The Present and Future of Colorectal Cancer Screening

There have been multiple recent updates for recommendations pertaining to colorectal cancer (CRC) screening. Among the most notable is the recommendation from several guideline-issuing bodies to initiate CRC screening examinations at 45 years of age for individuals at average risk for CRC. Current CRC screening methods include stool-based tests and colon visualization examinations. Currently recommended stool-based tests include fecal immunochemical testing, high-sensitivity guaiac-based fecal occult blood testing, and multitarget stool DNA testing. Visualization examinations include colonoscopy, computed tomography colonography, colon capsule endoscopy, and flexible sigmoidoscopy. Although these screening tests have shown encouraging results for CRC detection, there are important differences between these testing modalities for precursor lesion detection and management. In addition, emerging CRC screening methods are being developed and evaluated. However, additional large, multicenter clinical trials in diverse populations are needed to validate the diagnostic accuracy and generalizability of these new tests. This article reviews the recently updated CRC screening recommendations and current and emerging testing options.

Safety of same-day discharge after peroral endoscopic myotomy

There are limited data on the safety of same-day discharge (SDD) after peroral endoscopic myotomy (POEM). The aim of our study is to assess the frequency and relationship to POEM for emergency department (ED) visits and hospitalizations after SDD in these patients. We retrospectively identified consecutive patients between November 2019 and August 2021 who underwent POEM with SDD and at least 6 months follow-up. Criteria for SDD includes: (1) no serious procedure-related adverse event; (2) post-POEM esophagram without leak; (3) stable vital signs; (4) ability to take liquids orally; (5) pain controlled without IV analgesia; (6) adequate social support; (7) American Society of Anesthesiologists (ASA) class I-III. A causative relationship between POEM and ED visits and hospitalizations was assigned by consensus. Out of 185 POEMs performed, 78 (41.7%, 42M, mean 51±16 years) had SDD. Within 30 days of POEM, 8 ED visits occurred in 7/78 (9%) patients and 2 (25%) were considered related to POEM; hospitalization was required in 3 (38%). After 30 days, 11 ED visits occurred in 10/78 (12.8%) patients and 1 (9%) was considered related to POEM; hospitalization was required in 5 (45%). In this study of consecutive SDD patients after POEM, 3/19 (16%) ED visits and 2/8 (25%) hospitalizations within 6 months were considered related to the procedure. Therefore, eligible patients who follow and fulfill a strict protocol after POEM may be safely discharged the same day.

COLORECTAL POLYP DETECTION USING IMAGE ENHANCEMENT AND SCALED YOLOv4 ALGORITHM

Colorectal cancer (CRC) is the common cancer-related cause of death globally. It is now the third leading cause of cancer-related mortality worldwide. As the number of instances of colorectal polyps rises, it is more important than ever to identify and diagnose them early. Object detection models have recently become popular for extracting highly representative features. Colonoscopy is shown to be a useful diagnostic procedure for examining anomalies in the digestive system’s bottom half. This research presents a novel image-enhancing approach followed by a Scaled YOLOv4 Network for the early diagnosis of polyps, lowering the high risk of CRC therapy. The proposed network is trained using the CVC ClinicDB and the CVC ColonDB and the Etis Larib database are used for testing. On the CVC ColonDB database, the performance metrics are precision (95.13%), recall (74.92%), F1-score (83.19%), and F2-score (89.89%). On the ETIS Larib database, the performance metrics are precision (94.30%), recall (77.30%), F1-score (84.90%), and F2-score (80.20%). On both the databases, the suggested methodology outperforms the present one in terms of F1-score, F2-score, and precision compared to the futuristic method. The proposed Yolo object identification model provides an accurate polyp detection strategy in a real-time application.

Intraductal fully covered self-expanding metal stents in the management of post-liver transplant anastomotic strictures: a UK wide experience

Background

Fully covered intraductal self-expanding metal stents (IDSEMS) have been well described in the management of post-liver transplant (LT) anastomotic strictures (ASs). Their antimigration waists and intraductal nature make them suited for deployment across the biliary anastomosis.

Objectives

We conducted a multicentre study to analyse their use and efficacy in the management of AS.

Design

This was a retrospective, multicentre observational study across nine tertiary centres in the United Kingdom.

Methods

Consecutive patients who underwent endoscopic retrograde cholangiopancreatography with IDSEMS insertion were analysed retrospectively. Recorded variables included patient demographics, procedural characteristics, response to therapy and follow-up data.

Results

In all, 162 patients (100 males, 62%) underwent 176 episodes of IDSEMS insertion for AS. Aetiology of liver disease in this cohort included hepatocellular carcinoma (n = 35, 22%), followed by alcohol-related liver disease (n = 29, 18%), non-alcoholic steatohepatitis (n = 20, 12%), primary biliary cholangitis (n = 15, 9%), acute liver failure (n = 13, 8%), viral hepatitis (n = 13, 8%) and autoimmune hepatitis (n = 12, 7%). Early AS occurred in 25 (15%) cases, delayed in 32 (20%) cases and late in 95 (59%) cases. Age at transplant was 54 years (range, 12-74), and stent duration was 15 weeks (range, 3 days-78 weeks). In total, 131 (81%) had complete resolution of stricture at endoscopic re-evaluation. Stricture recurrence was observed in 13 (10%) cases, with a median of 19 weeks (range, 4-88 weeks) after stent removal. At removal, there were 21 (12%) adverse events, 5 (3%) episodes of cholangitis and 2 (1%) of pancreatitis. In 11 (6%) cases, the removal wires unravelled, and 3 (2%) stents migrated. All were removed endoscopically.

Conclusion

IDSEMS appears to be safe and highly efficacious in the management of post-LT AS, with low rates of AS recurrence.

Colon and Rectal Cancer Management in Low-Resource Settings

Colorectal cancer (CRC) incidence is rising in low- and middle-income countries, which also face disproportionate mortality from CRC, mainly due to diagnosis at late stages. Various challenges to CRC care exist at multiple societal levels in underserved populations. In this article, barriers to CRC care, strategies for screening, and treatment in resource-limited settings, and future directions are discussed within a global context.

Peroral Endoscopy Myotomy (POEM) for Esophageal Motility Disorders

PURPOSE OF REVIEW

This review aims to provide an overview of the current role of per oral endoscopic myotomy (POEM) in the management of primary esophageal motility disorders and treatment of Zenker's diverticulum.

RECENT FINDINGS

POEM has been shown to be an effective treatment for achalasia. Recent research has suggested that the length of myotomy may be tailored to the disease phenotype and that short myotomy may be equally effective compared to long myotomy. The role of intra-operative EndoFLIP has shown promise as a tool to assess of the adequacy of myotomy. Further research is needed to determine the role of POEM in other esophageal motility disorders and for treatment of Zenker's diverticulum. Per oral endoscopic myotomy has been shown to be an effective and durable treatment option for achalasia with additional potential roles for the treatment of other esophageal motility disorders and Zenker's diverticulum.

