Therapeutic Strategies to Modulate Gut Microbial Health: Approaches for Chronic Metabolic Disorder Management

Numerous recent studies have suggested that the composition of the intestinal microbiota can trigger metabolic disorders, such as diabetes, prediabetes, obesity, metabolic syndrome, sarcopenia, dyslipidemia, hyperhomocysteinemia, and non-alcoholic fatty liver disease. Since then, considerable effort has been made to understand the link between the composition of intestinal microbiota and metabolic disorders, as well as the role of probiotics in the modulation of the intestinal microbiota. The aim of this review was to summarize the reviews and individual articles on the state of the art regarding ideal therapy with probiotics and prebiotics in order to obtain the reversion of dysbiosis (alteration in microbiota) to eubiosis during metabolic diseases, such as diabetes, prediabetes, obesity, hyperhomocysteinemia, dyslipidemia, sarcopenia, and non-alcoholic fatty liver diseases. This review includes 245 eligible studies. In conclusion, a condition of dysbiosis, or in general, alteration of the intestinal microbiota, could be implicated in the development of metabolic disorders through different mechanisms, mainly linked to the release of pro-inflammatory factors. Several studies have already demonstrated the potential of using probiotics and prebiotics in the treatment of this condition, detecting significant improvements in the specific symptoms of metabolic diseases. These findings reinforce the hypothesis that a condition of dysbiosis can lead to a generalized inflammatory picture with negative consequences on different organs and systems. Moreover, this review confirms that the beneficial effects of probiotics on metabolic diseases are promising, but more research is needed to determine the optimal probiotic strains, doses, and administration forms for specific metabolic conditions.

Screening and management of hospital hyperglycemia in non-critical patients: a position statement from the Brazilian Diabetes Society (SBD)

BACKGROUND

Hospital Hyperglycemia (HH) is linked to poorer outcomes, including higher mortality rates, increased ICU admissions, and extended hospital stays, and occurs in both people living with diabetes or not. The prevalence of HH in non-critical patients ranges from 22 to 46%. This panel reviewed the evidence and made recommendations for the best care for hospitalized hyperglycemic patients, with or without diabetes mellitus.

METHODS

The methodology was published previously and was defined by the internal institutional steering committee. The SBD Acute and Hospital Complications Department drafted the manuscript, selecting key clinical questions for a narrative review using MEDLINE via PubMed. The best available evidence was reviewed, including randomized clinical trials (RCTs), meta-analyses, and high-quality observational studies related to Hospital Hyperglycemia.

RESULTS AND CONCLUSIONS

The department members and external experts developed 23 recommendations for the management of patients with HH, including screening, initial interventions, treatment adjustments, and care for potential complications. Based on the best available evidence, our article provides safe and effective management strategies for both public and private healthcare settings.

ARE QUALITY INDICATORS IMPORTANT IN COLONOSCOPIES? ANALYSIS OF 3,076 EXAMS IN A PRIVATE TERTIARY SERVICE IN SOUTHEASTERN BRAZIL

BACKGROUND

The carcinogenesis of colorectal cancer is well understood. Adenomas are the precursor lesions in about 70% of cases, highlighting the importance of screening programs.

AIMS

The aim of this study was to analyze the effectiveness of colonoscopy examinations performed in a private tertiary service by calculating the polyp detection rate (PDR) and adenoma detection rate (ADR) and comparing these rates with literature data.

METHODS

This retrospective observational study evaluated colonoscopies performed at Hospital Centro Médico de Campinas between 2018 and 2020. It assessed the indications and complications of colonoscopy, sex, age group, bowel preparation, cecal intubation rate, ADR, PDR, and advanced adenoma detection rate (AADR).

RESULTS

During the period, 3,686 colonoscopies were performed, and 3,076 were included in the analysis. The mean patient age was 57.2 years, and most patients were female (53.5%). Complications occurred in 39 colonoscopies (1.3%), with bleeding in six cases and perforation in one case. Tubular adenoma was the most prevalent histological subtype found in 20% of tests and in 62.7% of those with positive findings. The PDR was 23% and significantly increased with advancing age (p<0.01). The ADR was 20% and also significantly increased with age (p<0.001). This rate was higher in men (27%). The AADR was 4%.

CONCLUSIONS

Colonoscopy is an effective polyp detection method, and the PDR was higher in men and significantly increased with age. The ADR and AADR were comparable to the literature data.

Early Rectal Cancer: Advances in Diagnosis and Management Strategies

Colorectal cancer (CRC) is the second most prevalent cause of cancer-related death and the third most common cancer globally. Early-stage rectal cancer is defined by lesions confined to the bowel wall, without extension beyond the submucosa in T1 or the muscularis propria in T2, with no indication of lymph node involvement or distant metastasis. The gold standard for managing rectal cancer is total mesorectal excision (TME); however, it is linked to considerable morbidities and impaired quality of life. There is a growing interest in local resection and non-operative treatment of early RC for organ preservation. Local resection options include three types of transanal endoscopic surgery (TES): transanal endoscopic microsurgery (TEM), transanal endoscopic operations (TEO), and transanal minimally invasive surgery (TAMIS), while endoscopic resection includes endoscopic mucosal resection (EMR), underwater endoscopic mucosal resection (UEMR), and endoscopic submucosal dissection (ESD). Although the oncological outcome of local resection of early rectal cancer is debated in the current literature, some studies have shown comparable outcomes with radical surgery in selected patients. The use of adjuvant and neoadjuvant chemoradiotherapy in early rectal cancer management is also controversial in the literature, but a number of studies have reported promising outcomes. This review focuses on the available literature regarding diagnosis, staging, and management strategies of early rectal cancer and provides possible recommendations.

Gastrointestinal Subepithelial Lesions: Evolution in Management and Endoscopic Resection Techniques

PURPOSE OF REVIEW

Subepithelial lesions (SELs) are tumors originating from the gastrointestinal (GI) tract wall (muscularis mucosa, submucosa, or muscularis propria) and are covered by overlying mucosa. They are typically incidental findings during routine endoscopy. This article reviews the latest advancements in endoscopic techniques and devices used to resect subepithelial lesions.

RECENT FINDINGS

Endoscopic Ultrasound (EUS) should be employed to characterize SELs, with fine needle core biopsy (FNB) utilized with EUS for histopathologic tissue acquisition. EUS can be used as "endoscopic mapping" to mitigate serious complications prior to endoscopic resection. Techniques such as Submucosal Tunnelling Endoscopic Resection (STER), Device-Assisted Endoscopic Full Thickness Resection, and Freehand Full Thickness Resection are available for the complete resection of SELs. The choice of technique depends on the characteristics of the lesion and the level of expertise of the endoscopist. Multiple endoscopic resection techniques for SELs have been developed, each utilizing different tools and devices. A significant shift has occurred from traditional laparoscopic surgical resection to minimally invasive, organ-sparing endoscopic resection. Advancements in "third space" endoscopy and the innovation of novel devices continue to offer less invasive resection techniques for lesions arising from the GI tract wall.

Gut Microecological Prescription: A Novel Approach to Regulating Intestinal Micro-Ecological Balance

The intestinal microecology is comprises intestinal microorganisms and other components constituting the entire ecosystem, presenting characteristics of stability and dynamic balance. Current research reveals intestinal microecological imbalances are related to various diseases. However, fundamental research and clinical applications have not been effectively integrated. Considering the importance and complexity of regulating the intestinal microecological balance, this study provides an overview of the high-risk factors affecting intestinal microecology and detection methods. Moreover, it proposes the definition of intestinal microecological imbalance and the definition, formulation, and outcomes of gut microecological prescription to facilitate its application in clinical practice, thus promoting clinical research on intestinal microecology and improving the quality of life of the population.

