Comparison of the ability of resection versus nonresection surgery to prevent the recurrence of sigmoid volvulus: A protocol of a meta-analysis and systematic review

PURPOSE

Based on clinical research guidelines and clinical practice, patients with sigmoid volvulus (SV) who receive conservative treatment have a greater recurrence rate than patients who do not receive conservative treatment, which is almost without any controversy. Surgical treatment is usually the final treatment for patients with SV. However, there are multiple surgical methods for the treatment of SV, which can be roughly divided into resection and nonresection methods. The available evidence on the effectiveness of surgery for preventing postoperative recurrence is still inadequate. Therefore, we drafted this systematic review protocol with meta-analysis aimed to compare the effects of these two major types of surgery on preventing the recurrence of SV.

METHODS

We comprehensively and systematically reviewed the PubMed, EMBASE, MEDLINE and Cochrane Library databases of articles on SV from inception to November 16, 2023. Two independent authors will screen and analyze the detected literature, and disputes will be resolved through communication with a third experienced person. After evaluating the quality of the literature and estimating the risk of bias, we calculate the pooled effect size and 95% confidence interval. Heterogeneity is analyzed by subgroup analysis, and sensitivity analysis can be carried out to assure the reliability of the results. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) will be used to evaluate the strength of the evidence. The results of each analysis will be recorded in detail. The whole process was carried out in strict accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines (PRISMA-P).

TRIAL REGISTRATION

Protocol registration: The study protocol has been registered at the International Prospective Register of Systematic Reviews platform (PROSPERO) (CRD42024508350). Protocol version 1.0, 13 Feb 2024.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Software as a Medical Device (SaMD) in Digestive Healthcare: Regulatory Challenges and Ethical Implications

The growing integration of software in healthcare, particularly the rise of standalone software as a medical device (SaMD), is transforming digestive medicine, a field heavily reliant on medical imaging for both diagnosis and therapeutic interventions. This narrative review aims to explore the impact of SaMD on digestive healthcare, focusing on the evolution of these tools and their regulatory and ethical challenges. Our analysis highlights the exponential growth of SaMD in digestive healthcare, driven by the need for precise diagnostic tools and personalized treatment strategies. This rapid advancement, however, necessitates the parallel development of a robust regulatory framework to ensure SaMDs are transparent and deliver universal clinical benefits without the introduction of bias or harm. In addition, the discussion highlights the importance of adherence to the FAIR principles for data management-findability, accessibility, interoperability, and reusability. However, enhanced accessibility and interoperability require rigorous protocols to ensure compliance with data protection guidelines and adequate data security, both of which are crucial for effective integration of SaMDs into clinical workflows. In conclusion, while SaMDs hold significant promise for improving patients' outcomes in digestive medicine, their successful integration into clinical workflow depends on rigorous data protection protocols and clinical validation. Future directions include the need for adequate clinical and real-world studies to demonstrate that these devices are safe and well-suited to healthcare settings.

A safe method for rapid therapeutic pancreatic cooling

Acute pancreatitis (AP) has no targeted therapy. Previously, pancreatic cooling to 31°C-33°C and 24°C-27°C, respectively, ameliorated mild and severe AP in rats. Here, Yucatan pigs (40-50Kg) whose abdominal size and anatomy are like humans underwent pancreatic cooling. This was via a gastric cooling balloon placed endoscopically with catheters exteriorized on the abdominal wall. Laparoscopically placed wireless transmitters monitored pancreas tail, head, and urinary bladder temperatures. Controls included un-perfused water filled balloons, and sedation-only groups. Tap water perfusion (375 mL/min) over 1-month was well tolerated without sedation. Perfusion with ≤19°C water achieved pancreatic temperatures ≤32°C and perfusion at ≤10°C achieved ≤26°C in <90 min in sedated supine pigs, which normalized an hour after balloon evacuation. Bladder temperatures, behavioral, biochemical, hematological, and histological parameters were similar between groups. Therefore, rapid transgastric pancreatic cooling can be achieved safely in large animals with relevant anatomy like humans, warranting future clinical studies.

