Advancements in the diagnosis of biliopancreatic diseases: A comparative review and study on future insights

Owing to the complex and often asymptomatic presentations, the diagnosis of biliopancreatic diseases, including pancreatic and biliary malignancies, remains challenging. Recent technological advancements have remarkably improved the diagnostic accuracy and patient outcomes in these diseases. This review explores key advancements in diagnostic modalities, including biomarkers, imaging techniques, and artificial intelligence (AI)-based technologies. Biomarkers, such as cancer antigen 19-9, KRAS mutations, and inflammatory markers, provide crucial insights into disease progression and treatment responses. Advanced imaging modalities include enhanced computed tomography (CT), positron emission tomography-CT, magnetic resonance cholangiopancreatography, and endoscopic ultrasound. AI integration in imaging and pathology has enhanced diagnostic precision through deep learning algorithms that analyze medical images, automate routine diagnostic tasks, and provide predictive analytics for personalized treatment strategies. The applications of these technologies are diverse, ranging from early cancer detection to therapeutic guidance and real-time imaging. Biomarker-based liquid biopsies and AI-assisted imaging tools are essential for non-invasive diagnostics and individualized patient management. Furthermore, AI-driven models are transforming disease stratification, thus enhancing risk assessment and decision-making. Future studies should explore standardizing biomarker validation, improving AI-driven diagnostics, and expanding the accessibility of advanced imaging technologies in resource-limited settings. The continued development of non-invasive diagnostic techniques and precision medicine approaches is crucial for optimizing the detection and management of biliopancreatic diseases. Collaborative efforts between clinicians, researchers, and industry stakeholders will be pivotal in applying these advancements in clinical practice.

Current Role of Robotic Surgery in Colorectal Disease

Background

Robot-assisted surgery aims to combine the advantages of open surgery with those of minimally invasive surgery to overcome the previous limitations of laparoscopy. Compared to conventional laparoscopic methods, robot-assisted techniques offer significant advantages, which are currently increasingly employed despite mostly longer operating times and higher costs. The aim of this review was to describe the current role of robotics in the treatment spectrum of colorectal surgery.

Summary

A comprehensive literature review was conducted using PubMed, Medline, and Embase to identify studies, systematic reviews, and meta-analyses on robotic surgery for colorectal benign and malignant disease, focusing on studies and meta-analyses comparing the laparoscopic with the robotic approach; articles published between 2004 and 2024 were screened: results of studies on surgical techniques must always be interpreted with caution, taking into account the technical skills and preferences of the participating surgeons. Compared to conventional laparoscopic methods and independent of the indication, robot-assisted techniques offer obvious technical and ergonomic advantages. Most colorectal procedures can safely be conducted via robotic-assisted surgery. Throughout the various indications described in this manuscript, the most evident advantage of robotic surgery remains a lower conversion rate, followed by less blood loss and a shorter hospital stay at the price of a longer operating time. For malignant disease, robotic surgery seems to be additionally associated with a higher lymph node yield in the majority of the studies. In acute or chronic inflammatory colorectal diseases, robotic-assisted surgery may facilitate interventions through improved visibility and a potentially more precise dissection of the correct plane; furthermore, robotic-assisted surgery offers advantages for performing complex intracorporal anastomoses. Last but not least, the surgeon's well-being and preferences make a relevant impact on the utilization of the system in colorectal surgery.

Key Messages

The use of robot-assisted procedures has increased significantly in the last decade across the various surgical specialties, with the largest increase in colorectal surgery. Next to the surgeons' preferences, capacity and costs will define the future role of robotic surgery in colorectal disease. As robotic surgery is becoming a mainstream surgical approach, there is a crying need for implementable training concepts of robotic techniques in colorectal surgery.

Breath biomarkers for esophageal cancer: identification, quantification, and diagnostic modeling

Esophageal cancer is a major global health issue with a high mortality rate. Early diagnosis is crucial for improving patient outcomes, but traditional diagnostic methods are often invasive and costly. This study explores the potential of exhaled volatile organic compounds (VOCs) as a non-invasive diagnostic tool for esophageal cancer. Using gas chromatography-mass spectrometry (GC-MS), we analyzed the breath samples of 80 esophageal cancer patients and 60 healthy controls, identifying and quantifying over 100 VOCs. The results revealed significant differences in the concentrations of VOCs such as acetone, ethanol, and isoprene between the two groups. A multi-parameter regression diagnostic model based on a neural network algorithm achieved an accuracy of 90.3% in distinguishing esophageal cancer patients from healthy individuals. Further optimization incorporating physiological factors, including smoking, drinking, and dietary habits, improved the model's accuracy to 92.4%, with a specificity of 93.1%, representing a significant improvement over previous studies. These results suggest that VOCs analysis in exhaled breath holds great promise as a non-invasive, cost-effective, and accurate method for early detection of esophageal cancer.

Isolated Adult Gastrointestinal Tract Langerhans Cell Histiocytosis-Report of Two Rare Patients with Review of Literature

Langerhans cell histiocytosis is a rare disorder marked by monoclonal proliferation of Langerhans cells, primarily affecting the skin and bones. Isolated gastrointestinal tract involvement by Langerhans cell histiocytosis in adults is exceedingly rare, with only a few examples documented to date. Here, we report two patients with adult Langerhans cell histiocytosis with gastrointestinal tract involvement, accompanied by BRAF mutation analysis. Patient 1 was a 51-year-old man presenting with intermittent abdominal pain. Colonoscopy revealed five polyps, with histopathology and immunohistochemistry confirmation of Langerhans cell histiocytosis. BRAF testing was positive for the V600E mutation. Patient 2 was a 76-year-old woman, who presented with anemia and recurrent C. difficile colitis, leading to gastrointestinal distress and weight loss. Colonoscopy revealed two polyps which on pathologic evaluation were diagnosed as Langerhans cell histiocytosis. BRAF testing was negative. Both the patients exhibited benign clinical course with no multisystem involvement. Though Langerhans cell histiocytosis involvement of the gastrointestinal tract is uncommon in adults, it should be considered in differential diagnoses when histiocytic proliferation is observed.

Endoscopic treatment of unresectable perihilar cholangiocarcinoma: beyond biliary drainage

Perihilar cholangiocarcinoma (PHCC) is an aggressive biliary malignancy originating from the epithelial cells of the bile duct, typically located in the extrahepatic biliary tree, proximal to the cystic duct. PHCC often presents with a rapid onset of jaundice. While radical surgical resection remains the only curative treatment, only a minority of patients are eligible due to early metastasis and challenges associated with preoperative evaluations. Comprehensive treatments, including chemotherapy, radiotherapy, targeted therapy, and immunotherapy, are crucial for managing PHCC. However, in advanced stages, complications such as cholestatic liver injury, malnutrition, and biliary infections pose significant obstacles to these treatments. Therefore, biliary drainage (BD) is essential in the management of PHCC. In addition to external drainage methods like percutaneous transhepatic biliary drainage (PTBD), endoscopic biliary drainage (EBD), particularly endoscopic retrograde cholangiopancreatography (ERCP), offer an effective option for internal drainage, which is more physiologically compatible and better tolerated. Furthermore, the integration of various endoscopic techniques has expanded the management of PHCC beyond mere drainage. Techniques such as radiofrequency ablation (RFA), photodynamic therapy (PDT), and endoscopic ultrasound (EUS) based methods present new therapeutic avenues, albeit with variable results. This review aims to summarize current advancements and ongoing debates in the field of endoscopic treatment for unresectable PHCC.

The 50% effective dose of remimazolam combined with different doses of esketamine for painless gastroscopy

OBJECTIVE

Remimazolam is a novel benzodiazepine sedative that provides effective sedation, stable haemodynamics, and minimal adverse effects during intravenous general anaesthesia. The aim of this study was to determine the 50% effective dose (ED50) of remimazolam combined with different doses of esketamine for painless gastroscopy and to evaluate the efficacy and safety of this combination.

METHODS

This was a randomised, double-blind, up-and-down sequential allocation study. Patients undergoing painless gastroscopy who met all the inclusion criteria and did not meet any of the exclusion criteria were randomised in a 1:1:1 ratio into the ES0 group (0 mg/kg of esketamine), ES1 group (0.2 mg/kg of esketamine), and ES2 group (0.4 mg/kg of esketamine). The initial dose of remimazolam was 0.3 mg/kg in each group, with the dose increased or decreased by 0.05 mg/kg for the subsequent patient based on the success or failure of sedation in the previous patient. The trial was concluded when seven successful failure crossovers were achieved. The ED50 and 95% confidence intervals (CI) of remimazolam were calculated using Probit regression. Haemodynamic parameters, time to induction of anaesthesia, time to gastroscopy, time to awakening from anaesthesia, and adverse events were recorded.