EUS-guided rendezvous is a viable salvage technique for failed billiary cannulation in patients with Roux-en-Y gastric bypass undergoing BAE-ERCP

Background and study aims

Biliary cannulation via balloon-assisted-ERCP (BAE-ERCP) can be challenging. Patients with Roux-en-Y gastric bypass (RYGB) have among the lowest reported BAE-ERCP success rates when compared with other types of surgically altered anatomy. We explored the role of EUS-guided rendezvous (EUS-RV) as a rescue technique when BAE-ERCP fails.

Patients and methods

Consecutive patients with RYGB underwent BAE-ERCP for both benign and malignant indications. Among them, patients in whom BAE-ERCP failed despite use of conventional advanced biliary cannulation techniques underwent EUS-RV if the ampulla could be reached.

Results

Forty-three consecutive patients with RYGB underwent BAE-ERCP. The procedure was successful in 30 patients (69.7%). Among the 13 patients with failed ERCP, EUS-RV was performed in five. Technical success was achieved in all five patients (100%), thereby increasing the overall BAE-ERCP success to 35 patients (81.3%). There were no major procedure-related adverse events on immediate and 3-month follow-up. Average total procedure time for failed BAE-ERCP followed by EUS-RV was 129 minutes (range 47-205 minutes).

Conclusions

EUS-RV in patients with RYGB has high technical and clinical success and can be a viable alternative to more invasive options when BAE-ERCP fails using traditional cannulation techniques.

Evaluation of gastric content in fasting patient during semaglutide use: an observational study

BACKGROUND

The evident influence of GLP-1 agonists as semaglutide on gastric emptying even in adherence to recommended fasting protocols instigates debates.

OBJECTIVE

To investigate the effect of semaglutide on gastric content by gastric ultrasonography in volunteers.

SETTING

Private hospital.

METHODS

The present study is an observational, cross-sectional, and single-center study. We included 30 consecutive volunteers aged ≥18 years who had undergone a minimum fasting period of 8 hours for solid foods and 2 hours for clear, residue-free liquids. The intervention group consisted of 15 volunteers who had used semaglutide within the last 7 days, whereas the control group consisted of 15 volunteers who had never used semaglutide. The main objective was to determine whether the stomach was full or not.

RESULTS

Between June 2023 and August 2023, a total of 30 adult volunteers were included in the study, and no participant was excluded. The semaglutide group exhibited a higher prevalence of full stomach (11 of 15 [73%] versus 1 of 15 [7%], P < .001; adjusted to age P = .003). The semaglutide group also exhibited a higher prevalence of early satiety (10 of 15 [67%] versus 0 of 15 [0%], P < .001), loss of appetite (10 of 15 [67%] versus 0 of 15 [0%], P < .001), gastric fullness (8 of 15 [53%] versus 0 of 15 [0%], P = .002), and nausea (7 of 15 [47%] versus 1 of 15 [7%], P = .035). Additionally, there is no case in the semaglutide group with no gastric contents.

CONCLUSIONS

The use of semaglutide is associated with full stomach even after appropriate overnight fasting. Semaglutide is also associated with increased gastrointestinal symptoms such as loss of appetite, early satiety, gastric fullness, and nausea.

Difficult cannulation during endoscopic retrograde cholangiopancreatography-needle-knife precut versus transpancreatic sphincterotomy on the basis of successful cannulation and adverse events

BACKGROUND

When cannulation is challenging during endoscopic retrograde cholangiopancreatography (ERCP), and the standard guidewire technique with sphincterotomy is unsuccessful, alternative cannulation techniques can be used to access the biliary tree. The purpose of this study was to compare the incidence of adverse events and cannulation success rates between transpancreatic sphincterotomy (TPS) and precut sphincterotomy (PCS).

METHODS

Data from the Swedish Registry for Gallstone Surgery and ERCP (GallRiks), collected from 2011 to 2022, were analyzed. A total of 105,303 ERCP procedures were recorded in GallRiks during the study period. After exclusions, the study population consisted of 47,486 ERCP procedures. Of these, 4547 received PCS and 3273 received TPS. The remaining 39,666 ERCP procedures with conventional sphincterotomy served as the control group. The primary endpoints were successful cannulation and adverse events within 30 days.

RESULTS

Successful cannulation was more frequent with the TPS technique than with the PCS technique (86.5% vs. 69.7%), but both groups had a lower cannulation rate than the control group (92.4%; OR-PCS 0.20, 95% CI 0.18-0.21; OR-TPS 0.58, 95% CI 0.52-0.64). The TPS group had a higher incidence of adverse events than the PCS group (24.1% vs. 18.8%) and both groups had a higher incidence of adverse events than the control group (15.5%; OR-PCS 1.25, 95% CI 1.15-1.36; OR-TPS 1.71, 95% CI 1.57-1.87). Adverse events for TPS were driven by a higher incidence of pancreatitis (10.5% vs. 6.4% vs. 4.5%; OR 2.53, 95% CI 2.23-2.86) and perforation (1.6% vs. 0.8% vs. 0.5%; OR 2.99, 95% CI 2.20-4.06) compared to both PCS and control.

CONCLUSION

TPS is more successful at cannulation than PCS; however, this success comes at a higher cost in terms of adverse events, particularly pancreatitis and perforation.

TC-325 Superiority in Malignant Gastrointestinal Bleeding: An Individual Patient Data Meta-Analysis of Randomized Trials

INTRODUCTION

The efficacy of topical hemostatic agents, recommended for peptic ulcer bleeding, remains poorly characterized in malignant gastrointestinal bleeding (GIB).

METHODS

We performed an individual patient data meta-analysis assessing the efficacy of topical hemostatic agents in malignant GIB. The literature was searched using OVID MEDLINE, EMBASE, and ISI Web of Science databases (database inception to November 2023). Only randomized controlled trials (RCTs) comparing topical hemostatic agents with conventional endoscopic modalities in malignant GIB were included. Original RCT patient-level data were obtained. Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were followed. Quality of the evidence was evaluated using the revised Cochrane risk-of-bias tool and certainty of evidence with the Grading of Recommendations Assessment, Development, and Evaluation approach. The primary outcome was immediate hemostasis; secondary outcomes were 30-day rebleeding and the composite measure of further bleeding (persistent bleeding or 30-day rebleeding). Other outcomes were all-cause mortality, adverse events, and need for additional nonendoscopic treatment. Odds ratios (ORs) from endpoint comparisons were pooled using logistic regression models.

RESULTS

Overall, 985 citations were identified; 3 RCTs (n = 160 patients) were included with all assessing TC-325 (Hemospray). TC-325 achieved immediate hemostasis more often than conventional endoscopic modalities (OR 46.6, 95% confidence interval [CI] 5.89-369.1) (low-level certainty). Thirty-day rebleeding (OR 0.28, 95% CI 0.11-0.70) and further bleeding (OR 0.11, 95% CI 0.05-0.26) were both significantly lower with TC-325 (very-low-level certainty). All-cause mortality and need for additional nonendoscopic treatment did not differ between groups. No adverse events were reported. Subgroup analysis confirmed TC-325 superiority in patients with upper GIB.

DISCUSSION

TC-325 seems superior to conventional endoscopic therapy in managing patients with malignant GIB. TC-325 results in improvements in immediate hemostasis, 30-day rebleeding, and further bleeding, based on very low-to-low certainties of evidence.

Effectiveness of cholangioscopy guided biopsy versus ERCP guided brushings in diagnosing malignant biliary strictures

BACKGROUND

Evaluation of lesions of the biliary tract are essential to diagnose given the dismal outcomes of cholangiocarcinoma. Historically, these diagnoses were made using brush biopsies obtained under Endoscopic Retrograde Cholangiopancreatography (ERCP). To increase the accuracy of biliary biopsies, SpyGlassTM Discover cholangioscopy guided biopsy has been developed, providing greater tissue yield and direct visualization of the biliary epithelium. We evaluated the diagnostic accuracy of ERCP guided brushings and SpyGlassTM Discover guided biopsies at a single institution.