Early prediction of post-ERCP pancreatitis by post-procedure amylase and lipase levels: A systematic review and meta-analysis

Background and study aims  Post-ERCP pancreatitis (PEP) is the most common complication attributed to the procedure, its incidence being approximately 9.7 %. Numerous studies have evaluated the predictive efficacy of post-procedure serum amylase and lipase levels but with varied procedure-to-test time intervals and cut-off values. The aim of this meta-analysis was to present pooled data from available studies to compare the predictive accuracies of serum amylase and lipase for PEP. Patients and methods  A total of 18 studies were identified after a comprehensive search of various databases until June 2021 that reported the use of pancreatic enzymes for PEP. Results  The sample size consisted of 11,790 ERCPs, of which PEP occurred in 764 (6.48 %). Subgroups for serum lipase and amylase were created based on the cut-off used for diagnosing PEP, and meta-analysis was done for each subgroup. Results showed that serum lipase more than three to four times the upper limit of normal (ULN) performed within 2 to 4 hours of ERCP had the highest pooled sensitivity (92 %) for PEP. Amylase level more than five to six times the ULN was the most specific serum marker with a pooled specificity of 93 %. Conclusions  Our analysis indicates that a lipase level less than three times the ULN within 2 to 4 hours of ERCP can be used as a good predictor to rule out PEP when used as an adjunct to patient clinical presentation. Multicenter randomized controlled trials using lipase and amylase are warranted to further evaluate their PEP predictive accuracy, especially in high-risk patients.

Predictive Modeling of Colonoscopic Findings in a Fecal Immunochemical Test-Based Colorectal Cancer Screening Program

BACKGROUND

The fecal immunochemical test (FIT) is the primary modality used by the Los Angeles County Department of Health Services (LADHS) for colorectal cancer (CRC) screening in average-risk patients. Some patients referred for FIT-positive diagnostic colonoscopy have neither adenomas nor more advanced pathology. We aimed to identify predictors of false-positive FIT (FP-FIT) results in our largely disenfranchised, low socioeconomic status population.

METHODS

We conducted a retrospective study of 596 patients who underwent diagnostic colonoscopy following a positive screening FIT. Colonoscopies showing adenomas (or more advanced pathology) were considered positive. We employed multiple logistic and linear regression as well as machine learning models (MLMs) to identify clinical predictors of FP-FIT (primary outcome) and the presence of advanced adenomas (secondary outcome).

RESULTS

Overall, 268 patients (45.0%) had a FP-FIT. Female sex and hemorrhoids (odds ratios [ORs] 1.59 and 1.89, respectively) were associated with increased odds of FP-FIT and fewer advanced adenomas (β = - 0.658 and  - 0.516, respectively). Conversely, increasing age and BMI (ORs 0.94 and 0.96, respectively) were associated with decreased odds of FP-FIT and a greater number of advanced adenomas (β = 0.073 and 0.041, respectively). MLMs predicted FP-FIT with high specificity (93.8%) and presence of advanced adenoma with high sensitivity (94.4%).

CONCLUSION

Increasing age and BMI are associated with lower odds of FP-FIT and greater number of advanced adenomas, while female sex and hemorrhoids are associated with higher odds of FP-FIT and fewer advanced adenomas. The presence of the aforementioned predictors may inform the decision to proceed with diagnostic colonoscopy in FIT-positive patients.

Role of endoscopic ultrasound in vascular interventions: Where are we now?

From a mere diagnostic tool to an imperative treatment modality, endoscopic ultrasound (EUS) has evolved and revolutionized safer efficient options for vascular interventions. Currently it is an alternative treatment option in the management of gastrointestinal bleeding, primarily variceal type bleeding. Conventional treatment option prior to EUS incorporation had limited efficiency and high adverse events. The characterization and detail provided by EUS gives a cutting edge towards a holistically successful management choice. Data indicates that EUS-guided combination therapy of coil embolization and glue injection has the higher efficacy for the treatment of varices. Conversely, similar treatment options that exist for esophageal and other ectopic variceal bleeding was also outlined. In conclusion, many studies refer that a combination therapy of coil and glue injection under EUS guidance provides higher technical success with fewer recurrence and adverse events, making its adaptation in the guideline extremely favorable. Endo-hepatology is a novel disciple with a promising future outlook, we reviewed topics regarding portal vein access, pressure gradient measurement, and thrombus biopsy that are crucial interventions as alternative of radiological procedures. The purpose of this review is to provide an update on the latest available evidence in the literature regarding the role of EUS in vascular interventions. We reviewed the role of EUS in variceal bleeding in recent studies, especially gastric varices and novel approaches aimed at the portal vein.

Systematic review and meta-analysis of the incidence rates of adverse events after digestive endoscopy in children

BACKGROUND

With the widespread use of digestive endoscopy in children, a variety of adverse events (AEs) have occurred after digestive endoscopy. However, there are notable differences in the incidence of adverse reactions in digestive endoscopy in children at present, which makes it difficult to assess the safety of digestive endoscopy in children.

METHODS

Studies related to digestive endoscopy in children were screened from January 2005 to October 2021 from PubMed, Web of Science, Spring, CNKI, and Science Direct databases. RevMan5.3 and Stata were employed to carry out meta-analysis on the incidence of adverse respiratory events, myoclonus, abdominal pain, fever, bleeding, chest pain, sore throat, vomiting, and delayed capsule discharge after digestive endoscopy in children. The article quality was evaluated by the Agency for Healthcare Research and Quality (AHRQ). The chi-square test and I² were adopted to test literature heterogeneity, and the article publication bias was assessed by displaying an inverted funnel plot as a funnel plot.

RESULTS

In all, 15 articles were included, involving a total of 27,770 children. In all, 15 articles were included, involving a total of 27,770 children. The risk ratio (RR) value of adverse respiratory events after digestive endoscopy in children was 1.31 [95% confidence interval (CI): 1.17 to 1.47, P<0.00001]; the odds ratio (OR) value of the incidence of myoclonus was 1.21 (95% CI: 1.01 to 1.46, P=0.04); the incidence of abdominal pain was 1.18 (95% CI: 1.11 to 1.27, P<0.00001); the incidence of fever was 1.09 (95% CI: 1.06 to 1.12, P<0.00001); the incidence of bleeding was 1.24 (95% CI: 0.94 to 1.64, P=0.13); the incidence of chest pain was 1.06 (95% CI: 1.03 to 1.09, P<0.0001); incidence of sore throat was 1.11 (95% CI: 1.05 to 1.18, P=0.0004); incidence of vomiting was 1.13 (95% CI: 1.06 to 1.21, P=0.0001); and the incidence of delayed capsule expulsion was 1.18 (95% CI: 1.00 to 1.40, P=0.05).

DISCUSSION

The incidence of AEs after digestive endoscopy in children was low, which can be used in the diagnosis and therapy of digestive system diseases in children.

A novel machine learning model and a public online prediction platform for prediction of post-ERCP-cholecystitis (PEC)

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an established treatment for common bile duct (CBD) stones. Post- ERCP cholecystitis (PEC) is a known complication of such procedure and there are no effective models and clinical applicable tools for PEC prediction.

METHODS

A random forest (RF) machine learning model was developed to predict PEC. Eligible patients at The First Hospital of Lanzhou University in China with common bile duct (CBD) stones and gallbladders in-situ were enrolled from 2010 to 2019. Logistic regression analysis was used to compare the predictive discrimination and accuracy values based on receiver operation characteristics (ROC) curve and decision and clinical impact curve. The RF model was further validated by another 117 patients. This study was registered with ClinicalTrials.gov, NCT04234126.