Nomogram for assistant diagnosing acute suppurative cholangitis: a case-control study

BACKGROUND

Acute suppurative cholangitis (ASC) lacks sensitive and specific preoperative diagnostic criteria. Some researchers suggest treating ASC as severe cholangitis. This study aimed to explore the relationship between the Tokyo Guidelines 2018 (TG18) grading system for acute cholangitis (AC) and the diagnosis of acute suppurative cholangitis (ASC), searching for independent risk factors of ASC and develop a nomogram to discriminate ASC from acute nonsuppurative cholangitis (ANSC) accurately.

METHODS

After applying the inclusion and exclusion criteria, 401 patients with acute cholangitis (AC) were retrospectively analyzed at Nanjing First Hospital between January 2015 and June 2023. SPSS version 27.0 and R studio software were used to analyze data obtained from medical records. The results were validated in a prospective cohort of 82 AC patients diagnosed at Nanjing First Hospital between July 2023 and February 2024.

RESULTS

Among the 401 patients, 102 had suppurative bile (the ASC group; AC grade I: 40 [39.2%], AC grade II: 27 [26.5%], AC grade III: 35 [34.3%]), whereas 299 did not have (the ANSC group; AC grade I: 157 [52.5%], AC grade II: 92 [30.8%], AC grade III: 50 [16.7%]). The specificity of ASC for diagnosing moderate-to-severe cholangitis is 79.7%. Multivariate logistic regression analysis identified concurrent cholecystitis, CRP, PCT, TBA, and bile duct diameter as independent risk factors for suppurative bile, and all of these factors were included in the nomogram. The calibration curve exhibited consistency between the nomogram and the actual observation, and the area under the curve was 0.875 (95% confidence interval: 0.835-0.915), sensitivity was 86.6%, and specificity was 75.5%.

CONCLUSION

Suppurative bile is a specific indicator for diagnosing moderate-to-severe cholangitis. However, diagnosing ASC with AC grade II and AC grade III has the risk of missed diagnosis as the sensitivity is only 60.8%. To improve the diagnostic rate of ASC, this study identified concurrent cholecystitis, CRP, PCT, TBA, and preoperative bile duct diameter as independent risk factors for ASC, and a nomogram was developed to help physicians recognize patients with ASC.

Endoscopic Ultrasound and Intraductal Ultrasound in the Diagnosis of Biliary Tract Diseases: A Narrative Review

Endoscopic ultrasound (EUS) and intraductal ultrasound (IDUS) play very important roles in the field of biliary tract disease. Because of their excellent spatial resolution, the detection of small lesions and T- or N-staging of tumors have become possible. Additionally, contrast-enhanced EUS and the new imaging technique of detective flow imaging are reported to be useful for differential diagnosis. Furthermore, EUS-guided tissue acquisition is used not only for pathological diagnosis but also to collect tissue samples for cancer genome profiling. This review provides an overview of diagnosis utilizing the features and techniques of EUS and IDUS.

Anal carcinoma - exploring the epidemiology, risk factors, pathophysiology, diagnosis, and treatment

Anal carcinoma is a relatively rare tumor that accounts for approximately 2% of gastrointestinal malignancies and less than 7% of anorectal cancers. Most anal tumors originate between the anorectal junction and the anal verge. Risk factors for the disease include human papillomavirus infection, human immunodeficiency virus, tobacco use, immunosuppression, female sex, and older age. The pathogenesis of anal carcinoma is believed to be linked to human papillomavirus-related inflammation, leading to dysplasia and progression to cancer. Squamous cell carcinoma is the most common type of anal tumor, with an annual incidence of approximately 1 to 2 per 100000 persons. Treatment regarding anal cancer has emerged over time. However, chemoradiation therapy remains the mainstay approach for early localized disease. Patients with metastatic disease are treated with systemic therapy, and salvage surgery is reserved for disease recurrence following chemoradiation. This article aims to provide background information on the epidemiology, risk factors, pathology, diagnosis, and current trends in the management of anal cancer. Future directions are briefly discussed.