METHODS

Following IRB approval, all diagnostic biliary biopsies utilizing both ERCP guided brushings and/or SpyGlassTM Discover between 8/2015 and 6/2022 were retrospectively evaluated. Demographic and clinicopathologic data were collected. Fischer's t-tests and Chi-square analyses were completed as appropriate (p < 0.05).

RESULTS

Overall, 46 patients with an average age of 61 years were included in this study; 59% of the patients were female and 41% were male. 87% of patients had at least one SpyGlassTM Discover guided biopsy and one ERCP guided brushing and 13% of patients had at least one SpyGlassTM Discover guided biopsy alone. SpyGlassTM Discover correctly identified 82% of malignancies while brushings identified only 47% of malignancies.

CONCLUSIONS

SpyGlassTM Discover guided biopsies yield a greater diagnostic result than ERCP guided brushings. Therefore, SpyGlassTM Discover should be considered as the standard for diagnosing biliary lesions at our institution in conjunction with ERCP procedure. The classification of visual characteristics of biliary lesions should be investigated in the future as the high-resolution image generated by SpyGlassTM Discover can allow for detailed visual observation of strictures and potentially aid in better characterization and location of disease.

Current State of Endoscopic Bariatric Therapies

The obesity epidemic poses a significant global health challenge. Despite proven efficacy, accessibility to bariatric surgery is limited. Endoscopic bariatric therapies offer less invasive alternatives. Reversible space-occupying devices like intragastric balloons are suitable for both primary obesity treatment and bridging to surgery. Restrictive therapies that reduce gastric volume like the primary obesity surgery endoluminal and endoscopic sleeve gastroplasty have shown promising short-term results. Diverting devices such as intestinal liners/barriers or magnet-assisted anastomoses aim to replicate surgical effects with lower risks, though efficacy varies. Finally, endoscopic revisional procedures like transoral outlet reduction address weight regain post-bariatric surgery.

Endoscopic ultrasonography-guided coil embolization and cyanoacrylate injection versus cyanoacrylate injection alone for gastric varices: a randomized comparative study

BACKGROUND

Bleeding from gastric varices is life-threatening, with significant rebleeding risk despite standard cyanoacrylate glue injection therapy. Our aim was to evaluate the efficacy and safety of endoscopic ultrasonography (EUS)-guided coil embolization with cyanoacrylate injection (Coil+CYA) compared with EUS-guided cyanoacrylate injection alone (CYA) for the treatment of gastric varices.

METHODS

The study was conducted at a tertiary referral center in India, using a single-blinded, prospective, and parallel-group randomized design. A total of 50 patients were randomly assigned (1 : 1) to Coil+CYA or CYA. The primary outcome was clinical success (i.e. variceal obliteration). Secondary outcomes involved technical success, gastric variceal recurrence during follow-up, rebleeding episodes, reintervention, and survival.

RESULTS

Post-intervention, gastric variceal obliteration assessed by EUS was higher in the Coil+CYA group (100% vs. 92.3%; P = 0.49), with both groups achieving 100% technical success. Rebleeding episodes during 0-12 and 12-24 weeks were comparable in the two groups. At 12 weeks, on EUS, variceal reappearance was less common in the Coil+CYA group (12.5% vs. 19.2%; P = 0.70). Significantly fewer reinterventions were needed in the Coil+CYA group (20.8% vs. 53.8%; P = 0.03). The time to reintervention was significantly longer in the Coil+CYA group (P = 0.01), and the survival time was also longer (P = 0.04).

CONCLUSIONS

EUS-guided coil embolization with cyanoacrylate injection achieved superior clinical success, reducing the need for reintervention and resulting in improved survival compared with cyanoacrylate injection alone.

The Contemporary Diagnostic Approaches to Esophageal Symptomatology

Esophageal symptoms, including dysphagia, heartburn, and non-cardiac chest pain, are prevalent concerns in gastroenterology. This review examines the roles of advanced diagnostic modalities such as high-resolution manometry (HRM), pH-impedance monitoring, and EndoFLIP in understanding esophageal physiology and pathology. Here, we discuss the clinical presentations of common esophageal symptoms and explore how structural abnormalities like strictures and motility disorders, including achalasia and esophageal spasms, are assessed using these tools. The diagnostic utility of endoscopy in visualizing mucosal and structural changes is highlighted alongside emerging technologies like artificial intelligence in enhancing detection capabilities. Complementary techniques, such as barium esophagrams and reflux monitoring, provide additional functional and anatomical insights, crucial for comprehensive patient evaluation. The integration of these diagnostic approaches fosters a deeper understanding of esophageal disorders, guiding effective management strategies and improving patient outcomes. This review aimed to highlight the importance of adopting a multimodal diagnostic approach in modern gastroenterological practice.

Endoscopic bariatric and metabolic therapies and its effect on metabolic dysfunction-associated steatotic liver disease: a review of the current literature

Endoscopic bariatric and metabolic therapies (EBMTs) are minimally invasive endoscopic procedures that have shown to demonstrate significant weight loss in people with obesity. While abundant data support their positive effect on weight loss, there remains a notable dearth of information regarding their effects on metabolic dysfunction-associated steatotic liver disease (MASLD). As rates of type 2 diabetes and obesity have grown worldwide, so has the rate of MASLD. Therefore, addressing these knowledge gaps is crucial in improving liver health worldwide. In this review, we aim to provide the existing evidence delineating the effects of primary and secondary endoscopic bariatric therapies on MASLD and determine knowledge gaps requiring future study. Utilizing PubMed search with relevant keywords such as "endoscopic bariatric therapies," "NAFLD" (nonalcoholic fatty liver disease), "MAFLD" (metabolic dysfunction-associated fatty liver disease), "MASLD" (metabolic dysfunction-associated steatotic liver disease), we gathered case reports, reviews, and retrospective analyses, evaluating their data and limitations. In our manuscript, we detail many primary and secondary endoscopic therapies and the literature available exploring their impact on liver health. This review demonstrates that primary EBMTs improve noninvasive liver markers, weight loss, and overall metabolic syndrome suggesting significant benefit in MASLD. There is, however, a significant lack of literature studying how primary endoscopic therapies compare amongst each other and how revisional therapies affect MASLD. We additionally offer suggestions for future research to deepen our understanding of EBMTs and their effects on MASLD.

Diagnostic work-up of bile duct strictures: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends the combination of endoscopic ultrasound-guided tissue acquisition (EUS-TA) and endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition as the preferred diagnostic approach for tissue acquisition in patients with jaundice and distal extrahepatic biliary stricture in the absence of a pancreatic mass. 2: ESGE suggests that brushing cytology should be completed along with fluoroscopy-guided biopsies, wherever technically feasible, in patients with perihilar biliary strictures. 3: ESGE suggests EUS-TA for perihilar strictures when ERCP-based modalities yield insufficient results, provided that curative resection is not feasible and/or when cross-sectional imaging has shown accessible extraluminal disease. 4: ESGE suggests using standard ERCP diagnostic modalities at index ERCP. In the case of indeterminate biliary strictures, ESGE suggests cholangioscopy-guided biopsies, in addition to standard ERCP diagnostic modalities. Additional intraductal biliary imaging modalities can be selectively used, based on clinical context, local expertise, and resource availability.

A systematic review of the use of GLP-1 receptor agonists in surgery

BACKGROUND

Surgeons are likely to encounter patients on GLP-1 receptor agonists (GLP-1RAs) and should be aware of any associated risks or complications. Here we review the existing literature on GLP-1RA use as it pertains to non-bariatric surgeons.