RESULTS

A total of 59 patients were included in the final analysis: 19 in the ES0 group, 23 in the ES1 group, and 17 in the ES2 group. The ED50 (95% CI) of remimazolam in the ES0, ES1, and ES2 groups was 0.344 (0.302-0.389) mg/kg, 0.289 (0.249-0.328) mg/kg, and 0.193 (0.145-0.239) mg/kg, respectively. Additionally, the ES1 and ES2 groups exhibited more stable haemodynamics compared to the ES0 group. However, the ES1 and ES2 groups had significantly longer recovery times than the ES0 group. The incidence of hypotension was higher in the ES0 group compared to the ES1 and ES2 groups.

CONCLUSION

The ED50 of remimazolam combined with 0 mg/kg, 0.2 mg/kg, and 0.4 mg/kg of esketamine for induction of anaesthesia during painless gastroscopy was 0.344 mg/kg, 0.289 mg/kg, and 0.193 mg/kg, respectively. Combining esketamine with remimazolam for induction of anaesthesia during painless gastroscopy offers advantages in terms of haemodynamic stability and reduced adverse effects.

The impact of the novel EUS scope and ultrasonographic system for diagnosis and therapy in patients with pancreatobiliary diseases (videos)

PURPOSE

We evaluated the diagnostic and therapeutic capabilities of endoscopic ultrasonography (EUS) in pancreaticobiliary diseases. We aimed to validate the efficiency of detective flow imaging (DFI), shear wave elastography (SWE), and other advanced imaging techniques.

METHODS

We used new EUS scopes (EG-740 UT and G-580UR) and the latest ultrasound equipment (ARIETTA 850) (Fujifilm Healthcare, Kanagawa, Japan). Diagnostic procedures were performed in 16 cases, including pancreatic cancer and intraductal papillary mucinous neoplasms, and therapeutic procedures in eight cases, involving complex biliary and pancreatic interventions. The utility of SWE in assessing tissue stiffness was quantified by measuring the shear wave velocity (SWV) in pancreatic cancer and autoimmune pancreatitis.

RESULTS

We found no significant difference in SWVs among different pancreatic conditions; however, significant variations were observed in the net percentage of effective SWV. Interventional EUS had a 100% technical and clinical success rate, demonstrating the efficacy of new imaging techniques and equipment in enhancing procedural safety and diagnostic accuracy.

CONCLUSIONS

The integration of advanced EUS imaging technologies, particularly DFI, contrast-enhanced EUS, and SWE, significantly enhances the diagnosis and treatment of pancreaticobiliary diseases.

Rapid pathologic grading-based diagnosis of esophageal squamous cell carcinoma via Raman spectroscopy and a deep learning algorithm

BACKGROUND

Esophageal squamous cell carcinoma is a major histological subtype of esophageal cancer. Many molecular genetic changes are associated with its occurrence. Raman spectroscopy has become a new method for the early diagnosis of tumors because it can reflect the structures of substances and their changes at the molecular level.

AIM

To detect alterations in Raman spectral information across different stages of esophageal neoplasia.

METHODS

Different grades of esophageal lesions were collected, and a total of 360 groups of Raman spectrum data were collected. A 1D-transformer network model was proposed to handle the task of classifying the spectral data of esophageal squamous cell carcinoma. In addition, a deep learning model was applied to visualize the Raman spectral data and interpret their molecular characteristics.

RESULTS

A comparison among Raman spectral data with different pathological grades and a visual analysis revealed that the Raman peaks with significant differences were concentrated mainly at 1095 cm-1 (DNA, symmetric PO, and stretching vibration), 1132 cm-1 (cytochrome c), 1171 cm-1 (acetoacetate), 1216 cm-1 (amide III), and 1315 cm-1 (glycerol). A comparison among the training results of different models revealed that the 1D-transformer network performed best. A 93.30% accuracy value, a 96.65% specificity value, a 93.30% sensitivity value, and a 93.17% F1 score were achieved.

CONCLUSION

Raman spectroscopy revealed significantly different waveforms for the different stages of esophageal neoplasia. The combination of Raman spectroscopy and deep learning methods could significantly improve the accuracy of classification.

RCPE in association with the American College of Gastroenterology and the Scottish Society of Gastroenterology - Gastroenterology: A global perspective

On 6 November 2024, the Royal College of Physicians of Edinburgh (RCPE) hosted its annual gastroenterology symposium, marking the first collaboration with the American College of Gastroenterology (ACG) and the Scottish Society of Gastroenterology (SSG). The event addressed key global challenges in gastroenterology, including obesity, liver disease, inflammatory bowel disease (IBD), the gut microbiome, endoscopy quality and artificial intelligence (AI) applications. Discussions emphasised the growing burden of metabolic dysfunction-associated steatotic liver disease (MASLD), with promising pharmacologic and endoscopic interventions emerging. Advances in microbiome-targeted therapies, including faecal microbiota transplantation (FMT), were explored for recurrent Clostridium difficile infection and IBD. Professor David Rubin delivered the esteemed Sir Stanley Davidson lecture, highlighting the era of disease modification in IBD, emphasising early intervention and personalised treatment strategies. The symposium also addressed the role of AI in improving endoscopic detection rates and optimising resource allocation. This international collaboration underscored the importance of a multidisciplinary approach to tackling global digestive diseases, integrating clinical innovation, policy interventions and technological advancements. The event fostered knowledge exchange among global experts, aiming to advance patient care and improve long-term outcomes in gastroenterology.

Splenic injuries following upper endoscopic procedures: a systematic review of cases

Background

Splenic injury is a rare complication of upper endoscopic procedures described in case reports. These injuries can result in significant morbidity due to the spleen's vascularity and propensity for intraperitoneal bleeds. This review aims to collect data regarding patient characteristics, procedural factors, clinical presentations and treatment courses for analysis.

Methods

A systematic review of case reports on PubMed, Embase, and Web of Science was conducted for splenic injuries following upper endoscopic procedures (as of 14 July 2023). A total of 52 cases from 50 reports were included. All cases were from case reports or series, including conference abstracts, published in English. Cases were excluded if they were: not published in English; dealt with splenic injuries not following upper endoscopic procedures, including colonoscopy; documented a later complication of an upper endoscopic procedure, such as a migrating stent; not case reports or case series, such as review articles. Risk of bias was analyzed with Joanna Briggs Institute critical appraisal tools. Cases were analyzed using descriptive statistics.

Results

The mean age was 56 years, with a median of 55 years, and a range of 21-86 years. Prior abdominal surgeries were identified in 31% of cases (16/52), and chronic pancreatitis in 15% (9/52). Procedural difficulty was reported in 21% (11/52). Most occurred following endoscopic retrograde cholangiopancreatography (ERCP) (71%, 37/52). Common symptoms were abdominal pain (79%, 41/52), hypotension and/or tachycardia (67%, 35/52), and postoperative drops in hemoglobin (58%, 30/52). Mean time to symptom onset was 21 hours, with a median of 4 hours, and a range of 0-144 hours. Most were diagnosed with computerized tomography (69%, 36/52), followed by laparotomy (17%, 9/52). Most were treated surgically (76%, 40/52). Most patients recovered fully (82%, 42/51).

Conclusions

Splenic injury is a rare complication of upper endoscopy that should be considered given the risk for delayed diagnosis and mortality. Most patients presented with abdominal pain and signs of hemorrhagic shock, although many had delayed onset of symptoms. Potential risk factors include prior abdominal surgeries, chronic pancreatitis, and difficult or prolonged procedures. Our review was limited by a low number of cases and inconsistent reporting of variables, which limited our statistical analysis.

Predictive Factors of Cytomegalovirus Colonic Reactivation in Patients with Active Ulcerative Colitis

Cytomegalovirus (CMV)-associated colitis reflects the adverse impact of CMV reactivation on ulcerative colitis (UC). Its diagnosis requires the detection of viral markers in intestinal biopsies sampled during endoscopy, which may constitute invasive and expensive analyses. Moreover, less than 30% of acute flare-ups in steroid refractory UC are associated with CMV colitis. This retrospective study aimed to identify non-invasive factors that are predictive of CMV reactivation, and was conducted from 2014 to 2019 in a cohort of UC patients consulting at the University Hospital of Saint-Etienne, France. Patient characteristics, disease activity, immunosuppressive treatment and tissue CMV DNA load were collected at the time of UC relapse. Factors potentially associated with CMV reactivation were analyzed through a multivariate analysis. A total of 173 UC patients providing 323 pairs of intestinal biopsies were analyzed. In the CMV seropositive subgroup, a Mayo endoscopic score ≥2 (OR 2.553, 95% CI 1.353-4.818, p = 0.004) was identified as a predictive factor of CMV colitis in the multivariate analysis; in contrast, biological parameters exhibited no predictive value. In addition, the use of anti-TNFα monoclonal antibodies was associated with a reduced risk of CMV reactivation (OR 0.384, 95% CI 0.158-0.935, p = 0.035). Intestinal biopsies appear to be unavoidable for assessing disease activity and CMV reactivation in UC patients.