FINDINGS

A total of 1117 patients were enrolled (90 PEC, 8.06%) to build the predictive model for PEC. The RF method identified white blood cell (WBC) count, endoscopic papillary balloon dilatation (EPBD), increase in WBC, residual CBD stones after ERCP, serum amylase levels, and mechanical lithotripsy as the top six predictive factors and has a sensitivity of 0.822, specificity of 0.853 and accuracy of 0.855, with the area under curve (AUC) value of 0.890. A separate logistic regression prediction model was built with sensitivity, specificity, and AUC of 0.811, 0.791, and 0.864, respectively. An additional 117 patients (11 PEC, 9.40%) were used to validate the RF model, with an AUC of 0.889 compared to an AUC of 0.884 with the logistic regression model.

INTERPRETATION

The results suggest that the proposed RF model based on the top six PEC risk factors could be a promising tool to predict the occurrence of PEC.

[The Latest Knowledge on Endoscopic Retrograde Cholangiopancreatography-related Pancreatitis]

ERCP has been established as a golden diagnostic and therapeutic modality in various pancreatobiliary diseases, including gallstones and malignancy. On the other hand, ERCP is a relatively invasive procedure with radiation hazards and major complications. Among the major complications, ERCP-related pancreatitis has been reported in more than 14.7% of high-risk patients, which might lead to extended hospitalization and a substantial burden for both patients and physicians. Recent guidelines have defined the high-risk factors for ERCP-related pancreatitis. In addition, several outstanding studies have shown that rectal non-steroidal anti-inflammatory drugs, aggressive hydration with lactated Ringer's solution, and pancreatic stents can reduce ERCP-related pancreatitis in high-risk patients or all patients. A prevention algorithm for ERCP-related pancreatitis was provided based on advanced research.

Recent advances in targeted drug delivery systems for resistant colorectal cancer

Colorectal cancer (CRC) is one of the deadliest cancers in the world, the incidences and morality rate are rising and poses an important threat to the public health. It is known that multiple drug resistance (MDR) is one of the major obstacles in CRC treatment. Tumor microenvironment plus genomic instability, tumor derived exosomes (TDE), cancer stem cells (CSCs), circulating tumor cells (CTCs), cell-free DNA (cfDNA), as well as cellular signaling pathways are important issues regarding resistance. Since non-targeted therapy causes toxicity, diverse side effects, and undesired efficacy, targeted therapy with contribution of various carriers has been developed to address the mentioned shortcomings. In this paper the underlying causes of MDR and then various targeting strategies including exosomes, liposomes, hydrogels, cell-based carriers and theranostics which are utilized to overcome therapeutic resistance will be described. We also discuss implication of emerging approaches involving single cell approaches and computer-aided drug delivery with high potential for meeting CRC medical needs.

Effect of Programmed Nursing Plan Based on Thinking Map Guidance Mode on Hemodynamics and Intestinal Function Recovery of Patients Undergoing Endoscopic Retrograde Cholangiopancreatography

ERCP is an effective method for the diagnosis and treatment of pancreatic and biliary diseases. With the improvement of endoscopes by researchers and the intubation and angiography technologies of medical workers, the role of ERCP in the diagnosis and treatment of pancreatic and biliary diseases has become increasingly important. Although ERCP is a minimally invasive diagnostic technique, it still falls into the category of surgery, and thus the physical and psychological dysfunction of patients undergoing ERCP caused by various factors such as surgery cannot be ignored. This study explored the effects of the procedural nursing plan based on the thinking map guidance mode on hemodynamics and intestinal function recovery of ERCP patients. The results showed that this plan could reduce the effects of ERCP on hemodynamics of patients, promote intestinal function recovery, relieve their bad psychology, reduce postoperative complications, and help to improve patients’ satisfaction with the nursing work, and it was worthy of promotion.

Diagnostic accuracy of a novel artificial intelligence system for adenoma detection in daily practice: a prospective nonrandomized comparative study

BACKGROUND

Adenoma detection rate (ADR) varies significantly between endoscopists, with adenoma miss rates (AMRs) up to 26 %. Artificial intelligence (AI) systems may improve endoscopy quality and reduce the rate of interval cancer. We evaluated the efficacy of an AI system in real-time colonoscopy and its influence on AMR and ADR.

METHODS

This prospective, nonrandomized, comparative study analyzed patients undergoing diagnostic colonoscopy at a single endoscopy center in Germany from June to October 2020. Every patient was examined concurrently by an endoscopist and AI using two opposing screens. The AI system, overseen by a second observer, was not visible to the endoscopist. AMR was the primary outcome. Both methods were compared using McNemar test.

RESULTS

150 patients were included (mean age 65 years [standard deviation 14]; 69 women). There was no significant or clinically relevant difference (P = 0.75) in AMR between the AI system (6/197, 3.0 %; 95 % confidence interval [CI] 1.1-6.5) and routine colonoscopy (4/197, 2.0 %; 95 %CI 0.6-5.1). The polyp miss rate of the AI system (14/311, 4.5 %; 95 %CI 2.5-7.4) was not significantly different (P = 0.72) from routine colonoscopy (17/311, 5.5 %; 95 %CI 3.2-8.6). There was no significant difference (P = 0.50) in ADR between routine colonoscopy (78/150, 52.0 %; 95 %CI 43.7-60.2) and the AI system (76/150, 50.7 %; 95 %CI 42.4-58.9). Routine colonoscopy detected adenomas in two patients that were missed by the AI system.

CONCLUSION

The AI system performance was comparable to that of experienced endoscopists during real-time colonoscopy with similar high ADR (> 50 %).

Adverse Events Associated With Peroral Endoscopic Myotomy Affecting Extended Hospital Stay: A Multi-center Retrospective Study in South Korea

Background/Aims

To analyze various adverse events (AEs) related to the peroral endoscopic myotomy (POEM) procedure and to analyze whether these AEs are related to an extended hospital stay.

Methods

Patients admitted for POEM for esophageal motility disorders from August 2012 to February 2020 at 5 centers were retrospectively collected. Length of hospital stay, AEs during or after the POEM procedure were analyzed.

Results

Of the 328 patients, 63.1% did not have any AEs, but 2.4% had major AEs, and 33.4% had minor AEs. Major AEs included mucosal injury, bleeding, and hemothorax, accounting for 1.5%, 0.6%, and 0.3%, respectively. Among the minor AEs, pneumoperitoneum was the most common gas-related AEs. Among non-gas-related minor AEs, pneumonia was the most common at 4.6%, followed by pain, fever, and pleural effusion. All major AEs had meaningful delayed discharge and significantly extended hospital stay compared to the no AEs group (median differences range 4.5-9.0 days). Among gas-related minor AEs, except for 4 cases of emphysema, the extended hospital stay was meaningless. All non-gas-related minor AEs was associated with a significant prolongation of hospital stay compared to that in the no AEs group (median differences range 2.0-4.0 days).

Conclusions

In conclusion, most gas-related minor AEs do not significantly affect the patient's clinical course. However, subcutaneous emphysema and minor non-gas related AEs such as pneumonia, pain, fever, and pleural effusion can prolong the hospital stay, therefore careful observation is required. Efforts will be made to reduce major AEs that significantly prolong hospitalization.