METHODS

A systematic review was conducted following PRISMA 2020 guidelines. Three databases were queried for articles discussing the use of GLP-1RAs in a surgical context. Articles went through two rounds of manual screening.

RESULTS

21 articles were included in analysis, which found that pre-operatively, GLP-1RAs can aid patients in meeting the BMI threshold for surgery. Peri-operatively, GLP-1RAs were associated with improved glycemic control and lower intraoperative insulin use. Complications such as delayed gastric emptying and increased rates of hypoglycemic events were reported.

CONCLUSION

Surgeons may leverage GLP-1RAs to help prepare patients for surgery and should understand potential surgical complications associated with the use of these medications and to screen preoperative patients appropriately.

Efficacy of Revisional Endoscopic Sleeve Gastroplasty After Laparoscopic Sleeve Gastrectomy

BACKGROUND

Recurrent weight gain after laparoscopic sleeve gastrectomy (LSG) is common. Revisional endoscopic sleeve gastroplasty (r-ESG) has been shown to be a promising endoscopic bariatric therapy (EBT) to treat weight recurrence after LSG. However, to date, weight loss outcomes beyond 1-year follow-up are unknown. Our study aims as follows: (1) examine 1 year, 18-month, and 24-month weight loss outcomes post-r-ESG and (2) determine if weight loss outcomes post-LSG predict clinical outcomes post-r-ESG.

METHODS

This was a retrospective cohort data of patients who completed r-ESG from December 2020 to November 2023. The primary outcome was percentage of total body weight loss (TBWL) at 1-year post-r-ESG. Secondary outcomes included TBWL at 18- and 24-month post-r-ESG. Multivariable logistic regression analysis was used to determine predictors of weight loss ≥ 5% at 12 months.

RESULTS

A total of 55 patients completed r-ESG. TBWL post-r-ESG at 12 months was 8.6% (n = 37), at 18 months was 10.7% (n = 31), and at 24 months was 12.6% (n = 18) (Table 2). There were no statistically significant variables associated with weight loss ≥ 5% at 12 months (Table 3).

CONCLUSIONS

Our study demonstrates that r-ESG is an effective and durable EBT for post-LSG weight recurrence. Further research is needed to determine optimal timing of r-ESG for weight recurrence as well as the adjunctive role of anti-obesity medications.

Assessment of residual gastric volume by ultrasound prior to upper endoscopy: a prospective cohort study

PURPOSE

Pulmonary aspiration is an adverse event with high morbidity and mortality. Despite fasting for > 8 hr, some patients still have residual gastric volume and are thus at risk of aspiration. We aimed to determine the accuracy of gastric ultrasound in assessing residual gastric content in patients undergoing upper gastrointestinal endoscopy.

METHODS

In a prospective cohort study, we performed gastric ultrasound immediately before upper gastrointestinal endoscopy in a sample of 294 patients. We categorized the ultrasound results as high risk of aspiration when the fluid volume was > 1.5 mL·kg-1 or when there was thick/solid content. We applied Spearman's test to determine the correlation between aspirated volume and ultrasound-estimated volume using three mathematical models. We assessed the method's accuracy by calculating its sensitivity and specificity.

RESULTS

We included 282 patients in the analysis. The incidence of residual gastric contents was 5%. There were no aspiration events. Prokinetic use (relative risk [RR], 7.5; 95% confidence interval [CI], 1.9 to 29.1; P < 0.01), previous stroke (RR, 4.0; 95% CI, 1.2 to 13.6; P = 0.02), and male sex (RR, 3.3; 95% CI, 1.2 to 9.4; P = 0.02) were significantly more frequent among those with residual gastric content. The ultrasonography's specificity and sensitivity to predict gastric content at risk of aspiration were 100% and 77%, respectively, with a positive predictive value of 100% and a negative predictive value of 99%.

CONCLUSION

Ultrasonography was an effective way to assess residual gastric content, which can help improve patient safety.

Position statement and guidelines about Endoscopic Sleeve Gastroplasty (ESG) also known as "Endo-sleeve"

IS ESG EFFECTIVE IN THE TREATMENT OF OBESITY AND ASSOCIATEDCOMORBIDITIES?: Endoscopic Sleeve Gastroplasty (ESG) is more effective than lifestyle modifications alone for weight loss and improving obesity-related comorbidities. While it has less effect on weight loss compared to Laparoscopic Sleeve Gastrectomy (LSG) in the short to medium term, it offers similar comorbidities resolution to LSG. IS ESG A SAFE PROCEDURE, AND WHAT ARE ITS RISKS?: The safety profile of ESG is consistently supported in the literature. Surgical complications after ESG, ranging from 1.5 to 2.3%, such as bleeding, perforation, fistula, or upper bowel obstruction, are rare and typically managed endoscopically. The incidence of new-onset gastro-esophageal reflux disease (GERD) is deemed negligible and occurs less frequently after ESG compared to SG. WHAT ARE THE INDICATIONS AND MANAGEMENT METHODS?: Multidisciplinary care for patients undergoing ESG should be provided in an accredited center authorized to perform bariatric and metabolic surgery, with validation through a multidisciplinary consultation meeting (RCP). Perioperative management should be personalized and ideally modeled after the protocols already in place for bariatric and metabolic surgery to ensure satisfactory and lasting weight and metabolic outcomes. Adherence to follow-up visits is a significant predictor of successful weight loss outcomes after ESG. Additionally, all endoscopic surgical procedures should be documented in a registry affiliated with a recognized scientific society, as is standard for other bariatric surgical procedures. WHICH HEALTHCARE PROFESSIONALS CAN PERFORM ESG?: ESG must be performed by a practitioner trained in endoscopy and obesity management, capable of ensuring thorough preoperative care and comprehensive postoperative follow-up, supported by an experienced multidisciplinary team. In France, Notice No. 2021.0040/AC/SEAP of June 10, 2021, issued by the Haute Autorité de santé (HAS) college, specifies that "the technology of ESG via the trans-oral approach, involving wide plication of the greater gastric curvature […] with an endoscopic suture placement device, enables a gastroenterologist or a visceral and digestive surgeon to perform gastric plication through digestive endoscopy by placing sutures in the stomach". Ideally, this should take place in an accredited center authorized to perform bariatric and metabolic surgery, such as those approved by the Agence régionale de santé (ARS), in accordance with Article R6123-212 of December 2022 of the French Public Health Code. WHAT ARE THE RECOMMENDATIONS AND VIEWS OF OTHER INTERNATIONAL SCIENTIFICSOCIETIES?: ESG is an integral part of the therapeutic arsenal available to bariatric and metabolic surgeons, offering an effective and valuable treatment option for obesity in specific patient populations. The International Federation for the Surgery of Obesity (IFSO) Bariatric Endoscopy Committee, following a comprehensive systematic review and meta-analysis, endorsed ESG as an effective and valuable treatment for obesity. ESG is particularly beneficial for patients with class I and II obesity, as well as for those with class III obesity who are not suitable candidates for metabolic bariatric surgery. Additionally, it can be proposed as an addition to lifestyle interventions in adolescent patients with class II obesity. The SOFFCOMM endorses endoscopic sleeve gastroplasty (ESG) as an effective and valuable treatment for obesity and highlights the importance of appropriate patient selection, coupled with rigorous evaluation of long-term outcomes, to refine its indications further.