Artificial intelligence-assisted phase recognition and skill assessment in laparoscopic surgery: a systematic review

With the widespread adoption of minimally invasive surgery, laparoscopic surgery has been an essential component of modern surgical procedures. As key technologies, laparoscopic phase recognition and skill evaluation aim to identify different stages of the surgical process and assess surgeons' operational skills using automated methods. This, in turn, can improve the quality of surgery and the skill of surgeons. This review summarizes the progress of research in laparoscopic surgery, phase recognition, and skill evaluation. At first, the importance of laparoscopic surgery is introduced, clarifying the relationship between phase recognition, skill evaluation, and other surgical tasks. The publicly available surgical datasets for laparoscopic phase recognition tasks are then detailed. The review highlights the research methods that have exhibited superior performance in these public datasets and identifies common characteristics of these high-performing methods. Based on the insights obtained, the commonly used phase recognition research and surgical skill evaluation methods and models in this field are summarized. In addition, this study briefly outlines the standards and methods for evaluating laparoscopic surgical skills. Finally, an analysis of the difficulties researchers face and potential future development directions is presented. Moreover, this paper aims to provide valuable references for researchers, promoting further advancements in this domain.

Invasive Therapeutic Strategies for Stricturing Crohn's Disease in Childhood: A Systematic Review and Meta-Analysis

BACKGROUND

Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract. Current drugs are not effective for treating the primary fibrotic component of CD. Recommended invasive treatments include endoscopic balloon dilation, surgery with resection, or strictureplasty. This meta-analysis compared invasive treatment techniques for CD-related strictures in the pediatric population.

METHODS

The MEDLINE, EMBASE, and LILACS databases were searched from inception to December 2023. This meta-analysis was performed as per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The outcome was measured by the rate of stenosis recurrence and the adverse events of the techniques. Eligibility criteria were studies that involved the analysis of the recurrence rate of stenosis in pediatric patients with CD requiring surgical intervention after undergoing any of the previously proposed therapies. Additionally, adverse events were analyzed.

RESULTS

Three studies comprising a total of 106 endoscopic balloon dilations demonstrated a combined rate of stricture recurrence in patients with CD requiring surgical intervention of 0.171 (95% confidence interval [CI], 0.110-0.255). Three studies comprising a total of 49 surgical resections demonstrated a pooled event rate of 0.100 (95% CI, 0.038-0.240). Finally, 2 studies comprising a total of 38 strictureplasties demonstrated a pooled event rate of 0.347 (95% CI, 0.070-0.789). Concerning adverse events, the most common occurrences were found after surgical resection.

CONCLUSIONS

Surgical resection is the best option for treating strictures in pediatric CD patients in terms of recurrence rate, compared with endoscopic balloon dilation and strictureplasty. Nevertheless, surgical resection is associated with more adverse events.

After stent placement in patient with left colon cancer with intestinal obstruction safety and efficacy analysis

PURPOSE

This study aimed to evaluate the safety and efficacy of intestinal stent placement as a bridge to surgery in patients with left colon cancer complicated by intestinal obstruction (LCCO).

METHODS

A retrospective cohort analysis was conducted on 111 patients diagnosed with LCCO at The Second Affiliated Hospital of Chongqing Medical University between January 2015 and August 2019. Patients were divided into two groups: the stent group (SG, n = 41) and the emergency surgery group (EG, n = 70). Primary endpoints included 3-year progression-free survival (PFS), local recurrence, and distant metastasis rates. Secondary endpoints encompassed 3-year overall survival (OS), intraoperative parameters (lymph node dissection, blood loss, operative time), enterostomy rate, postoperative complications, and hospital stay duration.

RESULTS

No significant differences were observed between SG and EG in 3-year PFS (59% vs. 41%, P = 0.091), OS (61% vs. 44%, P = 0.051), or metastasis rates (19.5% vs. 20%, P = 0.95). However, SG demonstrated superior short-term outcomes, including reduced intraoperative blood loss (60 mL vs. 78 mL, P = 0.02), shorter hospital stay (10.2 vs. 16.1 days, P < 0.001), lower enterostomy rate (0% vs. 100%, P < 0.001), and fewer postoperative complications (14.6% vs. 24.3%, P = 0.012).

CONCLUSION

Stenting in patients with left colon cancer with obstruction can relieve the symptoms of intestinal obstruction in time. Compared with emergency open surgery, it has better short-term results and does not affect the long-term curative effect of the tumor.

Pancreatic Neuroendocrine Diagnostic Imaging Order and Reader Evaluation over Two Decades in a Tertiary Academic Center

Background/Objective: Identifying patterns of diagnostic imaging workflow parallel to the influence of certain variables, such as pathology guidelines over time, provides valuable insight for clinical decision making. This study presents a recurring trend of initial imaging orders and follow-ups, up to the diagnosis of pancreatic neuroendocrine tumors (pNETs), across two decades, with scans which led to pathological investigation. Methods: Three readers evaluated common conventional imaging among initial and follow-up studies for lesion detection and localization. Inter-reader and intra-reader analyses were controlled as contributing factors to the imaging diagnostic trend. Results: Our results show that CT was the prominent initial scan in pNET workup, likely due to their wide availability, high spatial resolution, and rapid acquisition, with a sufficient detection rate throughout both decades, regardless of technical advances. However, MRI scans also gained soaring popularity, especially among syndromic patients, likely due to follow-up and anatomical surgery precision. Conclusions: Newer modalities may be eventually useful and only requested for pNETs staging and further treatment.

Advances in Endo-Hepatology: The Role of Endoscopic Ultrasound in the Management of Portal Hypertension

Portal hypertension (PH) is a complication of advanced liver diseases, including cirrhosis and hepatocellular carcinoma, often leading to unfavorable outcomes. Endo-hepatology, particularly endoscopic ultrasound (EUS) has revolutionized the assessment of PH. Notably, EUS-guided portal pressure gradient (EUS-PPG) enables measurement of portal and hepatic venous pressures, offering diagnostic precision for both cirrhotic and non-cirrhotic forms of PH, including porto-sinusoidal vascular disorder (PSVD). EUS-based assessment of PH in advanced liver disease can refine diagnostic workup and prognostication, supporting therapeutic decisions. Additionally, EUS-guided liver biopsy (EUS-LB) achieves high-quality histological samples with fewer complications compared to percutaneous techniques, enabling thorough evaluation of chronic liver diseases and vascular abnormalities. EUS-shear wave elastography (EUS-SWE) further refines stiffness measurements where standard imaging fails. Moreover, EUS plays a major role in controlling variceal hemorrhage, a severe PH complication. EUS-guided coil and cyanoacrylate injection for gastric varices demonstrate a great efficacy, often surpassing conventional endoscopy. Similarly, EUS-based identification and treatment of perforator vessels feeding esophageal varices reduce rebleeding risks, particularly in challenging patients. The combination of these state-of-the-art interventions supports a "one-stop strategy", integrating variceal screening, biopsy, and portal pressure measurement within a single procedure. Despite these advancements, refinements in sedation protocols, patient selection, and cost-effectiveness data are necessary. While noninvasive tools remain central in guidelines, EUS-based methods continue to expand their role, especially in complex cases. This review summarizes the applications and impact of EUS in evaluating PH, emphasizing its importance in contemporary hepatology and its potential as a pivotal diagnostic modality in cirrhosis complicated by PH.

Inflammation-Associated Carcinogenesis in Inflammatory Bowel Disease: Clinical Features and Molecular Mechanisms

Inflammatory bowel disease (IBD), comprising ulcerative colitis (UC) and Crohn's disease (CD), is a chronic condition marked by persistent intestinal inflammation of unknown etiology. Disease onset involves genetic predisposition and environmental factors that disrupt the intestinal immune homeostasis. The intestinal microbiome and immune response play pivotal roles in disease progression. Advances in molecular therapies and early interventions have reduced surgery rates; however, colorectal cancer (CRC) remains a significant concern, driven by chronic inflammation. In UC, the risk of UC-associated neoplasia (UCAN) increases with disease duration, while CD patients face elevated risks of small intestine, anal fistula, and anal canal cancers. Endoscopic surveillance is advised for UCAN, but optimal screening intervals remain undefined, and no established guidelines exist for CD-associated cancers. UCAN morphology often complicates detection due to its flat, inflammation-blended appearance, which differs pathologically from sporadic CRC (sCRC). UCAN is frequently surrounded by dysplasia, with p53 mutations evident at the dysplasia stage. IBD-associated gastrointestinal cancers exemplify inflammation-driven carcinogenesis with distinct molecular mechanisms from the adenoma-carcinoma sequence. This review explores the epidemiology, risk factors, clinical and pathological features, current surveillance practices, and molecular pathways underlying inflammation-associated cancers in IBD.