Clinical safety and outcomes of glucagon use during endoscopic retrograde cholangiopancreatography (ERCP)

Background and study aims  Injectable glucagon enables easier biliary cannulation by inhibiting gastrointestinal motility and decreasing the frequency and amplitude of phasic activity of the sphincter of Oddi during endoscopic retrograde cholangiopancreatography (ERCP). Data about the safety profile of glucagon use and patient clinical outcomes are scarce. Patients and methods  We used a federated cloud-based network research database, TriNetX, comprising 92 US healthcare organizations to find adult patients undergoing ERCP with glucagon use (Group A) vs. without using glucagon (Group B) from August 1, 2010, to August 1, 2021. The primary outcomes were rates of gastrointestinal bleeding, gastrointestinal perforation, post-ERCP pancreatitis, inpatient hospitalizations, and 30-day overall mortality measured after 1:1 propensity matching of the groups based on the baseline demographics and comorbidities. Results  There were 9,008 patients in Group A compared to 256,597 in Group B. After matching, Group A patients had lower rates of gastrointestinal bleeding (risk ratio [RR], 0.68; CI, 0.52-0.86), post-ERCP pancreatitis (RR, 0.64; CI, 0.58-71), inpatient hospitalization (RR 0.34; CI:0.32 to 0.36) and overall mortality (RR, 0.81; CI, 0.66-0.99). The rates of gastrointestinal perforation (RR, 0.64; CI: 0.34 to 1.19), hyperkalemia (RR, 0.83; CI, 0.64-1.09) and hyperglycemia (RR, 0.65; CI, 0.41-1.03) did not differ between the two groups. Discussion  Glucagon use during ERCP was associated with low rates of gastrointestinal bleeding, post-ERCP pancreatitis, inpatient hospitalization, and overall mortality. Moreover, the rates of hyperkalemia and hyperglycemia did not differ between the two groups even after matching for diabetes, indomethacin use, obesity, and chronic kidney disease.

Gender-Specific Coagulation Profiles of Peripheral and Portal Blood May Help to Differentiate Malignant from Benign Pancreatic Tumour-Pilot Study

Objective: Pancreatic adenocarcinoma (PDAC) and mass forming chronic pancreatitis (CP) can be easily misdiagnosed due to their resemblances in clinical, radiological, and biochemical criteria. In our previous study, we reported a very high concentration of D-Dimers in portal blood in patients with pancreatic cancer which may help to differentiate malignant from benign pancreatic tumours. In this study, we aim to describe other portal and peripheral coagulation profiles of PDAC in comparison to CP patients, as well to test the hypothesis; thus, it is possible to distinguish pancreatic malignancy and benign tumour based on these parameters. Methods: We included retrospectively 115 patients with the absence of venous thromboembolism (VTE), qualified to surgical treatment due to pancreatic tumours, both PDAC and CP. Patients underwent surgery in General and Transplant Surgery Unit of Medical University of Lodz between December 2011 and February 2014. Patients with distant metastases diagnosed before or during the surgery were excluded. The coagulation profile, which includes fibrinogen, activated partial thromboplastin time (aPTT), prothrombin time (PT), and thrombin time (TT), was determined in blood samples from the portal and peripheral vein taken intraoperatively. Results: The fibrinogen level was higher and the aPTT index shortened in the peripheral and portal blood of the PDAC group, which reflects the well-known link between PDAC and general hypercoagulability. Furthermore, these effects are sex-specific. The mean age in the CP group was lower than in the PDAC group (54.63 ± 12.37 vs. 63.77 ± 3.23, p < 0.001) and correlated with the fibrinogen distribution in male patients with CP (portal r = 0.34; p = 0.07; peripheral r = 0.39; p = 0.04). We calculated sex-specific logistic regression models (male: peripheral aPTT and age, AUC: 0.795, female: portal fibrinogen and age, AUC: 0.805), both maintaining the good discrimination properties after V-fold cross validation (0.759, 0.742). Conclusions: Our study shows that the differences between coagulation profiles in PDAC and CP patients not only seems to be a reflection of gender-specific biological features, but also helps to discriminate between them. The main goal of the study was to explore the biology of pancreatic cancer and lay a solid base for further investigations of PDAC biomarkers. This paper is the first to describe the detailed coagulation profile in portal blood in patients with pancreatic solid tumors. At present, the clinical application of our results is not clear; however, we hope that it may improve our understanding of this complex disease.

Applications of Artificial Intelligence in Screening, Diagnosis, Treatment, and Prognosis of Colorectal Cancer

Colorectal cancer (CRC) is one of the most common cancers worldwide. Accurate early detection and diagnosis, comprehensive assessment of treatment response, and precise prediction of prognosis are essential to improve the patients’ survival rate. In recent years, due to the explosion of clinical and omics data, and groundbreaking research in machine learning, artificial intelligence (AI) has shown a great application potential in clinical field of CRC, providing new auxiliary approaches for clinicians to identify high-risk patients, select precise and personalized treatment plans, as well as to predict prognoses. This review comprehensively analyzes and summarizes the research progress and clinical application value of AI technologies in CRC screening, diagnosis, treatment, and prognosis, demonstrating the current status of the AI in the main clinical stages. The limitations, challenges, and future perspectives in the clinical implementation of AI are also discussed.

Large Hepatic Subcapsular Hematoma Following Endoscopic Retrograde Cholangiopancreatography: A Case Report

For decades, endoscopic retrograde cholangiopancreatography (ERCP) has been the cornerstone in the treatment of several biliopancreatic diseases. Although it is a relatively safe procedure, there are certain hazards involved. Hepatic subcapsular hematoma (HSH) is an uncommon complication of ERCP, with only a few cases reported in the literature to date. We present here a case of large HSH that developed 48 hours after an otherwise uneventful ERCP for choledocholithiasis. After being apparently well for the first two days post-ERCP, the patient began to develop abdominal pain and restlessness associated with hemodynamic instability and a decline in hemoglobin levels. Computed tomography (CT) confirmed the presence of a large HSH. The patient was managed nonsurgically with vascular angioembolization followed by ultrasound-guided percutaneous catheter drainage of hematoma. This case highlights the necessity of increasing awareness about this complication in order to aid in early diagnosis and management.

Endoscopic retrograde cholangiopancreatography-related adverse events in Korea: A nationwide assessment

BACKGROUND

Although endoscopic retrograde cholangiopancreatography (ERCP) is a pivotal procedure for the diagnosis and treatment of a variety of pancreatobiliary diseases, it has been known that the risk of procedure-related adverse events (AEs) is significant.

OBJECTIVE

We conducted this nationwide cohort study since there have been few reports on the real-world data regarding ERCP-related AEs.

METHODS

Patients who underwent ERCP were identified between 2012 and 2015 using Health Insurance Review and Assessment database generated by the Korea government. Incidence, annual trends, demographics, characteristics according to the types of procedures, and the risk factors of AEs were assessed.

RESULTS

A total of 114,757 patients with male gender of 54.2% and the mean age of 65.0 ± 15.2 years were included. The most common indication was choledocholithiasis (49.4%) and the second malignant biliary obstruction (22.8%). Biliary drainage (33.9%) was the most commonly performed procedure, followed by endoscopic sphincterotomy (27.4%), and stone removal (22.0%). The overall incidence of ERCP-related AEs was 4.7% consisting of post-ERCP pancreatitis (PEP; 4.6%), perforation (0.06%), and hemorrhage (0.02%), which gradually increased from 2012 to 2015. According to the type of procedures, ERCP-related AEs developed the most commonly after pancreatic stent insertion (11.4%), followed by diagnostic ERCP (5.9%) and endoscopic sphincterotomy (5.7%). Younger age and diagnostic ERCP turned out to be independent risk factors of PEP.

CONCLUSIONS

ERCP-related AEs developed the most commonly after pancreatic stent insertion, diagnostic ERCP and endoscopic sphincterotomy. Special caution should be used for young patients receiving diagnostic ERCP due to increased risk of PEP.