Role of Endoluminal Functional Lumen Imaging Probe in Bariatric Surgery and Bariatric Endoscopy

Obesity is associated with significant morbidity, with an estimated prevalence of 42.4% in the USA. Treatment of severe obesity often involves Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy. More recently, endoscopic sleeve gastroplasty has emerged as a minimally invasive option for patients with mild to moderate obesity. Endoluminal functional luminal impedance planimetry (EndoFLIP) uses impedance planimetry to assess tissue distensibility and geometric changes across an area but its role in bariatric surgery and bariatric endoscopy has not been fully elucidated. EndoFLIP has some utility in measuring gastric sleeve pouch size during sleeve surgery, assessing gastric sleeve stenosis, predicting the risk of post-sleeve GERD and response to endoscopic dilation, assisting in intraoperative gastric bands adjustment, and evaluating gastrojejunal anastomosis to predict weight regain after gastric bypass.

Glucagon-like peptide-1 receptor agonists and upper endoscopy: a real-world experience

OBJECTIVE

Increased use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) has raised safety concerns during endoscopy due to their mechanism of delaying gastric emptying. This study aims to evaluate the impact of GLP-1RAs on technical success and safety of esophagogastroduodenoscopy (EGD).

METHODS

This was a retrospective study of bariatric patients who underwent EGD between January 2022 and December 2023. Only patients on GLP-1RAs were included and were categorized into those who held GLP-1RAs prior to EGD (GLP-HELD group) and those who did not (GLP-CONTINUED group). The primary outcome was technical success, defined as completion of EGD without interruption. Secondary outcomes included the presence of residual gastric contents during EGD and aspiration rates.

RESULTS

A total of 629 patients were included. Baseline age and BMI were mean (SD) 54.9 (13.0) years and 37.3 (8.0) kg/m2, respectively. Of 629 patients, 146 (23%) were in the GLP-HELD group, and 483 (77%) were in the GLP-CONTINUED group. For the primary outcome, rates of early termination of EGD were similar between groups (1.4% for GLP-CONTINUED vs. 0% for GLP-HELD; p = 0.36). For secondary outcomes, incidence of residual gastric contents was similar between groups (6.4% for GLP-CONTINUED vs. 2.7% for GLP-HELD; p = 0.09). There were no aspiration events in either group.

CONCLUSIONS

Continuation of GLP-1RAs did not appear to be associated with an increased incidence of residual gastric contents, early procedural termination, or aspiration events.

Glucagon-like peptide-1 receptor agonists significantly affect the quality of bowel preparation for colonoscopy

BACKGROUND

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) affect gastrointestinal motility, slowing gastric emptying and colonic transit. GLP-1RAs have an impact on gastric residue before endoscopy, but only limited data are available regarding its effect on the adequacy of colonic preparation. We investigated the association between GLP-1RA use and inadequate bowel preparation (IBP) for colonoscopy.

METHODS

We performed a multicenter retrospective study with GLP-1RA cases matched with controls (using propensity scores for age, sex, diabetes mellitus [DM], obesity, and co-morbidities). Data on demographics, medication use, procedural indications, and colonoscopy findings were collected. IBP ("poor preparation" on Aronchik scale or Boston Bowel preparation scale <5) was the primary outcome.

RESULTS

4876 patients treated with GLP-1RAs were included in the analysis and compared with 4876 controls selected from 333 648 patients without GLP-1RA use. Among the GLP-1RA patients, 10% (n = 487) had IBP compared with 197 (4%) of the control group (P<0.001). Subgroup analysis showed a higher rate of IBP among diabetic patients treated with GLP-1RA (284/2364 [12%]) than among diabetic patients without GLP-1RA treatment (118/2364 [5%]; P<0.001). Additionally, 203/2512 nondiabetic patients treated with GLP-1RAs had IBP (8%) compared with 79 of the nondiabetic non-GLP-1RA group (3%; P<0.001). On multivariate analysis, diabetes and GLP-1RA use were both found to be independent risk factors for IBP (odds ratio [OR] 1.4 and OR 2.7, respectively; both P<0.001).

CONCLUSION

Our findings highlight the necessity for special attention and tailored recommendations for both diabetic and nondiabetic patients treated with GLP-1RAs in terms of colonic preparation prior to colonoscopy.

Endoscopic ultrasound-guided gastrojejunostomy with wire endoscopic simplified technique: Move towards benign indications (with video)

OBJECTIVES

Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is an alternative to duodenal stenting and surgical GJ (SGGJ) in malignant gastric outlet obstruction (MGOO). European Society of Gastrointestinal Endoscopy guidelines restricted EUS-GJ for MGOO only, because of misdeployment. The aim was to evaluate its outcomes focusing on benign indications.

METHODS

This was a retrospective study conducted from 2016 to 2023 in a tertiary center. Patients included had malignant or benign GOO indicated for EUS-GJ. Techniques were the direct approach until August 2021, and the wire endoscopic simplified technique (WEST) afterwards. The main objective was to compare outcomes in benign vs. MGOO. Secondary end-points were technical success, adverse events rates, and describing the evolution of techniques and indications.

RESULTS

In all, 87 patients were included, 46 men, mean age 66 ± 16.2 years. Indications were malignant in 60.1% and benign in 39.1%. The EUS-GJ technique was direct in 33 patients (37.9%) and WEST in 54 (62.1%). No difference was found in terms of technical, clinical, or adverse events rates. The initial technical success rate was 88.5%. The final technical and clinical success rates were 96.6% and 94.25%, respectively. In the last year, benign exceeded malignant indications (70.4% vs. 29.6%, P < 0.05). Seven misdeployments occurred, six being addressed with the rescue technique. The misdeployment rate was significantly decreased using the WEST approach compared to the direct one: 3.7% vs. 18% (P < 0.05). The severe postoperative adverse events rate was 2.3%.

CONCLUSION

This study demonstrated similar outcomes of EUS-GJ between benign and MGOO, with a decreasing misdeployment rate (<4%) applying WEST. This represents an additional step towards recommending EUS-GJ in benign indications.

Safety of endoscopist-directed nurse-administered sedation in an Italian referral hospital: An audit of 2 years and 19,407 procedures

BACKGROUND AND STUDY AIMS

Balanced propofol sedation (BPS) administered by adequately trained non-anaesthesiologist personnel has gained popularity in GI endoscopy because of its shorter procedure and recovery time, high patient satisfaction, and low rate of adverse events (AEs), despite being considered controversial. We report data from an audit of endoscopist-directed (ED) nurse-administered sedation in an Italian referral hospital.

PATIENTS AND METHODS

Consecutive endoscopic procedures performed between 2020 and 2022 were considered. Under the guidance of the endoscopist, the nurse administered midazolam/fentanyl, followed by a progressive top-up dosage of a 10-20 mg bolus of propofol to achieve moderate to deep sedation. The endoscopists and nurses were all certified in our hospital with a continuous and scheduled training from 2006.

RESULTS

During the study period, a total of 19,407 examinations (7,803 EGDS, 10,439 colonoscopies, 77 PEG, 697 EUS, and 365 ERCP) and 14,415 patients were included. Of these, 29.4 % of patients were classified as ASA I, 66.5 % as ASA II, and 5.1 % as ASA III. Hypotension was recorded in 1,293 (6 %) examinations and bradycardia in 176 (0.9 %) patients. Eleven patients (0.06 %) had minor respiratory adverse events. Two patients (0.01 %) had major AEs requiring orotracheal intubation.

CONCLUSIONS

ED-BPS is safe in low-risk patients. Major AEs occurred in 0.01 % of procedures.

Endoscopic Papillary Large Balloon Dilatation With or Without Endoscopic Sphincterotomy in the Treatment of Common Bile Duct Stones

PURPOSE OF REVIEW

Endoscopic papillary large balloon dilation (EPLBD) has been proved to have better efficacy and safety in removing common bile duct stones. Conventional endoscopic sphincterotomy (EST) is usually performed before EPLBD. However, EPLBD without EST has recently reported short-term outcomes similar to those of EPLBD with EST. This article summarizes the latest research advances in EPLBD with or without EST for the treatment of large common bile duct stones (CBDS) as a way to provide further evidence to support the ERCP surgeon's choice of which technique to use for the treatment of large CBDS.