An artificial intelligence model utilizing endoscopic ultrasonography for differentiating small and micro gastric stromal tumors from gastric leiomyomas

BACKGROUND

Gastric stromal tumors (GSTs) and gastric leiomyomas (GLs) represent the primary subtypes of gastric submucosal tumors (SMTs) characterized by distinct biological characteristics and treatment modalities. The accurate differentiation between GSTs and GLs poses a significant clinical challenge. Recent advancements in artificial intelligence (AI) leveraging endoscopic ultrasonography (EUS) have demonstrated promising results in the categorization of larger-diameter SMTs (> 2.0 cm). However, the diagnostic capacity of AI models for micro-diameter SMTs (< 1.0 cm) remains uncertain due to limited imaging features. This study seeks to develop a specialized diagnostic model utilizing EUS images to differentiate small and micro GSTs from GLs effectively.

METHODS

In this study, a dataset comprising 358 EUS images of GSTs or GLs was utilized for training the EUS-AI model. Subsequently, 216 EUS images were allocated for validation purposes, with 159 images in validation set 1 (micro SMTs: tumor diameter < 1.0 cm) and 216 images in validation set 2 (small SMTs: tumor diameter < 2.0 cm). The diagnostic performance of the EUS-AI model for individual tumors was assessed by consolidating the diagnostic outcomes of the corresponding images. Comparative analyses were conducted between the diagnostic outcomes of endoscopists, clinical signatures, and those of the EUS-AI models.

RESULTS

The EUS-AI models were developed using DenseNet201, ResNet50, and VGG19 architectures. Among the three models, the ResNet50 model demonstrated superior performance on EUS images, achieving area under the curve (AUC) values of 0.938, 0.832, and 0.841 in the training set, validation set 1, and validation set 2, respectively. By combining predictions from multiple images for each tumor, the diagnostic efficacy of ResNet50 was further enhanced, resulting in AUCs of 0.994, 0.911, and 0.915 in the aforementioned sets. In comparison, both clinical signatures and endoscopists exhibited notably lower AUC values than those obtained with the EUS-AI model.

CONCLUSIONS

The EUS-AI model utilizing ResNet50 architecture effectively discriminates between micro GSTs and GLs from both image-centric and tumor-centric perspectives. Demonstrating superior diagnostic efficiency compared to clinical models and assessments by endoscopists, the EUS-AI model serves as a valuable tool for clinicians in precisely distinguishing small and micro GSTs from GLs before surgery.

The physical biogeography of Fusobacterium nucleatum in health and disease

Fusobacterium nucleatum (Fn) is an oral commensal inhabiting the human gingival plaque that is rarely found in the gut. However, in colorectal cancer (CRC), Fn can be isolated from stool samples and detected in metagenomes. We hypothesized that ecological characteristics of the gut are altered by disease, enabling Fn to colonize. Multiple genomically distinct populations of Fn exist, but their ecological preferences are unstudied. We identified six well-separated populations in 133 Fn genomes and used simulated metagenomes to demonstrate sensitive detection of populations in human oral and gut metagenomes. In 9,560 samples from 11 studies, Fn population C2 animalis is elevated in gut metagenomes from CRC and Crohn's disease patients and is observed more frequently in CRC stool samples than in the gingiva. Polymorphum, the most prevalent gingival Fn population, is significantly increased in Crohn's stool samples; this effect was significantly stronger in male hosts than in female. We find polymorphum genomes are enriched for biosynthetic gene clusters and fluoride exporters, while C2 animalis are high in iron transporters. Fn populations thus associate with specific clinical and demographic phenotypes and harbor distinct functional features. Ecological differences in closely related groups of bacteria inform microbiome impacts on human health.

IMPORTANCE

Fusobacterium nucleatum is a bacterium normally found in the gingiva. F. nucleatum generally does not colonize the healthy gut, but is observed in approximately a third of colorectal cancer (CRC) patient guts. F. nucleatum's presence in the gut during CRC has been linked to worse prognosis and increased tumor proliferation. Here, we describe the population structure of F. nucleatum in oral and gut microbiomes. We report substantial diversity in gene carriage among six distinct populations of F. nucleatum and identify population disease and body-site preferences. We find the C2 animalis population is more common in the CRC gut than in the gingiva and is enriched for iron transporters, which support gut colonization in known pathogens. We find that C2 animalis is also enriched in Crohn's disease and type 2 diabetes, suggesting ecological commonalities between the three diseases. Our work shows that closely related bacteria can have different associations with human physiology.

Curriculum for training in peroral endoscopic myotomy (POEM) in Europe (Part I): European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

Peroral endoscopic myotomy (POEM) is an advanced endoscopic procedure that has become a first-line treatment for esophageal achalasia and other esophageal spastic disorders. Structured training is essential to optimize the outcomes of this technique. The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in POEM. This Position Statement presents the results of a systematic review of the literature and a formal Delphi process, providing recommendations for an optimal training program in POEM that aims to produce endoscopists competent in this procedure. In a separate document (POEM curriculum Part II), we provide technical guidance on how to perform the POEM procedure based on the best available evidence. 1: POEM trainees should acquire a comprehensive theoretical knowledge of achalasia and other esophageal motility disorders that encompasses pathophysiology, diagnostic tool proficiency, clinical outcome assessment, potential adverse events, and periprocedural management. 2: Experience in advanced endoscopic procedures (endoscopic mucosal resection and/or endoscopic submucosal dissection [ESD]) is encouraged as a beneficial prerequisite for POEM training. 3: ESGE suggests that POEM trainees without ESD experience should perform an indicative minimum number of 20 cases on ex vivo or animal models before advancing to human POEM cases with an experienced trainer. 4: ESGE recommends that the trainee should observe an indicative minimum number of 20 live cases at expert centers before starting to perform POEM in humans. 5: The trainee should undertake an indicative minimum number of 10 cases under expert supervision for the initial human POEM procedures, ensuring that trainees can complete all POEM steps independently. 6: ESGE recommends avoiding complex POEM cases during the early training phase. 7: POEM competence should reflect the technical success rate, both the short- and long-term clinical success rates, and the rate of true adverse events. 8: A POEM center should maintain a prospective registry of all procedures performed, including patient work-up and outcomes, procedural techniques, and adverse events.

Risk scores for choledocholithiasis perform poorly in patients with hemolytic diseases: a PEDI database report

Patients with hemolytic diseases are at increased risk for gallstone-related complications. Modified scoring systems have been developed to assess which pediatric patients would benefit from endoscopic retrograde cholangiopancreatography (ERCP) to treat choledocholithiasis. This study aimed to evaluate the ability of the available criteria to determine which pediatric patients with hemolytic diseases are likely to benefit from ERCP. A secondary analysis was performed using the Pediatric ERCP Database Initiative database, which contains prospectively collected data from 1,124 ERCPs at tertiary-care institutions. We compared patients with a hemolytic disease to those without. Data was analyzed by two-tailed Fisher's exact test and paired student t-test. Of the 47 (17.0%) patients who had a hemolytic disease, 34 (72.3%) had one or more common bile duct (CBD) stones at the time of ERCP. Among patients with hemolytic diseases, there were no differences in pre-ERCP imaging or laboratory findings between those with a CBD stone removed at ERCP and those without. Patients with hemolytic diseases did not fit the current choledocholithiasis selection criteria well: 80% in the no-stone at ERCP group met the American Society of Gastrointestinal Endoscopy high-risk criteria, and 90% met the 2016 modified Baylor pediatric criteria. Although not statistically significant, there was an increased number of adverse events in patients with hemolytic diseases. Existing ERCP criteria perform poorly in patients with hemolytic diseases, overestimating their risk of choledocholithiasis. Peri-procedure evaluations such as endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography appear underutilized and may be essential modalities in this population.

Endoscopic Sleeve Gastroplasty for the Treatment of Metabolic Syndrome: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is an incisionless weight loss procedure that has been demonstrated to be safe and effective for the treatment of obesity; however, the efficacy of ESG for the treatment of comorbid type 2 diabetes mellitus (T2DM) and other components of metabolic syndrome (MetS) has been less well studied. We aimed to conduct a systematic review and meta-analysis of available literature to evaluate the outcomes of ESG on T2DM and MetS.

METHODS

Bibliographic databases were systematically searched for studies assessing the outcomes of ESG on T2DM and MetS. Studies were included if they reported at least one objective outcome related to T2DM or other components of MetS, including hyperlipidemia (HLD), hypertriglyceridemia, and hypertension (HTN). This study was deemed IRB exempt.