Using artificial intelligence to improve human performance: efficient retinal disease detection training with synthetic images

BACKGROUND

Artificial intelligence (AI) in medical imaging diagnostics has huge potential, but human judgement is still indispensable. We propose an AI-aided teaching method that leverages generative AI to train students on many images while preserving patient privacy.

METHODS

A web-based course was designed using 600 synthetic ultra-widefield (UWF) retinal images to teach students to detect disease in these images. The images were generated by stable diffusion, a large generative foundation model, which we fine-tuned with 6285 real UWF images from six categories: five retinal diseases (age-related macular degeneration, glaucoma, diabetic retinopathy, retinal detachment and retinal vein occlusion) and normal. 161 trainee orthoptists took the course. They were evaluated with two tests: one consisting of UWF images and another of standard field (SF) images, which the students had not encountered in the course. Both tests contained 120 real patient images, 20 per category. The students took both tests once before and after training, with a cool-off period in between.

RESULTS

On average, students completed the course in 53 min, significantly improving their diagnostic accuracy. For UWF images, student accuracy increased from 43.6% to 74.1% (p<0.0001 by paired t-test), nearly matching the previously published state-of-the-art AI model's accuracy of 73.3%. For SF images, student accuracy rose from 42.7% to 68.7% (p<0.0001), surpassing the state-of-the-art AI model's 40%.

CONCLUSION

Synthetic images can be used effectively in medical education. We also found that humans are more robust to novel situations than AI models, thus showcasing human judgement's essential role in medical diagnosis.

Radiation exposure to patients undergoing percutaneous transhepatic cholangiography and endoscopic retrograde cholangiography: an advanced phantom study

Fluoroscopic examinations like Endoscopic Retrograde Cholangiopancreatography (ERCP) and Percutaneous Transhepatic Cholangiography (PTC) are fundamental in diagnosing and treating hepatobiliary diseases. However, these procedures expose patients to significant radiation, highlighting the need for a detailed assessment of the radiation doses received by critical organs. The study's primary objective is to determine the experimental doses received by critical organs in patients undergoing these procedures. This study utilized an Alderson RANDO phantom outfitted with Thermoluminescent Dosemeters (TLDs) to experimentally measure the radiation doses received by various organs during ERCP and PTC procedures. This method provided direct and accurate data on organ-specific radiation exposure, contrasting with the traditional approach of relying on theoretical simulations. The analysis revealed that PTC generally results in higher radiation doses to organs compared to ERCP. Critical organs, such as the thyroid, spleen, liver, pancreas, ovaries, and uterus, were exposed to varying levels of radiation, with the thyroid and spleen receiving particularly high doses in PTC. The study also demonstrated that the per-minute radiation exposure was consistently higher in PTC across all examined organs. The study's findings underscore the significant radiation exposure associated with ERCP and PTC, with PTC posing a greater risk. Understanding these exposure levels is crucial for clinical decision-making, particularly when considering patients' pre-existing conditions and sensitivity to radiation. The study highlights the need for clinicians to carefully weigh the benefits of ERCP and PTC against the potential radiological risks. It suggests a preference for ERCP in situations where radiation exposure needs to be minimized. Furthermore, the findings advocate for ongoing advancements in medical imaging techniques to reduce radiation exposure, emphasizing the importance of patient safety in fluoroscopic examinations. This research contributes significantly to informed clinical decision-making, ensuring that the selection of diagnostic and therapeutic procedures aligns with the best interest of patient health and safety.

A Comprehensive Review of Artificial Intelligence and Colon Capsule Endoscopy: Opportunities and Challenges

Colon capsule endoscopy (CCE) enables a comprehensive, non-invasive, and painless evaluation of the colon, although it still has limited indications. The lengthy reading times hinder its wider implementation, a drawback that could potentially be overcome through the integration of artificial intelligence (AI) models. Studies employing AI, particularly convolutional neural networks (CNNs), demonstrate great promise in using CCE as a viable option for detecting certain diseases and alterations in the colon, compared to other methods like colonoscopy. Additionally, employing AI models in CCE could pave the way for a minimally invasive panenteric or even panendoscopic solution. This review aims to provide a comprehensive summary of the current state-of-the-art of AI in CCE while also addressing the challenges, both technical and ethical, associated with broadening indications for AI-powered CCE. Additionally, it also gives a brief reflection of the potential environmental advantages of using this method compared to alternative ones.