FINDINGS

EPLBD alone is recommended in cases of anatomical abnormalities or bleeding tendencies. EPLBD with EST is recommended in patients with stenosis of the duodenal papilla or distal common bile duct or with periportal diverticula. Most clinical studies have shown that the clinical efficacy and incidence of adverse events associated with ESLBD are comparable to those of standalone EPLBD. However, further large-scale prospective randomized controlled trials are needed to confirm these findings.

Variability in the management of GLP-1 agonists and endoscopic procedures: an opportunity for standardization

Glucagon-like peptide-1 receptor agonists (GLP-1RAs), also known as incretin mimetics, have significantly revolutionized the treatment of type 2 diabetes mellitus (T2DM) and obesity worldwide, far exceeding initial expectations regarding their global prescription. This class of medications has demonstrated weight losses of up to 20 % of baseline body weight. Beyond their proven benefits in T2DM and obesity, GLP-1RAs, as well as dual and triple agonists (GLP-1/GIP/glucagon), are being investigated for their effects on conditions such as metabolic-associated steatotic liver disease, various cardiovascular disorders, neurocognitive impairments, and certain addictions. These emerging effects appear to be linked not only to their metabolic action but also to their ability to modulate the chronic inflammatory state underlying these pathologies.

Perioperative Use of GLP-1 Receptor Agonists in Patients Undergoing Cardiac Procedures: A Scoping Review

BACKGROUND

Glucagon-like peptide-1 receptor agonist (GLP-1RA) therapies are increasingly used for the treatment of type 2 diabetes mellitus and obesity. Despite growing awareness of potentially increased risk of pulmonary aspiration due to delayed gastric emptying, the risks and benefits of their perioperative use in patients undergoing cardiac procedures remains unexplored. A scoping review was performed to investigate the perioperative GLP-1RA use in patients undergoing cardiac procedures and recommendations.

METHOD

PubMed and Ovid MEDLINE were searched up to April 2024 to identify English-language studies on the perioperative use of weekly and daily dosed GLP-1RAs in adult patients undergoing cardiac procedures (including cardiac surgery, trans-oesophageal echocardiograms, and cardiac catheterisation procedures).

RESULTS

Three studies were identified, which investigated daily dosed GLP-1RAs in patients undergoing cardiac surgery. No studies were found investigating GLP-1RA use in cardiac catheterisation or trans-oesophageal echocardiograms procedures, and none which specifically examined risk of pulmonary aspiration in patients using GLP-1RAs undergoing cardiac procedures.

CONCLUSIONS

GLP-1RAs are beneficial for perioperative weight loss, glycaemic control, and cardiovascular health. Existing guidelines and consensus recommendations are highly contradictory on perioperative GLP-1RA management. Although no known published case reports exist to date of pulmonary aspiration in patients using GLP-1RAs undergoing cardiac procedures, non-cardiac surgical literature strongly suggests that patients are at theoretical risk and a cautious approach is advised in the absence of robust evidence informing recommendations for optimal withholding periods.

Glucagon-like peptide-1 receptor agonists in peri-operative care: Dispelling myths and unveiling insights with essential considerations for anaesthesiologists

With the growing use of glucagon-like-peptide-1 (GLP-1) receptor (GLP-1R) agonists as anti-obesity medication it is becoming increasingly important to examine its consequences in the peri-operative period. GLP-1R agonists are known for their effects of glucose-lowering and gastroparesis the latter causing some safety concerns regarding induction of anaesthesia, more specifically the risk of pulmonary aspiration. This article gathers the available evidence on this subject in addition to the already established guidelines. Current evidence makes us assume there is indeed an increased level of gastroparesis, but there are no studies to date with evidential confirmation of a presumed elevated risk of pulmonary aspiration. Future perspectives should focus on the actual risk of pulmonary aspiration and the possible implementation of ultrasound in the preoperative assessment.

Surgical management, including the role of transplantation, for intrahepatic and peri-hilar cholangiocarcinoma

Intrahepatic and peri-hilar cholangiocarcinoma are life threatening disease with poor outcomes despite optimal treatment currently available (5-year overall survival following resection 20-35%, and <10% cured at 10-years post resection). The insidious onset makes diagnosis difficult, the majority do not have a resection option and the high recurrence rate post-resection suggests that occult metastatic disease is frequently present. Advances in perioperative management, such as ipsilateral portal vein (and hepatic vein) embolisation methods to increase the future liver remnant volume, genomic profiling, and (neo)adjuvant therapies demonstrate great potential in improving outcomes. However multiple areas of controversy exist. Surgical resection rate and outcomes vary between centres with no global consensus on how 'resectable' disease is defined - molecular profiling and genomic analysis could potentially identify patients unlikely to benefit from resection or likely to benefit from targeted therapies. FDG-PET scanning has also improved the ability to detect metastatic disease preoperatively and avoid futile resection. However tumours frequently invade major vasculo-biliary structures, with resection and reconstruction associated with significant morbidity and mortality even in specialist centres. Liver transplantation has been investigated for very selected patients for the last decade and yet the selection algorithm, surgical approach and both value of both neoadjuvant and adjuvant therapies remain to be clarified. In this review, we discuss the contemporary management of intrahepatic and peri-hilar cholangiocarcinoma.

Glucagon-like peptide-1 receptor agonists and capsule endoscopy in patients with diabetes: a matched cohort study

BACKGROUND AND AIMS

Video capsule endoscopy (VCE) is valuable for assessing conditions like GI bleeding, anemia, and inflammatory bowel disease. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are prescribed for diabetes and weight loss, with their pharmacologic effects including delayed gastric emptying. This study investigates the impact of GLP-1RA use on VCE outcomes in patients with diabetes.

METHODS

This retrospective cohort study involves patients with diabetes undergoing VCE while on GLP-1RAs matched in a 1:1 ratio with control subjects, who are not on GLP-1RAs, based on demographics and diabetes-related factors. The primary outcome was gastric transit time in VCE studies, whereas secondary outcomes were incomplete small-bowel evaluation and small-bowel transit time.

RESULTS

In the GLP-1RA cohort with 68 patients, 5 (7%) experienced failure to pass the video capsule through the stomach; all control subjects passed the video capsule successfully (P = .06). GLP-1RA patients had a longer gastric transit time (99.3 ± 134.2 minutes) compared with control subjects (25.3 ± 31.6 minutes, P < .001). Multivariate analysis revealed GLP-1RA use was associated with an increased gastric transit time by 74.5 minutes (95% confidence interval, 33.8-115.2; P < .001) compared with control subjects, after adjusting for relevant factors. Sixteen GLP-1RA patients (23.5%) experienced incomplete passage of the video capsule through the small intestine, a significantly higher rate compared with 3 patients in the control group (4.4%, P < .01).

CONCLUSIONS

GLP-1RA use is associated with a prolonged gastric transit time and a higher rate of incomplete small-bowel evaluation during VCE. Future studies may be crucial for evaluating strategies to mitigate these effects.

Endoscopic closure of esophageal, gastric, jejunal, and rectopelvic fistulas with cardiac septal occluder devices: a case series

Background and Aims

Treating GI fistulas and anastomotic leaks is a challenge. Traditionally, these adverse events have been treated with conservative measures or surgical interventions, both of which have been associated with high rates of morbidity. Although endoscopic techniques are available and commonly minimally invasive, their success can be variable and oftentimes require repeat interventions. Cardiac septal occluder (CSO) devices have emerged as an alternative for managing these complex GI fistulas and anastomotic leaks after the more conservative endoscopic options fail.