RESULTS

Ten studies with 4320 patients were included. At 12 months, ESG was associated with significant improvements in T2DM, HLD, and HTN, with risk difference of - 0.72 [95% CI, - 0.87 to - 0.58, p < 0.00001], - 0.65 [95% CI, - 0.78 to - 0.52, p < 0.00001], and - 0.60 [95% CI, - 0.66 to - 0.53, p < 0.00001], respectively. Disease improvement was defined as patients being able to stop some or all of their related treatment medications. Additionally, there were significant reductions in hemoglobin A1c (HGBA1c), fasting blood glucose, homeostatic model assessment for insulin resistance (HOMA-IR), low-density lipoprotein, and triglycerides.

CONCLUSIONS

ESG is an effective modality for the treatment of comorbid T2DM and MetS in patients with obesity. Additional studies are needed to establish long-term responses and to compare ESG against established pharmacologic and surgical techniques.

Infectious Agents and Esophageal Cancer: A Comprehensive Review

Esophageal cancer, primarily comprising the squamous cell carcinoma (ESCC) and adenocarcinoma (EAC) subtypes, is the sixth leading cause of cancer deaths globally. In addition to many well-established endogenous and exogenous risk factors, there is emerging evidence for the etiologic role of infectious agents in esophageal cancer, although these associations are incompletely understood. Here, we review the currently available literature on the relationship between infectious agents and esophageal cancer. By far, human papilloma virus (HPV), particularly HPV 16 and 18, have the strongest etiologic association with ESCC. Less robust is the association of high-risk HPV (hr-HPV) with EAC. Although H. pylori has been implicated in the development of EAC via increased acid reflux, decreased lower esophageal sphincter tone, and the resultant Barrett's metaplasia-dysplasia-adenocarcinoma pathway, some hypothesize based on epidemiological trends that H. pylori may in fact be a protective factor. In rare cases, EBV can cause esophageal lymphoepithelial carcinoma. Several other agents including HSV, polyomaviruses, and Candida are associated with esophageal cancer to varying degrees. In summary, while several studies, including those conflicting with each other, implicate several infectious agents, the evidence is weak, at best. Clearly, further work is needed to help solidify clear etiologies that will help facilitate prevention and treatment.

Endoscopic Submucosal Dissection (ESD) for the Management of Fibrotic Non-Lifting Colorectal Lesions (NLCLs): Results from a Large Multicenter Retrospective Study

Background/Objectives: The management of non-lifting colorectal lesions (NLCLs), often resulting from previous unsuccessful treatments or biopsies, remains challenging due to submucosal fibrosis that prevents adequate lifting. Endoscopic submucosal dissection (ESD) is a viable option for achieving complete resection in such cases. However, when standard ESD is not feasible, conversion to hybrid ESD (H-ESD) has been proposed as a rescue strategy. This study aimed to assess ESD's feasibility, effectiveness, and safety for NLCLs, including cases requiring conversion to H-ESD, when performed by experienced endoscopists in tertiary referral centers. Methods: In this multicenter retrospective study, data from patients with NLCLs treated by ESD/H-ESD between January 2009 and September 2022 were analyzed. The primary endpoint was the recurrence rate (RR). Secondary endpoints included the adverse event (AE) rate, technical success (TS) rate (en bloc resection regardless of technique), complete resection (CR), curative resection (cR) rates, and surgical intervention rate. Predictors of ESD technical success were identified. Results: In total, 178 patients with NLCLs were included (52 previously biopsied, 126 recurrent after previous resection). ESD was used in 111 (62.4%) and H-ESD in 67 (37.6%) cases. During a median follow-up of 373 days (IQR 540), the overall RR was 3.6%. The overall AE rate was 13.4%, and perforation was the most frequent (8.4%). All AEs were successfully managed endoscopically. The TS rate was 71.9%, significantly higher in previously biopsied lesions compared to recurrent ones (78.8% vs. 55.6%, p = 0.04). On multivariate analysis, rectal location (p < 0.001), F1 fibrosis (p = 0.026), and previously biopsied lesions (p = 0.006) predicted ESD TS without the need for conversion to H-ESD. Conclusions: ESD/H-ESD is feasible and safe for NLCLs when performed by experienced operators, with low RR amenable to endoscopic treatment. Previously biopsied lesions, rectal location, and low fibrosis predict ESD TS.

Retrospective Evaluation of the Prognostic Utility of Clinical and Laboratory Findings in Hospitalized Cats with Pancreatitis

Pancreatitis in cats ranges from mild forms with low mortality to severe cases with poor prognosis, and early identification of high-risk patients remains a challenge. The prognostic significance of hyperlactatemia and metabolic acidosis in feline pancreatitis is not well established. This study aimed to identify prognostic factors in hospitalized cats with pancreatitis and assess the predictive value of hyperlactatemia and metabolic acidosis. A retrospective study of 142 cats diagnosed between January 2020 and December 2023 was conducted, analyzing signalment, clinical signs, and clinicopathological findings. Diagnosis was based on clinical signs, abnormal feline pancreatic lipase assay, and abdominal sonography. Multivariate analysis identified jaundice (OR, 4.6; 95% CI, 1.7-12.7), renal disease (OR, 2.0; 95% CI, 1.05-5.40), hypoalbuminemia (OR, 3.91; 95% CI, 1.70-9.01), increased blood urea nitrogen (BUN) (OR, 4.76; 95% CI, 1.96-11.53), and neutrophil cytoplasmic toxic change (OR, 10.54; 95% CI, 4.17-26.7) as independent prognostic indicators. The combination of renal disease and jaundice increased the mortality risk 12-fold, while hypoalbuminemia and neutrophil toxic changes increased it 120-fold. However, hyperlactatemia and metabolic acidosis upon admission were not predictive of outcomes. These findings suggest that jaundice, renal disease, hypoalbuminemia, increased BUN, and neutrophil toxic changes are significant prognostic indicators in feline pancreatitis, whereas hyperlactatemia and metabolic acidosis do not predict mortality.

Endoscopic Full Thickness Resection Device (FTRD®) for the Management of Gastrointestinal Lesions: Current Evidence and Future Perspectives

Endoscopic full-thickness resection (EFTR) has emerged as a transformative technique for managing gastrointestinal (GI) lesions, previously deemed unsuitable for endoscopic removal. Unlike conventional endoscopic resection methods, such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), EFTR enables en bloc excision of both intraluminal and subepithelial lesions by resecting all layers of the GI wall, followed by defect closure to prevent complications. The introduction of the full-thickness resection device (FTRD®) has significantly enhanced the feasibility and safety of EFTR, particularly in the colon and upper GI tract, with increasing adoption worldwide. This review provides a comprehensive analysis of FTRD®, focusing on its clinical applications, procedural methodology, and comparative efficacy against other endoscopic resection techniques. The indications and contraindications for EFTR are explored, highlighting its utility in treating non-lifting adenomas, subepithelial tumours, and T1 carcinomas without lymph node involvement. This review synthesizes current clinical data and FTRD® advantages. Despite its strengths, EFTR via FTRD® incorporates challenges such as limitations in lesion size, procedural complexity, and potential adverse events. Strategies for overcoming these challenges, including hybrid techniques and modifications in procedural approach, are examined. The review also emphasizes the need for further research to optimize surveillance strategies and determine the long-term clinical impact of EFTR in GI lesion management. By integrating recent evidence, this paper provides valuable insights into the evolving role of EFTR in therapeutic endoscopy.

Simulators and training models for diagnostic and therapeutic gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Technical and Technology Review

Gastrointestinal (GI) endoscopy comprises both diagnostic and therapeutic procedures involving the luminal GI tract as well as the biliary tree, liver, and pancreas. GI endoscopy is challenging to learn, requiring both cognitive (nontechnical) and technical skills, and requires extensive practice to attain proficiency. Simulation-based training has been shown to assist trainees and young endoscopists in acquiring new skills and accelerating the learning curve. Moreover, simulation-based training creates an ideal environment for trainees to initially learn and practice skills while making mistakes with no risk to patients.This review, divided in two parts, offers a comprehensive summary of the different classes of simulators available for GI endoscopic training.In Part I, only mechanical simulators are reported and described. In Part II, animal simulators (ex vivo/in vivo) and virtual reality models are detailed, together with prototypes that are currently not commercially available.

Early cholangioscopy-guided lithotripsy for clearance of biliary stones associated with narrow lower bile duct

Background and study aims

Stones larger than the distal common bile duct (CBD) are difficult to remove with conventional techniques. Large papillary balloon dilatation (> 12 mm) of the biliary sphincter is an effective technique for stone removal but is associated with risk of leak in patients with narrower lower CBD. Mechanical or cholangioscopy-guided lithotripsy has been used in this situation for clearance of the bile duct. In the present study, we report outcomes of early cholangioscopy-guided lithotripsy in patients with narrow lower CBD compared with stone size.

Patients and methods

The present study is a retrospective analysis of prospectively collected data from all patients with large proximal stones with a narrow lower bile duct who underwent digital cholangioscopy and electrohydraulic lithotripsy (EHL). Outcomes were proportion of patients with complete bile duct clearance after the first session of electrohydraulic lithotripsy, mean number of EHL sessions for complete clearance, and complications.