Endoscopic Submucosal Dissection for Early Gastric Cancer Exceeding Expanded Criteria-Long-Term Outcomes from the German ESD Registry

Background and aims: Endoscopic submucosal dissection (ESD) has become a standard treatment for early gastric cancer (EGC), often fulfilling guideline criteria (GC) or expanded criteria (EC). When lesions exceed the EC, surgical resection is recommended. However, a subgroup of these patients are not treated surgically. The aim of this study was to investigate the long-term follow-up of patients after ESD for EGC outside the EC (out of indication; OI). Methods: Patients who were included in the prospective German ESD registry were analyzed when ESD was performed for EGC. Patients were stratified in three groups according to histopathological features (GC, EC and OI). The results were evaluated in terms of patient characteristics, procedure characteristics and follow-up data. Results: Over a 48-month period, 195 patients from 14 German centers were included. In total, 71 lesions (36.4%) met the guideline criteria, 70 lesions (35.9%) corresponded to the expanded criteria and 54 lesions (27.7%) turned out to be OI. The R0 resection rate was significantly higher for the GC and EC groups than for the OI group (94.4% vs. 84.3% vs. 55.6%, p < 0.001). Additional surgery was not performed in 72% (39/54) of patients in the OI group. During a mean follow-up of 37 months, overall survival showed no significant difference between the EC and OI groups when endoscopic follow-up was performed without additional surgery (p = 0.064). Conclusions: The results show that a good long-term survival can be achieved after ESD for patients with OI lesions without additional surgery. The treatment decision has to be made on an individual basis, taking the patient's comorbidities and the risk of surgical resection into account.

Pseudoinvasion and squamous metaplasia/morules in colorectal adenomatous polyp: a case report and literature review

BACKGROUND

Submucosal pseudoinvasion and squamous metaplasia (SM) are incidental and special morphological findings in colorectal adenomas, and both can mimic invasive carcinoma. The coexistence of these two findings further increases the risk of misdiagnosis, posing a great diagnostic challenge to pathologists. From 1979 to 2022, only 8 cases have been reported, which was extremely rare. In this report, we presented a case of sigmoid colon adenoma accompanied by pseudoinvasion and SM. Additionally, relevant literature was analyzed to summarize the clinical and pathological characteristics.

CASE PRESENTATION

A 51-year-old Chinese male patient presented with fresh blood after defecation. Electronic colonoscopy revealed multiple polyps, which were removed using a snare and subjected to high-frequency electrocoagulation resection. The largest polyp, located in the sigmoid colon, was a thick pedunculated and lobulated polyp with a maximum diameter of 2.8 cm. The surface of the polyp showed slight ruggedness and redness, and it was sent for pathological examination. Grossly, the polyp had a lobulated and slightly rough surface. Microscopically, it showed a tubulovillous adenoma with focal high-grade dysplasia and mucosal muscle hyperplasia. Glandular elements were observed in the submucosal layer, forming a well-defined lobular structure. Some of the glands displayed cystic change, and focal SM could be seen within the adenoma. SM could manifest as discrete solid cell nests of varying sizes or cribriform-morular-like structures. Immunohistochemical staining showed that SM cells were diffusely positive for cytokeratin 5/6 (CK5/6); p40, p63, and cytokeratin 20 (CK20) were negative; while caudal type homeobox 2 (CDX2) was weakly positive. β-catenin showed abnormal nuclear expression, and an extremely low Ki67 proliferation index was observed.

CONCLUSIONS

Coexistence of SM and pseudoinvasion in colorectal adenomas is highly rare. It is more commonly observed in males and tends to occur in the sigmoid colon. It primarily manifests in tubulovillous adenoma and tubular adenoma, with a majority of cases exhibiting a pedicle. Histologically, it is similar to invasive lesions. The cystic dilation of the submucosal glands, hemosiderin deposition, and the presence of a lamina propria around the submucosal glands without adjacent desmoplastic reaction, suggest pseudoinvasion rather than cancer. The bland cytological morphology and Immunohistochemical markers play a crucial role in distinguishing SM from true invasive lesions.