Methods

Before the introduction of the CSO device into the body, a CSO delivery system must first be created. After integrating this system with an endoscope, argon plasma coagulation is used on each of the fistulas, and the CSOs are then deployed under fluoroscopy.

Cases

We present 4 cases of CSO device placement throughout the GI tract: in the esophagus, jejunum, stomach, and rectosigmoid colon. Each of these cases presents unique challenges in maneuvering the anatomy, ensuring the CSOs fully occlude the fistulas, and are successful in causing tissue in-growth postplacement.

Conclusions

This study presents a case series of 4 successful closures of GI fistulas using CSO devices after the failure of more conservative therapies. Each of these cases takes place in a different part of the GI tract-the esophagus, stomach, small intestines, and large intestines-indicating the broad application of CSO devices. CSOs offer a promising alternative for managing complex GI fistulas and postsurgical anastomotic leaks endoscopically throughout the entire GI tract.

Endoscopic bariatric surgery for adults with overweight and obesity: a systematic review and network meta-analysis

BACKGROUND

Endoscopic bariatric surgery (EBS) is a new treatment for obesity. We compared the efficacy, safety, and probability of metabolic complications of different EBSs with laparoscopic sleeve gastrectomy (LSG).

METHODS

This systematic review and network meta-analysis (NMA) included searches of PubMed, Web of Science, and the Cochrane Library from January 1, 2017, to December 27, 2022, to find comparative trials of EBS procedures and EBS with LSG. We performed a frequentist model NMA to summarize the evidence and ranked the interventions according to SUCRA scores.

RESULTS

The search for this NMA yielded 14,160 articles, of which 18 eligible trials recruited 766,135 participants for procedures including LSG, endoscopic sleeve gastroplasty (ESG), nonadjustable intragastric balloon (NIB), BioEnterics Intragastric Balloon (BIB), and adjustable intragastric balloon (AIB). Definitive evidence suggests that LSG is most effective for weight reduction. Compared with LSG, NIB, SMD = -0.49 [95% CI -0.79, -0.18]; AIB, SMD = -0.41 [95% CI -0.76, -0.06] and ESG, SMD = -0.31 [95% CI -0.33, -0.29] in the index of percentage total weight loss under six months. In terms of safety outcomes, ESG had the lowest incidence of adverse events; the order of the observed incidence of adverse events from small to large was ESG, NIB, AIB, LSG, and BIB.

CONCLUSIONS

ESG is an effective and safe minimally invasive surgical method for people with overweight and obesity. Its 12-month effect is better than that of NIB, and its influence on lipid metabolism makes it more protective of the cardiovascular system and liver.

PROSPERO

CRD42022375343.

Postinsertion Management of Cholecystostomy Tubes for Acute Cholecystitis: A Systematic Review

BACKGROUND

Percutaneous gallbladder drainage (PGD) is indicated to treat high-risk patients with acute cholecystitis. Trends suggest increasing use of PGD over time as the population ages and lives longer with multiple comorbidities. There is no consensus on the management of cholecystostomies tube once inserted. This review aims to synthesize and describe the most common protocols in terms of the need and timing of follow-up imaging, management of a destination tube, timing of tube removal, and optimal interval time from tube positioning to delayed cholecystectomy.

METHODS

The study protocol has been registered on the International Prospective Register of Systematic Reviews-PROSPERO. Studies on adult patients diagnosed with acute cholecystitis who underwent a PGD from 2000 to November 2023 were included. The databases searched were MEDLINE, Embase, and Cochrane. The quality assessment tools provided by the NHLBI (National Heart, Lung, and Blood Institute) were applied and descriptive statistics were performed.

RESULTS

We included 22,349 patients from 94 studies with overall fair quality (6 prospective and 88 retrospective). In 92.7% of papers, the authors checked by imaging all patients with a PGD (41 studies included). Depending on protocol time, 30% of studies performed imaging within the first 2 weeks and 35% before tube removal (40 studies included). In the case of a destination tube, 56% of studies reported removing the tube (25 studies included). In the case of tube removal, the mean time after insertion was more than 4 weeks in 24 of the 33 included studies (73%). Interval cholecystectomies are more frequently performed after 5 weeks from PGD (32/38 included studies, 84%). Limitations included high clinical heterogeneity and prevalent retrospective studies.

CONCLUSIONS

A standard management for percutaneous cholecystostomy after insertion is difficult to define based on existing evidence, and currently we can only rely on the most common existing protocols.

Effects of glucagon-like peptide-1 receptor agonists on endoscopy outcomes: systematic review and meta-analysis

BACKGROUND AND AIMS

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are known to cause delayed gastric emptying; however, the effect on clinical outcomes during upper endoscopy and colonoscopy remains unclear. We conducted a meta-analysis to reconcile the data.

METHODS

Online databases were searched for studies evaluating GLP-1RAs versus a control group (no GLP-1RAs) in patients undergoing endoscopy. The outcomes of interest were rate of retained gastric contents (RGCs), aborted procedures, aspiration events, and subjective bowel preparation quality. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a random-effects model.

RESULTS

Twenty-three studies with 77,152 patients (4449 in the GLP-1RA arm and 72,703 in the control arm) were included. Mean patient age ranged from 47.6 to 72 years, and 58.4% were women. As compared with the control group, the GLP-1RA group had higher odds of RGCs (OR, 15.39; 95% CI, 4.65-50.99; P < .01) and aborted procedures (OR, 13.86; 95% CI, 4.42-43.43; P < .01). No significant differences were observed between the 2 groups in terms of aspiration events (OR, 21.06; 95% CI, .13-3379.01; P = .24) and subjective bowel preparation quality (OR, .94; 95% CI, .67-1.31; P = .83).

CONCLUSIONS

Although statistical significance was reached in terms of visible RGCs and early termination of endoscopies in patients on GLP-1RAs, these events were overall rare. GLP-1RAs do not appear to pose significant risk, as the odds of developing aspiration were comparable in the 2 groups.

EUS-guided coiling plus glue injection compared with endoscopic glue injection alone in endoscopic treatment for gastric varices: a systematic review and meta-analysis

BACKGROUND AND AIMS

EUS-guided coil plus glue injection has emerged as a safe and effective modality for gastric varices (GVs). Very few studies have compared EUS embolization with the direct endoscopic glue injection (EGI) technique for its safety and effectiveness. In this systematic review and meta-analysis, we compared the outcomes of EUS-guided coil plus glue injection versus EGI.

METHODS

MEDLINE, EMBASE, and Cochrane databases were searched for studies that compared EUS and EGI for GVs, and 1454 articles were screened following the Preferred Reporting Items for Systematic reviews and Meta-Analyses protocol. Endpoints were pulmonary embolism, recurrent bleeding rate, reintervention rate, technical success, abdominal pain, and mortality rate. A restricted maximum likelihood random-effects model with odds ratios (ORs) and 95% confidence intervals (CIs) was used for binary endpoints. Heterogeneity was evaluated through Cochrane's Q statistic and Higgins and Thompson's I2 statistic. Significance was defined as P < .05.

RESULTS

We included 6 studies with 445 patients treated for GVs. Mean patient age was 49 years, and 43% were women. EUS was associated with a reduction in recurrent bleeding rate (OR, .22; 95% CI, .11-.45; P < .001; I2 = 0) and reintervention rate (OR, .29; 95% CI, .09-.89; P = .03; I2 = 49%) compared with EGI. There were no differences between groups in pulmonary embolism (OR, .34; 95% CI, .10-1.18; P = .09; I2 = 0%), mortality rate (OR, .78; 95% CI, .28-2.13; P = .63; I2 = 0%), technical success (OR, 3.50; 95% CI, .60-20.49; P = .16; I2 = 0%), fever (OR, 1.49; 95% CI, .42-5.21 days; P = .5; I2 = 0%), and abdominal pain (OR, .96; 95% CI, .31-2.95; P = .94; I2 = 32%).