Results

Eighty-one patients with mean age 54 ± 17 years underwent digital cholangioscopy and EHL. Mean stone size was 14.02 ± 3.5 mm and 71 patients (87.7%) had a stone only in the bile duct. Three (3.7%) and seven patients (8.6%) had stones also in the cystic duct and intrahepatic ducts, respectively. Balloon sphincteroplasty never exceeding distal CBD size was performed in 12 patients (14.8%). Complete stone clearance was achieved in 78 patients (96.3%) after a single session. Mean number of EHL sessions were 1.04 ± 0.19. Three patients developed mild adverse events, which were managed conservatively.

Conclusions

Early upfront digital cholangioscopy with EHL has high efficacy and safety for stone clearance after a single session in patients with narrow distal CBD.

Endoscopic ultrasound-guided therapies versus retrograde transvenous obliteration for gastric varices: Multicenter propensity matched analysis

Background and study aims

Retrograde transvenous obliteration (RTO) is an established technique for managing fundal varices. Endoscopic ultrasound (EUS)-guided glue injection with or without coil is an alternate approach. The present study compared outcomes of EUS-guided therapies with RTO for managing fundal varices.

Patients and methods

We retrospectively analyzed data from patients with fundal varices undergoing EUS-guided intervention or RTO at 10 tertiary centers in India and compared after propensity score matching. The primary outcome was variceal bleeding within 1 year. Secondary outcomes included procedure-related adverse events (AEs), variceal obliteration, reintervention, and mortality.

Results

A total of 167 patients (EUS 108, RTO 59) were included, with 59 in each group after propensity score matching. Incidence of variceal bleeding (15.3% vs. 13.6%, P = 0.793) within 1 year was comparable between the groups. Procedure-related AEs were higher in the RTO group (22% vs. 5.1%, P = 0.007), primarily new onset or worsening of ascites. Variceal obliteration at 4 weeks was similar between groups (83.1% vs. 91.5%, P = 0.167). Although reintervention within 1 year of the index procedure (30.5% vs. 22.0%, P = 0.296) was comparable, the EUS group required more frequent reintervention for GVs (28.8% vs. 5.1%, P = 0.001), and the RTO group required more frequent reintervention for EVs (16.9% vs. 1.7%, P = 0.008).

Conclusions

EUS-guided therapy offers a safe and effective alternative to RTO for managing fundal varices. Although reintervention rate for GVs were higher than for EUS, incidence of AEs and reintervention for EVs was higher with RTO.

Exploring the diagnostic potential of plasma circ-CCDC66 in colorectal cancer

Owing to the subtle symptoms and low sensitivity of colorectal cancer (CRC), such as rectal bleeding, anemia, and abdominal pain, CRC generally occurs in late stages. This leads to delayed diagnosis and reduced treatment efficiency. Therefore, novel and effective CRC markers are needed. In this study, we conducted circRNA expression profiling on GSE datasets and identified circ-CCDC66 as a potential marker. Through qPCR analysis of plasma samples from 50 CRC patients, 50 with colorectal polyps, and 50 healthy individuals, circ-CCDC66 emerged as a promising biomarker for CRC detection capable of identifying polyps among healthy individuals. Furthermore, plasma circ-CCDC66 levels exhibited superior diagnostic accuracy, with an AUC of 0.920, compared to traditional markers, such as serum CEA and CA19-9. Remarkably, the combined detection of circ-CCDC66, CEA, and CA19-9 further increased the AUC for distinguishing the colorectal polyps' group from the healthy control group to 0.991, with sensitivity and specificity increasing to 98% and 96%, respectively. Additionally, a circ-CCDC66-miRNA-mRNA regulatory network was established to provide insight into how circ-CCDC66 influences CRC pathways. This pioneering study highlights circ-CCDC66's clinical relevance as a blood-based diagnostic marker for CRC and offers valuable insights into future developments in the diagnosis and treatment of the disease.

Per-oral Pancreatoscopy-Guided Lithotripsy Versus Extracorporeal Shock Wave Lithotripsy in Pancreatic Stone: A Meta-Analysis

INTRODUCTION

Pancreatic duct stones (PDS) pose a significant clinical challenge, and choosing treatment modality is crucial to achieving optimal outcomes. Extracorporeal shock wave lithotripsy (ESWL) has long been regarded as the primary intervention for PDS. However, per-oral pancreatoscopy-guided lithotripsy (POP), both electrohydraulic lithotripsy (EHL-POP) and laser lithotripsy (LL-POP), has emerged as a promising endoscopic alternative. This meta-analysis compares the efficacy and safety profiles of EHL-POP, LL-POP, and ESWL for treating PDS.

METHODS

A search of MEDLINE, EMBASE, and Cochrane databases until November 2023 was conducted to identify studies assessing the use of EHL-POP, LL-POP, or ESWL for the treatment of PDS. Primary outcomes were technical success and clinical success of stones. Secondary outcomes were any adverse events (AEs) and the incidence of post-intervention pancreatitis.

RESULTS

A total of 45 observational studies were included. Among the 9624 patients with PDS analyzed, 373 underwent POP (238 EHL-POP and 135 LL-POP), while 9,251 underwent ESWL. The pooled technical and clinical success rates of ESWL versus POP were 85.5% (95% CI: 79.1-90.2%) vs. 88.1% (95% CI: 75.1-94.8%) (p = 0.66) and 78.5% (95% CI: 70.9-84.5%) vs. 81.6% (95% CI: 65.1-91.4%) (p = 0.69), respectively. The pooled technical success rate of EHL-POP was 85.2% (95% CI: 68.5-93.9%, I2 = 63%), which was comparable to LL-POP at 92.7% (95% CI: 64.4-98.9%, I2 = 0%) (p = 0.48). The clinical success rates of EHL-POP and LL-POP were 74.4% (95% CI: 50.7-89.2%, I2 = 48%) and 85.7% (95% CI: 63.9-95.3%, I2 = 68%), respectively (p = 0.38). The rates of any adverse events and post-intervention pancreatitis for ESWL vs. POP were 10.1% (95% CI: 5.5-17.6%, I2 = 95%) vs. 9.3% (95% CI: 4.1-19.6%, I2 = 55%) (p = 0.87) and 4.3% (95% CI: 3.1-5.9%, I2 = 85%) vs. 2.8% (95% CI: 1.3-6.1%, I2 = 0%) (p = 0.32), respectively.

CONCLUSION

Both EHL-POP and LL-POP, emerges as highly effective and safe alternatives for managing PDS, with safety profiles comparable to ESWL. POP could be considered as an alternative first-line option to ESWL for PDS.

Ultrasound of Bile Ducts-An Update on Measurements, Reference Values, and Their Influencing Factors

Objective: To provide an overview of the technique and normal values of ultrasound studies of the bile system based on the published literature. Methods: A literature search for ultrasound studies with measurements of the bile ducts in healthy subjects was performed. Relevant data published between 1975 and end of 2024 were extracted, discussed, and complemented with the own experiences of the authors. The clinical implications are presented and discussed. Results: For the diameter of the common bile duct, reference values between 5 and 9 mm have been published. The main influencing factors are age and history of cholecystectomy, and other factors to be considered are discussed here. The cut-off for the common bile duct wall is set at 1.5 mm. The literature on measurements of intrahepatic bile ducts is scarce. A diameter of <2-3 mm can be considered normal. The method of ultrasound examination is presented here, as well as a comparison with other imaging methods and their clinical implications. Conclusions: Standardized measurement techniques and normal values in the context of influencing factors are crucial for the ultrasound examination of the bile system.

The prevalence of Barrett 's esophagus in Iranian patients with gastrointestinal symptoms: a systematic review and meta-analysis

BACKGROUND

Barrett's esophagus (BE) is a premalignant columnar metaplasia of the esophagus that predisposes victims to esophageal adenocarcinoma (EAC). Depending on differences in the study population and risk factors, the prevalence of BE may vary, from 0.4 to 20% globally. The current study aimed to systematically review and analyse the prevalence of BE in in patients with gastrointestinal symptoms in Iran. Furthermore, gastrointestinal malignancies are among the most common tumours in Iran, making this study even more significant.

METHODS

A systematic search was carried out in PubMed, Web of Science, Scopus, and EMBASE as well as some domestic databases including SID, Magiran, IranDoc, IranMedex from inception to the end of 2023. We included all cross-sectional studies which reported the prevalence of BE and calculated pooled prevalence.

RESULTS

The results of the analysis, including 9 studies in a total of 4978 cases (213 Barret diagnoses), revealed that by the results of these studies, the prevalence of Barret's esophagus is 4.4% [I2 = 94.9% [92.2%; 96.6%]/p-value < 0.0001]. Subgroup analysis, divided by region and year, revealed significant differences between groups.