An Adaptive Learning Model for Multiscale Texture Features in Polyp Classification via Computed Tomographic Colonography

Objective: As an effective lesion heterogeneity depiction, texture information extracted from computed tomography has become increasingly important in polyp classification. However, variation and redundancy among multiple texture descriptors render a challenging task of integrating them into a general characterization. Considering these two problems, this work proposes an adaptive learning model to integrate multi-scale texture features. Methods: To mitigate feature variation, the whole feature set is geometrically split into several independent subsets that are ranked by a learning evaluation measure after preliminary classifications. To reduce feature redundancy, a bottom-up hierarchical learning framework is proposed to ensure monotonic increase of classification performance while integrating these ranked sets selectively. Two types of classifiers, traditional (random forest + support vector machine)- and convolutional neural network (CNN)-based, are employed to perform the polyp classification under the proposed framework with extended Haralick measures and gray-level co-occurrence matrix (GLCM) as inputs, respectively. Experimental results are based on a retrospective dataset of 63 polyp masses (defined as greater than 3 cm in largest diameter), including 32 adenocarcinomas and 31 benign adenomas, from adult patients undergoing first-time computed tomography colonography and who had corresponding histopathology of the detected masses. Results: We evaluate the performance of the proposed models by the area under the curve (AUC) of the receiver operating characteristic curve. The proposed models show encouraging performances of an AUC score of 0.925 with the traditional classification method and an AUC score of 0.902 with CNN. The proposed adaptive learning framework significantly outperforms nine well-established classification methods, including six traditional methods and three deep learning ones with a large margin. Conclusions: The proposed adaptive learning model can combat the challenges of feature variation through a multiscale grouping of feature inputs, and the feature redundancy through a hierarchal sorting of these feature groups. The improved classification performance against comparative models demonstrated the feasibility and utility of this adaptive learning procedure for feature integration.

OUP accepted manuscript

Background and Aims

Although usually mild to moderate in severity, postoperative pain after peroral endoscopic myotomy (POEM) is common. There are no studies that have addressed minimizing postoperative pain in patients undergoing POEM for achalasia. We hypothesized that intraoperative topical intra-tunnel irrigation with ropivacaine would result in a significant reduction in pain scores in the postoperative period.

Methods

A double-blind, randomized, placebo-controlled trial was conducted at the Kingston Health Sciences Center. Patients received either 30 mL of 0.2% ropivacaine or 30 mL of placebo irrigated topically into the POEM tunnel after completing the myotomy and prior to closing the mucosal incision. The primary outcome was pain post-POEM at 6 h assessed by the Numeric Rating Scale (NRS). Secondary objectives included assessing pain score at 0.5, 1, 2, 4 h post-POEM and on discharge, Quality of Recovery (QoR-15) scores at discharge, narcotic requirement, adverse events, and patients’ willingness to have the procedure done on an outpatient basis.

Results

A total of 20 patients were enrolled. For the primary outcome of pain post-POEM at 6 h, the NRS was 1.1 in the placebo group and 2.4 in the ropivacaine group (95% CI of the difference: −3.2 to 0.6, P = 0.171). No statistical difference was seen in the pain scores. Overall usage of post-procedural narcotics was low with no differences between the two groups. Fifty percent of patients in both groups were willing to have the procedure done as an outpatient.

Conclusion

The addition of intra-procedural tunnel irrigation with 30 mL 0.2% ropivacaine did not lead to reduced post-POEM pain.

Endoscopic retrograde cholangiopancreaticography-related complications – Experience from tertiary care teaching centre over half a decade

Introduction:

Endoscopic retrograde cholangiopancreaticography (ERCP) is an essential therapeutic procedure with a significant risk of complications. Data regarding the complications and predictors of adverse outcomes such as mortality are scarce, especially from India and Asia. We aimed to look at the incidence and outcome of complications in ERCP patients.

Materials and Methods:

This study is a retrospective analysis of prospectively collected data of all the patients who underwent ERCP and had a complication from January 2012 to December 2018. Data were recorded in predesigned pro forma. The data analysis was done by appropriate statistical tests.

RESULTS:

A total of 17,163 ERCP were done. A total of 570 patients (3.3%) had complications; perforation (n = 275, 1.6%) was most common followed by pancreatitis (n = 177, 1.03%) and bleeding (n = 60, 0.35%). The majorities of perforations were managed conservatively (n = 205, 74.5%), and 53 (19%) required surgery. Overall, 69 (0.4%) patients died. Of these, 30 (10.9%) patients died with perforation. Age (odds ratio [OR]: 1.04, 95% confidence interval [CI]: 1.005–1.07) and need of surgery (OR: 5.11, 95% CI: 1.66–15.77) were the predictors of mortality in patients with perforation. The majority pancreatitis were mild (n = 125, 70.6%) and overall mortality was 5.6% (n = 10).

Conclusion:

ERCP complications have been remained static over the years, with perforation and pancreatitis contributing the most. Most perforations can be managed conservatively with good clinical outcomes.

TXI (Texture and Color Enhancement Imaging) for Serrated Colorectal Lesions

BACKGROUND AND AIM

Olympus Corporation released the texture and color enhancement imaging (TXI) technology as a novel image-enhancing endoscopic technique. We investigated the effectiveness of TXI in the imaging of serrated colorectal polyps, including sessile serrated lesions (SSLs).

METHODS

Serrated colorectal polyps were observed using white light imaging (WLI), TXI, narrow-band imaging (NBI), and chromoendoscopy with and without magnification. Serrated polyps were histologically confirmed. TXI was compared with WLI, NBI, and chromoendoscopy for the visibility of the lesions without magnification and for that of the vessel and surface patterns with magnification. Three expert endoscopists evaluated the visibility scores, which were classified from 1 to 4.

RESULTS

Twenty-nine consecutive serrated polyps were evaluated. In the visibility score without magnification, TXI was significantly superior to WLI but inferior to chromoendoscopy in the imaging of serrated polyps and the sub-analysis of SSLs. In the visibility score for vessel patterns with magnification, TXI was significantly superior to WLI and chromoendoscopy in the imaging of serrated polyps and the sub-analysis of SSLs. In the visibility score for surface patterns with magnification, TXI was significantly superior to WLI but inferior to NBI in serrated polyps and in the sub-analysis of SSLs and hyperplastic polyps.

CONCLUSIONS

TXI provided higher visibility than did WLI for serrated, colorectal polyps, including SSLs.

Radiomics in hepatocellular carcinoma: A state-of-the-art review

Hepatocellular carcinoma (HCC) is the most common cancer and the second major contributor to cancer-related mortality. Radiomics, a burgeoning technology that can provide invisible high-dimensional quantitative and mineable data derived from routine-acquired images, has enormous potential for HCC management from diagnosis to prognosis as well as providing contributions to the rapidly developing deep learning methodology. This article aims to review the radiomics approach and its current state-of-the-art clinical application scenario in HCC. The limitations, challenges, and thoughts on future directions are also summarized.

Perioperative outcomes of inpatient laparoscopic Heller myotomy and per-oral endoscopic myotomy in the United States

BACKGROUND

Per-oral endoscopic myotomy is an alternative to pneumatic dilation and laparoscopic Heller myotomy to treat lower esophageal sphincter diseases. Laparoscopic Heller myotomy and per-oral endoscopic myotomy perioperative outcomes data come from relatively small retrospective series and 1 randomized trial. We aimed to estimate the number of inpatient procedures performed in the United States and compare perioperative outcomes and costs of laparoscopic Heller myotomy and per-oral endoscopic myotomy using a nationally representative database.