Fluoroscopic-Guided Removal of Jejunal Sharp Foreign Body: An Alternative Approach to Surgery

Introduction

Foreign body (FB) ingestion represents a frequently encountered scenario in clinical practice. Most ingested FBs typically pass spontaneously, requiring no intervention. Endoscopic removal stands out as the least invasive method, with only a minimal 1% needing surgical intervention. Case Presentation. We present a case of a 30-year-old male who ingested multiple FBs located in the stomach and small bowel. While successful removal of the stomach FB was achieved through endoscopy, the second FB in the small bowel proved challenging due to perforation concerns and limited expertise. Given a history of prior surgical intervention resulting in a large incisional hernia, surgical removal was discouraged. Consequently, a collaborative decision involving surgeon and interventional radiologist (IR) led to the adoption of a fluoroscopic-guided removal approach facilitated by IR techniques.

Conclusion

This case highlights the potential for a less invasive alternative in situations where both endoscopic and surgical interventions are deemed not feasible.

Endoscopic vacuum assisted closure therapy for esophagopericardial fistula in a 16-year-old male: A case report

BACKGROUND

Esophagopericardial fistula (EPF) is a rare, life-threatening condition with limited scientific literature and no established management guidelines. This case report highlights a successful multidisciplinary approach and the innovative use of endoscopic vacuum assisted closure (endoVAC) therapy in treating this complex condition.

CASE SUMMARY

A 16-year-old male with a history of esophageal atresia and colon interposition presented with progressive chest pain, fever, and dyspnea. Imaging revealed an EPF with associated pleural and pericardial effusions. Initial management with an esophageal stent failed, prompting the use of an endoVAC system. The patient underwent multiple endoVAC device changes and received broad-spectrum antibiotics and nutritional support. The fistula successfully closed, and the patient recovered, demonstrating no new symptoms at a 6-month follow-up.

CONCLUSION

EndoVAC therapy can effectively manage EPF, providing a minimally invasive treatment option.

The Diagnostic Accuracy of Colon Capsule Endoscopy in Inflammatory Bowel Disease-A Systematic Review and Meta-Analysis

Colon capsule endoscopy (CCE) has regained popularity for lower gastrointestinal investigations since the COVID-19 pandemic. While there have been systematic reviews and meta-analyses on colonic polyp detection using CCE, there is a lack of comprehensive evidence concerning colonic inflammation. Therefore, this systematic review and meta-analysis aimed to assess the diagnostic accuracy of CCE for colonic inflammation, predominantly ulcerative colitis (UC) and Crohn's disease (CD). Methods: We systematically searched electronic databases (EMBASE, MEDLINE, PubMed Central, and Cochrane Library) for studies comparing the diagnostic accuracy between CCE and optical endoscopy as the standard reference. A bivariate random effect model was used for the meta-analysis. Results: From 3797 publications, 23 studies involving 1353 patients were included. Nine studies focused on UC, and ten focused on CD. For UC, CCE showed a pooled sensitivity of 92% (95% CI, 88-95%), a specificity of 71% (95% CI, 35-92%), and an AUC of 0.93 (95% CI, 0.89-0.97). For CD, the pooled sensitivity was 92% (95% CI, 89-95%), and the specificity was 88% (95% CI, 84-92%), with an AUC of 0.87 (95% CI, 0.76-0.98). Overall, for inflammatory bowel disease, the pooled sensitivity, specificity, and AUC were 90% (95% CI, 85-93%), 76% (95% CI, 56-90%), and 0.92 (95% CI, 0.94-0.97), respectively. Conclusions: Despite the challenges around standardised disease scoring and the lack of histological confirmation, CCE performs well in diagnosing inflammatory bowel disease. It demonstrates high sensitivity in both UC and Crohn's terminal ileitis and colitis and high specificity in Crohn's disease. Further studies are needed to evaluate the diagnostic accuracy of other colonic inflammatory conditions.