CONCLUSIONS

The epidemiology of BE in Iran is not completely identified. This is the first systematic review and meta-analysis evaluating the prevalence and of BE in Iran. Due to the importance of BE in progressing to esophageal adenocarcinoma, much importance should be given to its timely diagnosis. It is strongly recommended to conduct more comprehensive studies including more patients in this field.

Surgical management of rare tumors (Part 1)

With an annual cumulative occurrence of approximately 15,000 in North America, all childhood cancers are rare. Very rare cancers as defined by both the European Cooperative Study Group for Rare Pediatric Cancers and the Children's Oncology Group fall into two principal categories: those so uncommon (fewer than 2 cases/million) that their study is challenging even through cooperative group efforts (e.g., pleuropulmonary blastoma and desmoplastic small round cell tumor) and those that are far more common in adults and therefore rarely studied in children (e.g., thyroid, melanoma, and gastrointestinal stromal tumor). Treatment strategies for these latter tumors are typically based on adult guidelines, although the pediatric variants of these tumors may harbor different genetic signatures and demonstrate different behavior. If melanoma and differentiated thyroid cancer are excluded, other rare cancer types account for only 2% of the cancers in children aged 0 to 14. This article highlights several of the most common rare tumor types.

Balloon catheter-assisted endoscopic resection for papillary adenoma of non-exposed protruded type (with video)

Papillary adenomas, known precursors to papillary adenocarcinoma, warrant close monitoring due to their malignant potential. Historically, surgical resection represented the mainstay of treatment for papillary adenomas with intraductal extension. However, recent advancements in endoscopic techniques have facilitated the adoption of endoscopic papillectomy as a minimally invasive alternative in carefully selected cases. We report a case of an 82-year-old woman with a diagnosis of papillary adenoma exhibiting intraductal extension. This was managed with a novel endoscopic technique, balloon catheter-assisted endoscopic resection. Due to the obscured intraductal component of the papillary mass, a balloon occlusion catheter was deployed within the common bile duct and used as traction to facilitate endoscopic visualization of the mass. Endoscopic resection via papillectomy was subsequently performed. Histopathological examination of the resected specimen revealed a villous adenoma with high-grade dysplasia. Serial endoscopic ultrasound examinations with targeted papillary biopsies were performed to monitor for disease recurrence.

Idiopathic mesenteric phlebosclerosis: a rare but important disease in Asian populations

Idiopathic mesenteric phlebosclerosis (IMP) is a rare form of ischemic colitis that predominantly impacts Asian populations. Despite some recognizable signs, there is a significant lack of awareness about IMP. In this review, we explore the etiology, pathogenesis, imaging manifestations, endoscopic traits, and therapeutic modalities of IMP. In addition, we discuss the deficiencies in the current comprehension of IMP and the potential research orientations in future.

Pharyngeal Residues Following Swallowing of Pureed Diets Thickened with a Gelling Agent or a Xanthan Gum-Based Thickener in Elderly Patients with Dysphagia

The ideal texture of pureed diets to prevent aspiration pneumonia remains unclear. The aim of this study was to evaluate the effectiveness of a pureed diet with either a gelling agent or a xanthan gum-based thickener to prevent pharyngeal residues in patients with dysphagia. We retrospectively analyzed a randomized, crossover trial of pureed rice with either a gelling agent or a xanthan gum-based thickener in patients with dysphagia. The enrolled patients were classified into mild and moderate-to-severe dysphagia groups. The primary outcome measure was degree of need for cyclic ingestion using test jelly for pharyngeal residuals (cyclic ingestion score). The secondary outcome was the patient's sense of material remaining in the throat following swallowing. Sixty-two patients (58% men; mean age 83 ± 9 years) with dysphagia were included. They were classified into mild dysphagia (n = 26) and moderate-to-severe dysphagia (n = 36) groups. In the moderate-to-severe dysphagia group, pharyngeal residuals were significantly less likely with pureed diets using a gelling agent than with those using a xanthan gum-based thickener, with respective median cyclic ingestion scores (range) of 1 (0-4) vs. 2.5 (0-4) (p = 0.001). There was no significant difference in pharyngeal residuals between the pureed diets in the mild dysphagia group. The multivariate analysis identified gelling agent as an important factor significantly associated with less pharyngeal residual after swallowing of pureed diet in patients with moderate-to-severe dysphagia. Pureed diets thickened by a gelling agent decrease pharyngeal residues in patients with moderate-to-severe dysphagia and may reduce risk of aspiration pneumonia.

Endoscopic incisional balloon dilation combined with anti-scarring agents for postoperative esophageal anastomotic strictures

The management of locally advanced esophageal cancer typically involves esophagectomy; however, postoperative complications, particularly anastomotic stricture, remain prevalent. Anastomotic stricture can severely compromise patients' quality of life by leading to difficulties in food intake. Although endoscopic balloon dilation has become a standard treatment for gastrointestinal strictures, its efficacy is often limited due to the risk of perforation and the potential for recurrent stricture, necessitating multiple interventions. Recent advancements have introduced endoscopic radial incision and cutting methods, which aim to enhance patency by excising scar tissue. We experienced a case resistant to the radial incision and cutting therapy, necessitating further intervention strategies. This report details our experience utilizing a novel technique, endoscopic incisional balloon dilation, which combines endoscopic incisional technique and balloon dilation therapy with anti-scarring medications, in cases of refractory anastomotic strictures following esophageal cancer resection. We present three challenging cases in which endoscopic incisional balloon dilation yielded significant clinical improvements, alongside supportive literature. Our findings suggest that endoscopic incisional balloon dilation is an effective and safer alternative to conventional methods, capable of addressing complex stricture scenarios while potentially enhancing patient outcomes and quality of life.

Navigating Bowel Preparation for Colonoscopy: A Comprehensive Overview

Colorectal cancer (CRC) is the third most common cancer in the United States. Early detection through colonoscopy significantly improves survival rates. Detecting colon polyps depends on the quality of bowel preparation. However, inadequate bowel preparation remains a significant issue in clinical practice. Efforts to address this challenge have led to the development of bowel preparation regimens emphasizing efficacy, tolerability, and safety. Bowel preparation options can be categorized by their osmotic and volume properties. Isosmotic solutions based on polyethylene glycol-electrolyte lavage solutions (PEG-ELS) are available in both low-volume PEG-ELS with ascorbic acid (PEG-Asc) (e.g., MoviPrep, PLENVU) and high-volume formulations (e.g., GoLYTELY, CoLyte), as well as sulfate-free high-volume PEG-ELS formulations (SF-PEG-ELS). Hyperosmotic solutions include oral sulfate solution (OSS) (e.g., SUPREP), sodium phosphate tablets (NaP) (e.g., OsmoPrep), oral sulfate tablets (OST) (e.g., SUTAB), flavored PEG with sulfate salts (FPSS) (e.g., SUFLAVE), and magnesium citrate. Hypoosmotic solutions consist of PEG-sports drink (PEG-SD). In addition, combination solutions are available, such as sodium picosulfate with magnesium citrate (SPMC) with laxatives (e.g., CLENPIQ), and OSS with SF-PEG-ELS (Suclear). Each regimen differs in terms of cost, volume, taste, contraindications, and potential adverse effects. Therefore, clinicians must carefully evaluate each patient to determine the most suitable regimen for their patients.

The competency of the novel through-the-scope suture device for gastric mucosal defects: In vivo study in a porcine model (with video)

Objectives

Endoscopic closures of mucosal defects following endoscopic resection can be challenging and time-consuming. The novel through-the-scope suture device has demonstrated acceptable closure times, but its learning curve is still unknown. This study aims to evaluate the number of cases required to achieve competency in this device.

Methods

Two endoscopists participated; a novice with less than 400 experiences in upper gastrointestinal endoscopy and an expert with over 500 experiences in endoscopic submucosal dissection. Neither endoscopist had previous exposure to the device. In four porcine models, 24 gastric mucosal defects, each 2-4 cm in diameter, were created by endoscopic mucosal resection with ligation. Each endoscopist performed endoscopic closure for 12 mucosal defects with a single through-the-scope suture device per lesion. The primary endpoint was the number of cases needed to reach competency, defined as achieving a procedure time below the average closure time reported in the literature. Secondary endpoints included procedure time, complete closure success rates, and incidence of adverse events.

Results

The mean defect size was 2.9 (±0.2) cm. Competency was achieved after six cases in the expert and seven cases in the novice. The median closure time was 9.0 (interquartile range [IQR]: 6.0-11.0) min for the expert and 8.0 (IQR: 6.2-9.7) min for the novice (p = 0.862). Complete closure success rates were 75.0% (n = 9) for the expert and 83.3% (n = 10) for the novice. No adverse events were reported.

Conclusions

A small number of cases were required for both expert and novice endoscopists to reach competency in the novel through-the-scope suture device.