METHODS

Cross-sectional retrospective analysis of hospital admissions for laparoscopic Heller myotomy or per-oral endoscopic myotomy from October 2015 through December 2018 in the National Inpatient Sample. Patient and hospital characteristics, concurrent antireflux procedures, perioperative adverse events (any adverse event and those associated with extended length of stay ≥3 days), mortality, length of stay, and costs were compared. Logistic regression evaluated factors independently associated with adverse events.

RESULTS

An estimated 11,270 patients had laparoscopic Heller myotomy (n = 9,555) or per-oral endoscopic myotomy (n = 1,715) without significant differences in demographics and comorbidities. A concurrent anti-reflux procedure was more frequent with laparoscopic Heller myotomy (72.8% vs 15.5%, P < .001). Overall adverse event rate was higher with per-oral endoscopic myotomy (13.3% vs 24.8%, P < .001), and mortality was similar. Per-oral endoscopic myotomy had higher rates of adverse events associated with extended length of stay (9.3% vs 16.6%, P < .001), infectious adverse events (3.5% vs 8.2%, P < .001), gastrointestinal bleeding (3.4% vs 5.8%, P = .04), accidental injuries (3% vs 5.5%, P = .03), and thoracic adverse events (4.5% vs 9%, P < .01). Rates of adverse events of both procedures remained similar during the years of the study. Per-oral endoscopic myotomy was independently associated with adverse events. Length of stay (laparoscopic Heller myotomy: 3.2 ± 0.1 vs per-oral endoscopic myotomy: 3.7 ± 0.3 days, P = .17) and costs (laparoscopic Heller myotomy: $15,471 ± 406 vs per-oral endoscopic myotomy: $15,146 ± 1,308, P = .82) were similar.

CONCLUSION

In this national database review, laparoscopic Heller myotomy had a lower rate of perioperative adverse events at similar length of stay and costs than per-oral endoscopic myotomy. Laparoscopic Heller myotomy remains a safer procedure than per-oral endoscopic myotomy for a myotomy of the distal esophagus and lower esophageal sphincter in the United States.

BH-index: A predictive system based on serum biomarkers and ensemble learning for early colorectal cancer diagnosis in mass screening

BACKGROUND AND OBJECTIVE

Colorectal cancer is one of the most common malignancies among the general population. Artificial Intelligence methodologies based on serum parameters are in continuous development to obtain less expensive tools for highly sensitive diagnoses. This study proposes a predictive system based on serum biomarkers and ensemble learning to predict colorectal cancer presence and the related TNM stage in patients.

METHODS

We have selected 17 significant plasmatic proteins, i.e., Carcinoembryonic Antigen, CA 19-9, CA 125, CA 50, CA 72-4, Tissue Polypeptide Antigen, C-Reactive Protein, Ceruloplasmin, Haptoglobin, Transferrin, Ferritin, α-1-Antitrypsin, α-2-Macroglobulin, α-1 Acid Glycoprotein, Complement C4, Complement C3, and Retinol Binding Protein, regarding 345 patients (248 affected by the neoplastic disease). The proposed system consists of two predictors, i.e., binary and staging; the former predicts the presence/absence of cancer, while the latter identifies the related TNM stage (I, II, III, or IV). The experiments were conducted by deploying and comparing Random Forest, XGBoost, Support Vector Machine, and Multilayer Perceptron with feature selection based on Gini Importance and with dimensionality reduction via PCA.

RESULTS

The results show that the system composed of XGBoost as binary and staging predictor reaches 91.30% accuracy, 90% sensitivity, and 93.33% specificity for the absence/presence outcome, while 66.66% accuracy for the staging response. With the expansion of the training set in favor of positive patients and majority voting, the system composed of the combination of Support Vector Machine, XGBoost, and Multilayer Perceptron as the binary predictor reaches 98.03% accuracy, 100% sensitivity, and 92.30% specificity, while the combination of Random Forest, XGBoost, and Multilayer Perceptron as staging predictor achieves 60% accuracy. The final system reaches, in terms of accuracy, 98.03%, and 66.66% for the binary and staging predictors, respectively. It was also found that the biomarkers which contribute most to the binary decision are Ceruloplasmin and α-2-Macroglobulin, while the least significant dimensions are CA 50 and α-1-Antitrypsin; instead, Carcinoembryonic Antigen and α-1 Acid Glycoprotein are the most significant to the staging decision.

CONCLUSIONS

The present study proves the effectiveness of deploying serum biomarkers as feature dimensions for early colorectal cancer diagnosis and of using majority voting for noise reduction in the prediction.

The high rate of spontaneous migration of small size common bile duct stones may allow a significant reduction in unnecessary ERCP and related complications: results of a retrospective, multicenter study

INTRODUCTION

Common bile duct stones (CBDS) can spontaneously migrate through the duodenal papilla. In this case, ERCP could be unnecessary and a significant rate of complications could be avoided. In this study, we aim at retrospectively evaluating the rate of spontaneous stone passage in patients with an imaging diagnosis of CBDS and at analysing the factors associated to spontaneous stone migration.

METHODS

We conducted a retrospective multi-centre analysis of patients undergoing ERCP for CBDS in a 12-month period. 1016 patients with CBDS were analysed. In all patients CBDS was diagnosed with adequate imaging methods performed prior to ERCP. ERCPs with failed biliary cannulation were excluded. Data regarding patients' characteristics, imaging findings and ERCP procedure were analysed.

RESULTS

1016 patients with CBDS undergoing ERCP were analysed (male sex 43.3%; mean age 69.9 ± 16.5 years). Diagnosis of CBDS was obtained by EUS in 415 patients (40.8%), MR in 343 (33.8%), CT in 220 (21.7%), and US in 38 (3.7%). No stones were found at ERCP in 179 patients (17.6%), in 14 (6.2%) when ERCP was performed within 6 h from imaging study, in 114 (18.5%) between 7 h and 7 days, in 32 (24.6%) between 8 and 29 days, and in 19 (43.2%) after 30 days. The rate of unnecessary ERCP occurred significantly more frequently in patients in whom imaging methods demonstrated either sludge or ≤ 5 mm CBDS (29.9 vs. 8.3%; p < 0.001).

DISCUSSION

Spontaneous migration of small CBDS is a frequent event, and ≤ 5 mm size and a delay in ERCP > 7 days represent predictive factors for it. We suggest that CBDS ≤ 5 mm should not undergo immediate removal and this fact would allow reducing the rate of unnecessary ERCP with their related complications. Prospective studies are needed to confirm these results and demonstrate the safety of a conservative management in this setting.

Third space endoscopy: the future of treating gastrointestinal dysmotility

PURPOSE OF REVIEW

Third space endoscopy (TSE) or submucosal endoscopy provides with the opportunity for minimally invasive management of various gastrointestinal disorders. TSE is a relatively new field and the knowledge on its utility continues to advance. The purpose of this review is to provide with updated evidence on the efficacy and utility of TSE in gastrointestinal motility disorders including achalasia and refractory gastroparesis.