CONCLUSIONS

In patients with GVs, EUS-guided coil plus glue injection is associated with lower recurrent bleeding and reintervention rates than EGI with no difference in pulmonary embolization rate, abdominal pain, technical success, and mortality rate.

The Pilot Study on Detecting Perforation with Abdominal Ultrasound During Gastric Endoscopic Submucosal Dissection

Objectives: The indications for endoscopic submucosal dissection (ESD) for gastric adenoma and gastric cancer have expanded, leading to an increase in the number of patients with high procedural complexity. Post-ESD perforations prolong hospital stays and increase costs. However, no studies have focused on detecting micro-perforations during ESD. This study aimed to identify signs of perforation using abdominal ultrasound during gastric ESD. Materials and methods: This pilot study analyzed 50 patients who underwent abdominal ultrasound (VScan Air™, GE Healthcare) during ESD at Samsung Medical Center (March 2023-July 2024). Perforation was assessed via ultrasound, and post-procedure X-rays were performed for three days to detect free air. Results: Among 50 patients (median age 60, 76.1% male), the median procedure time was 60 min. Lesions were most common in the antrum (30.4%) and lesser curvature (17.4%). Pathology revealed 32.6% well-differentiated and 10.9% moderately differentiated adenomas, with 15.2% showing high-grade dysplasia. Free air was detected in three patients after procedures involving the body wall of the stomach. Abdominal US showed indirect signs of perforation, including an abnormal peritoneal line, hyperechoic shadowing, and an absence of normal gas patterns, confirmed by X-ray. Conclusions: Abdominal US is a simple, useful tool for rapid detection of perforation during ESD, enabling timely intervention. Further multicenter studies are needed to confirm these findings.

Diagnostic Approach to Biliary Strictures

Biliary strictures represent a narrowing of the bile ducts, leading to obstruction that may result from benign or malignant etiologies. Accurate diagnosis is crucial but challenging due to overlapping features between benign and malignant strictures. This review presents a comprehensive diagnostic approach that integrates biochemical markers, imaging modalities, and advanced endoscopic techniques to distinguish between these causes. Imaging tools such as ultrasound, MRI/MRCP, and CECT are commonly used, each with distinct advantages and limitations. Furthermore, endoscopic procedures such as ERCP and EUS are key in tissue acquisition, enhancing diagnostic accuracy, especially for indeterminate or complex strictures. Recent innovations, including artificial intelligence and new endoscopic techniques, hold promise in enhancing precision and reducing diagnostic challenges. This review emphasizes a multidisciplinary strategy to improve diagnostic pathways, ensuring timely management for patients with biliary strictures.

Gel immersion in endoscopy: Exploring potential applications

The challenge of effectively eliminating air during gastrointestinal endoscopy using ultrasound techniques is apparent. This difficulty arises from the intricacies of removing concealed air within the folds of the gastrointestinal tract, resulting in artifacts and compromised visualization. In addition, the overlap of folds with lesions can obscure their depth and size, presenting challenges for an accurate assessment. Conversely, in intricately folded regions of the gastrointestinal tract, such as the stomach, intestine, and colon, insufficient delivery of air or CO2 into the cavity impedes luminal expansion, hindering the accurate visualization of lesions concealed within the folds. Although this underscores the requirement for substantial airflow, excessive airflow can hinder visualization of bleeding lesions and other abnormalities. Considering these challenges, an ideal endoscopic device would facilitate the observation of lesions without the requirement for air or CO2 delivery whereas, ensuring optimal expansion of the gastrointestinal tract. Recently, transparent gels with specific viscosities have been employed more frequently to address this issue. This review aims to elucidate how these gels address these challenges and provide a solution for enhanced endoscopic visualization.

Outcomes of anesthesia-supported versus endoscopist-driven sedation modalities: a retrospective cohort study

BACKGROUND AND AIMS

The use of anesthesia has become commonplace in many procedural settings. The goal of this study is to compare sedation modalities used by endoscopists and anesthesiologists in the endoscopy suite, particularly with respect to recovery time and adverse events.

METHODS

We conducted a retrospective cohort study including adults (≥18 years of age) undergoing outpatient EGD and/or colonoscopy at Mayo Clinic in Jacksonville, Florida between October 1st, 2018 and December 31st, 2022. Cases were classified as using propofol only, propofol ± adjuvants (PA; including dexmedetomidine, ketamine, fentanyl, and midazolam), general anesthesia (GA) with endotracheal tube, or fentanyl/midazolam (FM) only. The primary outcome was length of stay (LOS) in the postanesthesia care unit (PACU), and secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), hypoxemia (Spo2 risk 90%), bradycardia (heart rate <60 bpm), and escalation of care (hospital admission).

RESULTS

The analysis included 56,361 cases. Among patients who received FM sedation, the mean PACU LOS was 52.01, 49.68, and 53.24 minutes for EGD, colonoscopy, and combined procedures, respectively. This was significantly higher than the mean PACU LOS for GA (44.65, 41.41, and 41.92 minutes, respectively), for PA (32.35, 35.75, and 33.42 minutes, respectively), and for propofol (31.63, 32.61, and 33.29 minutes, respectively; P < .0001). Of patients receiving FM, 8.39% experienced bradycardia, 6.12% experienced hypoxia, 0.24% experienced PONV, and 0.05% were hospitalized. These were substantially lower than the rates for other sedation groups, and odds ratios were significantly lower than 1.00 (P < .05) in 30 of 36 comparisons across procedural, sedative, and outcome categories.

CONCLUSIONS

Sedation achieved with FM correlated with a lower rate of adverse events but a significantly longer PACU LOS compared with propofol, PA, or GA.

Utility and clinical significance of endoscopic ultrasound-guided tissue acquisition for diagnosing lymphadenopathies in biliary tract cancer

Lymph node sampling with endoscopic ultrasound fine needle aspiration (EUS-FNA) may affect treatment options for biliary tract cancers. Our aim is to clarify its utility and clinical significance and the factors associated with FNA cytology positivity. Seventy-one consecutive patients with biliary tract cancer who underwent EUS-FNA to diagnose lymphadenopathies from April 2012 to July 2021 were enrolled retrospectively. Lymph nodes with a short diameter over 10 mm and/or fluorodeoxyglucose uptake were considered FNA targets. Samples eligible for cytology were attained in 70 patients with no complications. The FNA cytology-positive rate was 54%. In 35 patients with difficulty in obtaining pathological proof from primary tumors, obtaining a pathological diagnosis was successful in 24 patients. Thirteen of 16 FNA cytology-positive patients who were diagnosed with preoperative regional lymph node metastasis received chemotherapy prior to surgery. All seven FNA cytology-positive patients who were diagnosed with distant metastasis received systemic chemotherapy. Multivariate analyses showed a neutrophil-to-lymphocyte ratio over 2.5 (odds ratio (OR) 4.69, p = 0.04), fluorodeoxyglucose uptake (OR 5.34, p = 0.014), and a short diameter over 10.6 mm (OR 6.11, p = 0.018) as factors related to FNA cytology positivity. EUS-FNA of lymphadenopathies in biliary tract cancers may affect clinical biliary tract cancer strategies.

Glucagon-Like Peptide-1 Receptor Agonists in the Peri-Operative Period

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are emerging as an important class of drugs in the management of Type 2 Diabetes Mellitus (T2DM) and obesity. There are rising concerns of pulmonary aspiration with these medications due to drug-induced gastroparesis. While definitive association is uncertain, it is essential to be prudent and manage these patients as per the current evidence and recommendations.