUSIONS

Our findings underscore the importance of assessing patient- and procedure-related factors to mitigate the risk of PEP in patients undergoing easy cannulation. Despite the low incidence of PEP, the potential for the occurrence of severe cases emphasizes the need for cautious intervention, particularly in patients with a history of acute pancreatitis and acute cholangitis on admission. (Clinical trial registration number: KCT0005950.).