Left hepatic abscess with diaphragm involvement in the setting of biliary ostomy

This case report discusses the indications, surgical technique, and outcomes associated with a biliary ostomy in a patient with complex biliary tract disease, providing insights into its role in modern surgical practice.

Gallstone Ileus: A Rare Incidental Gallstone Migration Seen on CT in a Patient With Traumatic Splenic Laceration

Gallstone ileus, a rare but severe complication of cholelithiasis, causes bowel obstruction and is typically associated with high morbidity and mortality. Here, we present the case of a 76-year-old male who initially presented with left upper quadrant abdominal pain after a ground-level fall, with the incidental finding of cholelithiasis. Over subsequent days, the patient developed symptoms of small bowel obstruction, and further CT imaging showed a new-onset gallstone ileus. Exploratory laparotomy confirmed the obstruction within the distal jejunum, and a large gallstone was successfully extracted. This case highlights the importance of considering gallstone ileus in patients with atypical presentation and underscores the potentially critical role of CT imaging in diagnosing and tracking gallstone movement. Increased awareness and understanding among clinicians, particularly in trauma settings, are essential for timely intervention and improved patient outcomes.

Digital single-operator cholangioscopy-guided endoluminal radiofrequency of an intraductal papillary mucinous neoplasia of the bile duct

Watch a video of this article.

Executive Summary of the American Radium Society Appropriate Use Criteria for Management of Squamous Cell Carcinoma of the Cervical Esophagus: Systematic Review and Guidelines

OBJECTIVES

Cervical esophageal cancer (CEC) is an uncommon malignancy accounting for <5% of all esophageal carcinomas. Treatment of CEC varies and is adapted from established regimens used for squamous cell carcinoma (SCC) or the lower esophageal and head and neck. The present systematic review and guidelines are intended to assist treatment decision making for patients with CEC based on the available evidence.

METHODS

Using the Population, Intervention, Comparator, Outcome, Timing, and Study Design (PICOTS) framework, the evidence regarding treatment outcomes was assessed using Cochrane and PRISMA 2020 methodology. Eligible studies included prospective Phase II to III trials and retrospective analyses published between January 1, 2013 and February 23, 2024 in the Ovid Medline database. These references were assessed through the American Radium Society (ARS) Appropriate Use Criteria (AUC) methodology. A systematic review PRISMA 2020 checklist confirmed the completion of essential elements. RAND-UCLA consensus methodology was used by the expert panel to rate the appropriateness of the treatment options.

RESULTS

ARS AUC recommendations include (1) larynx preservation using endoscopic resection (EMR or ESD) alone for the typical case with pT1a cN0 cM0 CEC, (2) definitive CRT for the typical case with cT1bN0M0 in patients who cannot undergo endoscopic resection, (3) larynx-preserving using definitive CRT (with or without induction chemotherapy) for the typical case with nonmetastatic locally advanced CEC (advanced T-stage tumors or involved lymph nodes), with surgery reserved for those patients with incomplete response or locoregional recurrence.

CONCLUSIONS

This ARS AUC summary provides guidelines for the management of SCC of the cervical esophagus provides based on available evidence. Topics that warrant further investigation include optimization of (1) patient selection; (2) multimodality therapies including chemotherapy, immunotherapy, and targeted agents; (3) radiation dose, schedule, and treatment volume; and (4) supportive care for patients with CEC. Ongoing trials continue to improve outcomes for patients with CEC.

Endoscopic findings and outcomes of gastric mucosal changes relating to potassium-competitive acid blocker and proton pump inhibitor therapy

Gastric mucosal changes associated with long-term potassium-competitive acid blocker and proton pump inhibitor (PPI) therapy may raise concern. In contrast to that for PPIs, the evidence concerning the safety of long-term potassium-competitive acid blocker use is scant. Vonoprazan (VPZ) is a representative potassium-competitive acid blocker released in Japan in 2015. In order to shed some comparative light regarding the outcomes of gastric mucosal lesions associated with a long-term acid blockade, we have reviewed six representative gastric mucosal lesions: fundic gland polyps, gastric hyperplastic polyps, multiple white and flat elevated lesions, cobblestone-like gastric mucosal changes, gastric black spots, and stardust gastric mucosal changes. For these mucosal lesions, we have evaluated the association with the type of acid blockade, patient gender, Helicobacter pylori infection status, the degree of gastric atrophy, and serum gastrin levels. There is no concrete evidence to support a significant relationship between VPZ/PPI use and the development of neuroendocrine tumors. Current data also shows that the risk of gastric mucosal changes is similar for long-term VPZ and PPI use. Serum hypergastrinemia is not correlated with the development of some gastric mucosal lesions. Therefore, serum gastrin level is unhelpful for risk estimation and for decision-making relating to the cessation of these drugs in routine clinical practice. Given the confounding potential neoplastic risk relating to H. pylori infection, this should be eradicated before VPZ/PPI therapy is commenced. The evidence to date does not support the cessation of clinically appropriate VPZ/PPI therapy solely because of the presence of these associated gastric mucosal lesions.

Guidelines for endoscopic diagnosis and treatment of inflammatory bowel diseases

In recent years, we have seen a considerable increase in the number of patients with inflammatory bowel diseases of unknown etiology, including both Crohn's disease and ulcerative colitis. Inflammatory bowel diseases can cause intestinal lesions throughout the gastrointestinal tract, necessitating gastrointestinal endoscopy for examining all relevant aspects, especially lesion characteristics, for differential diagnosis and histological diagnosis, to select the appropriate treatment options, determine treatment effectiveness, etc. Specific guidelines are necessary to ensure that endoscopy can be performed in a safe and more tailored and efficient manner, especially since gastrointestinal endoscopy, including enteroscopy, is a common procedure worldwide, including in Japan. Within this context, the Japan Gastroenterological Endoscopy Society has formulated the "Guidelines for the Endoscopic Diagnosis and Treatment of Inflammatory Bowel Diseases" to provide detailed guidelines regarding esophagogastroduodenoscopy, enteroscopy, and colonoscopy procedures for definitive diagnosis, as well as determination of treatment effectiveness in clinical cases of inflammatory bowel diseases.

Clinical assessment of computed tomography for detecting ingested blister packs: A single-center retrospective study

Objectives

Blister pack (BP) ingestion poses serious risks, such as gastrointestinal perforation, and accurate localization by computed tomography (CT) is a common practice. However, while it has been reported in vitro that CT visibility varies with the material type of BPs, there have been no reports on this variability in clinical settings. In this study, we investigated the CT detection rates of different BPs in clinical settings.

Methods

This single-center retrospective study from 2010 to 2022 included patients who underwent endoscopic foreign body removal for BP ingestion. The patients were categorized into two groups for BP components, the polypropylene (PP) and the polyvinyl chloride (PVC)/polyvinylidene chloride (PVDC) groups. The primary outcome was the comparison of CT detection rates between the groups. We also evaluated whether the BPs contained tablets and analyzed their locations.

Results

This study included 61 patients (15 in the PP group and 46 in the PVC/PVDC group). Detection rates were 97.8% for the PVC/PVDC group compared to 53.3% for the PP group, a significant difference (p < 0.01). No cases of BPs composed solely of PP were detected by CT. Blister packs were most commonly found in the upper thoracic esophagus.

Conclusions

Even in a clinical setting, the detection rates of PVC and PVDC were higher than that of PP alone. Identifying PP without tablets has proven challenging in clinical. Considering the risk of perforation, these findings suggest that esophagogastroduodenoscopy may be necessary, even if CT detection is negative.

Ascending colon perforation by a migrated pancreatic spontaneous dislodgment stent: a case report

Here, we report a case of a 74-year-old woman treated for acute cholecystitis. She initially underwent percutaneous transhepatic gallbladder drainage; however, cholecystitis recurred when the drain was clamped. Therefore, endoscopic transpapillary gallbladder drainage (ETGBD) was performed. Endoscopic sphincterotomy was performed, and a transpapillary gallbladder stent was placed. Additionally, a pancreatic spontaneous dislodgment stent (PSDS) was inserted to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. Cholecystitis resolved, and the patient was discharged seven days later. Twenty-five days after ETGBD, she experienced abdominal pain, and computed tomography revealed ascending colon perforation by the migrated PSDS. She underwent laparoscopic surgery, in which the perforation was sutured, and an ileostomy was performed. The postoperative course was uneventful, and colonoscopy performed two months after surgery revealed multiple diverticula in the ascending colon. PSDS-induced gastrointestinal perforations are extremely rare. Previous case reports have suggested that perforation is caused by long-term stent retention in the gastrointestinal tract due to obstructions, such as peritonitis carcinomatosa or postoperative adhesions. We believe that in this case, the PSDS was retained because of multiple colonic diverticula. PSDS should be used with caution in patients with multiple colonic diverticula, peritonitis carcinomatosa, and postoperative adhesions.