RECENT FINDINGS

Peroral endoscopic myotomy (POEM) is a safe procedure with emerging evidence on its durability as well. Major technical variations do not appear to impact the outcomes of POEM. Recent randomized trials suggest superiority of POEM over pneumatic dilatation and noninferiority over Heller's myotomy in idiopathic achalasia. With regard to gastric POEM (G-POEM), recent evidence confirms its efficacy in refractory gastroparesis. Although effective, the long-term outcomes of G-POEM are not well known. In addition, the criteria for patient selection remain elusive.

SUMMARY

TSE has emerged as a new frontier in the endoscopic management of gastrointestinal motility disorders. While short-term outcomes are encouraging, the durability of TSE remains to be seen in achalasia as well as refractory gastroparesis. Insights regarding patient selection and predictors of outcomes may help optimizing the results of gastric POEM in refractory gastroparesis.

Rethinking the need for overnight admission after peroral endoscopic myotomy (POEM): a pandemic-driven approach to the future

Background and study aims  COVID-19 has significantly impacted endoscopic assessment and management of multiple conditions. Our group recommenced treatment of highly symptomatic achalasia patients (Eckardt score ≥ 6) adopting a same-day discharge (SDD) algorithm and present early outcomes of its utilization. Patients and methods  We enrolled all outpatients undergoing POEM at a single tertiary referral center. Patients qualified for SDD if all of the following a priori criteria were met: 1) ASA grade I-III; 2) No intraprocedural adverse events (AEs); 3) Secure mucosal closure; 4) Post-procedure pain/nausea responsive to oral medications; and 5) Patients tolerating clear fluids. Results  In 17 potential SDD candidates (female 82.4 %, median age 51 years [IQR 48-64]) undergoing POEM, SDD was achieved in 14 (82.4 %). The remaining were admitted due to post-procedure pain/nausea (n = 2) and intraprocedural concerns (capnoperitoneum requiring needle decompression, n = 1). There were no post-procedure AEs or unexpected readmissions. Conclusions  This study demonstrates the safety and feasibility of a SDD algorithm for POEM patients and challenges the necessity of routine post-POEM hospital admission. Critically important during the COVID-19 pandemic, this may in fact constitute a changing standard for POEM post-procedure care.

An Italian survey on the use of T-tube in liver transplantation: old habits die hard!

There is enough clinical evidence that a T-tube use in biliary reconstruction at adult liver transplantation (LT) does not significantly modify the risk of biliary stricture/leak, and it may even sustain infective and metabolic complications. Thus, the policy on T-tube use has been globally changing, with progressive application of more restrictive selection criteria. However, there are no currently standardized indications in such change, and many LT Centers rely only on own experience and routine. A nation-wide survey was conducted among all the 20 Italian adult LT Centers to investigate the current policy on T-tube use. It was found that 20% of Centers completely discontinued the T-tube use, while 25% Centers used it routinely in all LT cases. The remaining 55% of Centers applied a selective policy, based on criteria of technical complexity of biliary reconstruction (72.7%), followed by low-quality graft (63.6%) and high-risk recipient (36.4%). A T-tube use > 50% of annual caseload was not associated with high-volume Center status (> 70 LT per year), an active pediatric or living-donor transplant program, or use of DCD grafts. Only 10/20 (50%) Centers identified T-tube as a potential risk factor for complications other than biliary stricture/leak. In these cases, the suspected pathogenic mechanism comprised bacterial colonization (70%), malabsorption (70%), interruption of the entero-hepatic bile-acid cycle (50%), biliary inflammation due to an indwelling catheter (40%) and gut microbiota changes (40%). In conclusion, the prevalence of T-tube use among the Italian LT Centers is still relatively high, compared to the European trend (33%), and the potential detrimental effect of T-tube, beyond biliary stricture/leak, seems to be somehow underestimated.

Assessing Individual Risk for High-Risk Early Colorectal Neoplasm for Pre-Selection of Screening in Shanghai, China: A Population-Based Nested Case-Control Study

Objective

To identify people with high-risk early colorectal neoplasm is highly desirable for pre-selection in colorectal cancer (CRC) screening in low-resource countries. We aim to build and validate a risk-based model so as to improve compliance and increase the benefits of screening.

Patients and Methods

Using data from the Shanghai CRC screening cohort, we conducted a population-based nested case–control study to build a risk-based model. Cases of early colorectal neoplasm were extracted as colorectal adenomas and stage 0-I CRC. Each case was matched with five individuals without neoplasm (controls) by the screening site and year of enrollment. Cases and controls were then randomly divided into two groups, with two thirds for building the risk prediction model and the other one third for model validation. Known risk factors were included for risk prediction models using logistic regressions. The area under the receiver operating characteristic curve (AUC) and Hosmer–Lemeshow chi-square statistics were used to evaluate model discrimination and calibration. The predicted individual risk probability was calculated under the risk regression equation.

Results

The model incorporating age, sex, family history and lifestyle factors including body mass index (BMI), smoking status, alcohol, regular moderate-to-intensity physical activity showed good calibration and discrimination. When the risk cutoff threshold was defined as 17%, the sensitivity and specificity of the model were 63.99% and 53.82%, respectively. The validation data analysis also showed well discrimination.

Conclusion

A risk prediction model combining personal and lifestyle factors was developed and validated for high-risk early colorectal neoplasm among the Chinese population. This risk-based model could improve the pre-selection for screening and contribute a lot to efficient population-based screening in low-resource countries.

A Review of the Management of Bile Leaks

Bile leaks can be a complication of abdominal surgeries, specifically trauma to the biliary system during laparoscopic cholecystectomy, and can occur from a variety of sources, commonly a bile duct injury (BDI). Their management involves a multidisciplinary approach and depends on a multitude of factors. This consequence has also led to increased health care costs and morbidity and mortality for patients. Currently, there are no professional society-initiated guidelines that provide surgeons with a clear algorithm for managing bile leaks, as there are for other operative approaches and management in various surgical diseases. Thus, a literature search was performed that surveyed current research on the effective prevention and management of the different types of bile leaks. This review aims to provide all clinicians with an overview of factors to consider in the management of bile leaks and supports referral to a tertiary center with a hepatobiliary specialist.

Importance of second-look endoscopy after per-oral endoscopic myotomy for safe postoperative management

OBJECTIVES

Per-oral endoscopic myotomy (POEM) is a safe and effective treatment for achalasia and esophageal motility disorders. The role of second-look endoscopy (SE) on postoperative day 1 has not been examined. This study aimed to evaluate the findings and need of SE after POEM.

METHODS

This is a single-center, retrospective study. All consecutive patients who underwent POEM and SE on postoperative day 1 between December 2017 and September 2019 were included. The primary endpoint was the rate of newly-detected adverse events (nAE) during SE that required endoscopic intervention or deviation from the normal postoperative course. Multivariate logistic regression was used to identify predictors of nAE.

RESULTS

Four-hundred-ninety-seven patients (mean age, 50.3 years; female, 49.9%) were included. SE identified abnormal findings in a total of 71 patients (14.3%). nAE which required endoscopic intervention or deviation from the normal postoperative course were identified in 12 patients (2.4%): eight (1.6%) entry site dehiscence; two (0.4%) submucosal hemorrhage or hematoma; and two (0.4%) dehiscence of an intraoperative perforation site after endoclip closure. Other findings such as mucosal thermal damage without perforation and small submucosal hematoma were found in 54 patients (10.9%) and five patients (1.0%), respectively. Multivariate analysis showed that longer operation time and intraoperative adverse events (AE) were associated with clinically significant nAE during SE.

CONCLUSIONS

Second-look endoscopy can detect and treat nAE that may lead to severe AE. Thus, SE should be highly considered before starting oral ingestion in all cases, and especially in those who present an intraoperative AE and longer operation time.

Antibiotic prophylaxis in ERCP with failed cannulation

OBJECTIVES

Endoscopic retrograde cholangiopancreatography (ERCP) with failed biliary cannulation is associated with a high rate of adverse events, but the role of prophylactic antibiotics remains unclear. The primary aim was to investigate if prophylactically administered antibiotics affect the frequency of overall adverse complications in patients where biliary cannulation fails during ERCP. The secondary aim was to investigate if specific infectious complications, also were affected by the antibiotic prophylaxis.

MATERIALS AND METHODS

We analysed data from 96,818 ERCPs (2006-2018), from the Swedish National Quality Registry of Cholecystectomy and ERCP (GallRiks), excluding ERCPs with successful cannulation (n = 88,743), missing data (n = 2,014), or on-going antibiotic therapy (n = 1,062).

RESULTS

In total 4,996 procedures were included, 2,124 received (42.5%) and 2,872 (57.5%) did not receive antibiotic prophylaxis. There were fewer overall complications in the group receiving prophylaxis (13.6% vs. 17.1%, p < .001), which corresponded to a 24% adjusted odds reduction in the multivariable analysis (odds ratio [OR] 0.76; 95% confidence interval [CI] 0.65-0.89). In the prophylaxis group, there was a lower overall rate of infectious complications (2.1% vs. 3.2%; p = .038; OR 0.68; 95% CI 0.47-0.98) and abscesses (0.8% vs. 1.4%; p = .040; OR 0.54; 95% CI 0.31-0.96). However, no significant differences were seen in the rate of cholangitis (1.3% vs. 1.7%; p = .182; OR 0.74; 95% CI 0.46-1.18).

CONCLUSION

This national quality registry study of ERCPs with failed cannulation showed a significant reduction in overall and infectious complications when prophylactic antibiotics were administered.

Relations between Electronics, Artificial Intelligence and Information Society through Information Society Rules

This paper presents relations between information society (IS), electronics and artificial intelligence (AI) mainly through twenty-four IS laws. The laws not only make up a novel collection, currently non-existing in the literature, but they also highlight the core boosting mechanism for the progress of what is called the information society and AI. The laws mainly describe the exponential growth in a particular field, be it the processing, storage or transmission capabilities of electronic devices. Other rules describe the relations to production prices and human interaction. Overall, the IS laws illustrate the most recent and most vibrant part of human history based on the unprecedented growth of device capabilities spurred by human innovation and ingenuity. Although there are signs of stalling, at the same time there are still many ways to prolong the fascinating progress of electronics that stimulates the field of artificial intelligence. There are constant leaps in new areas, such as the perception of real-world signals, where AI is already occasionally exceeding human capabilities and will do so even more in the future. In some areas where AI is presumed to be incapable of performing even at a modest level, such as the production of art or programming software, AI is making progress that can sometimes reflect true human skills. Maybe it is time for AI to boost the progress of electronics in return.

Delayed Tension Symptomatic Pneumoperitoneum After POEM Requiring Needle Decompression

INTRODUCTION

Per-oral endoscopic myotomy (POEM) is an effective modality for the management of achalasia. Tension pneumoperitoneum is a significant complication that causes hemodynamic instability, generally within the periprocedural period.

METHODS

Here, we report 2 cases of delayed tension pneumoperitoneum that was recognized and treated several hours after uncomplicated POEM.

RESULTS

These cases illustrate the importance of continued vigilance for this complication outside of the immediate periprocedural period as well as the utility of computed tomography-guided aspiration in managing it.

DISCUSSION

When discharging patients after POEM, caregivers should be aware of this rare complication and alert patients to return for immediate care when it happens.

Clinical impact of routine esophagram after peroral endoscopic myotomy

BACKGROUND AND AIMS

It is unclear whether the common practice of postoperative day (POD) 1 esophagram impacts clinical care or reliably identifies significant adverse events (AEs) related to peroral endoscopic myotomy (POEM). Therefore, we aimed to correlate the most clinically relevant esophagram findings with postoperative outcomes after POEM.

METHODS

Patients were retrospectively reviewed and included if they underwent POEM at 1 of the 3 study institutions between 2014 and 2018. Patient outcomes were assessed in relation to relevant POD 1 esophagram findings such as esophageal dissection or leak.

RESULTS

One hundred seventy post-POEM contrast esophagrams (139 fluoroscopy-based vs 31 CT-based) performed on POD 1 were included. Most esophagrams (n = 98) contained abnormal findings but only 5 showed esophageal leak or dissection. Confirmed postoperative AEs of leak or dissection occurred in 4 patients. In 2 patients, POD 1 esophagram appropriately identified the leak or dissection, but in the other 2 patients the initial esophagram was negative, and the AEs were not recognized before clinical deterioration. One patient had a false-positive leak and dissection noted on esophagram leading to an unremarkable endoscopy.

CONCLUSIONS

Despite the low AE rate after POEM, follow-up esophagram on POD 1 frequently shows expected, unremarkable postprocedural findings and occasionally fails to diagnose serious AEs. This results in pitfalls in accuracy regarding agreement between esophagram versus clinical and endoscopic findings. Relying exclusively on esophagram for post-POEM clinical decision-making can lead to unnecessary additional testing or missed AEs.

Application of artificial intelligence in pancreaticobiliary diseases

The role of artificial intelligence and its applications has been increasing at a rapid pace in the field of gastroenterology. The application of artificial intelligence in gastroenterology ranges from colon cancer screening and characterization of dysplastic and neoplastic polyps to the endoscopic ultrasonographic evaluation of pancreatic diseases. Artificial intelligence has been found to be useful in the evaluation and enhancement of the quality measure for endoscopic retrograde cholangiopancreatography. Similarly, artificial intelligence techniques like artificial neural networks and faster region-based convolution network are showing promising results in early and accurate diagnosis of pancreatic cancer and its differentiation from chronic pancreatitis. Other artificial intelligence techniques like radiomics-based computer-aided diagnosis systems could help to differentiate between various types of cystic pancreatic lesions. Artificial intelligence and computer-aided systems also showing promising results in the diagnosis of cholangiocarcinoma and the prediction of choledocholithiasis. In this review, we discuss the role of artificial intelligence in establishing diagnosis, prognosis, predicting response to treatment, and guiding therapeutics in the pancreaticobiliary system.

The Role of Artificial Intelligence in Endoscopic Ultrasound for Pancreatic Disorders

The use of artificial intelligence (AI) in various medical imaging applications has expanded remarkably, and several reports have focused on endoscopic ultrasound (EUS) images of the pancreas. This review briefly summarizes each report in order to help endoscopists better understand and utilize the potential of this rapidly developing AI, after a description of the fundamentals of the AI involved, as is necessary for understanding each study. At first, conventional computer-aided diagnosis (CAD) was used, which extracts and selects features from imaging data using various methods and introduces them into machine learning algorithms as inputs. Deep learning-based CAD utilizing convolutional neural networks has been used; in these approaches, the images themselves are used as inputs, and more information can be analyzed in less time and with higher accuracy. In the field of EUS imaging, although AI is still in its infancy, further research and development of AI applications is expected to contribute to the role of optical biopsy as an alternative to EUS-guided tissue sampling while also improving diagnostic accuracy through double reading with humans and contributing to EUS education.