How secure can we expect the surveillance policies to be after the implementation in T1 polyps with carcinoma?

Approximately 7% of the polyps resected endoscopically have an adenocarcinoma focus, with no previous endoscopic evidence of malignancy. This raises the question of whether endoscopic resection has been curative. Furthermore, there is no consensus on what the endoscopic and histological criteria for good prognosis are, the appropriate follow-up strategy and what are the long-term results. The aim of the retrospective study by Fábián et al was to evaluate the occurrence of local relapse or distant metastasis in those tumors that were resected endoscopically compared to those that underwent oncologic surgery. They concluded that, regardless of the treatment strategy chosen, there was a higher recurrence rate than described in the literature and that adherence to follow-up was poor. The management approach for an endoscopically benign polyp histologically confirmed as adenocarcinoma depends on the presence of any of the previously described poor prognostic histological factors. If none of these factors are present and the polyp has been completely resected en bloc (R0), active surveillance is considered appropriate as endoscopic resection is deemed curative. These results highlight, once again, the need for further multicentric clinical practice studies to obtain more evidence for the purpose of establishing appropriate treatment and follow-up strategies.

An Unusual Abscess Associated with Gallbladder Perforation Successfully Treated with Percutaneous Transhepatic Gallbladder Drainage and Endoscopic Ultrasound-guided Abscess Drainage

Abscesses associated with gallbladder perforation are often confined to the peri-gallbladder region. We herein report a rare case of gallbladder perforation in which the abscess cavity extended into the left upper quadrant. A 79-year-old woman developed gallbladder perforation secondary to acalculous cholecystitis. Computed tomography revealed fluid collection extending from the peri-gallbladder to the dorsal left hepatic lobe in contact with the stomach. We successfully treated percutaneous transhepatic gallbladder drainage and simultaneous endoscopic ultrasound-guided transgastric internal and external abscess drainage. This minimally invasive approach is considered safe and feasible for managing such a rare case.

Site-specific N-glycan alterations on haptoglobin as potential biomarkers for distinguishing intrahepatic cholangiocarcinoma from hepatocellular carcinoma

Intrahepatic cholangiocellular carcinoma (ICC) is a challenging malignancy marked by subtle early symptoms and a high mortality rate, making effective diagnostic markers crucial for early detection and improved patient outcomes. Currently, the conventional diagnosis of ICC is not easily distinguishable from Hepatocellular Carcinoma (HCC) and lacks highly specific and sensitive diagnostic markers. Protein glycosylation, pivotal in biological processes, shows promise for cancer biomarkers due to its association with disease progression. This study aims to develop a novel biomarker discovery framework for ICC utilizing site-specific quantitative N-glycoproteomics to overcome the limitations of existing diagnostic approaches. Employing a tandem mass tag (TMT)-based quantitative analysis, we profiled serum glycoproteins from ICC, HCC, and control cohorts at site-specific glycosylation level. The identified markers underwent further validation in an independent cohort using label-free quantitative methods. Ultimately, we identified five site-specific N-glycans on haptoglobin (HP) as potential biomarkers (AUC > 0.9) for distinguishing ICC from HCC. This finding represents a considerable advance over traditional biomarkers, highlighting the significance of protein glycosylation alterations in ICC pathogenesis. This research, therefore, sets a new precedent for biomarker discovery in ICC, with potential applications in other cancers characterized by glycosylation abnormalities.

Long-Term Follow Up of Patients Treated for Inflammatory Bowel Disease and Cytomegalovirus Colitis

BACKGROUND

Pathological reactivation of latent Cytomegalovirus (CMV) is triggered by inflammation and immunosuppression; both present in the pathogenesis and treatment of Inflammatory Bowel Disease (IBD). Whether CMV reactivation is associated with escalating medical therapy, further hospital admissions, or worse clinical outcomes remains controversial. This study aimed to follow up IBD patients with an index episode of CMV colitis and analyse the clinical outcomes.

METHODS

A retrospective study of patients with IBD treated for CMV colitis was completed. The outcome results were collected at 6-month and 12-month time points after the first episode of CMV colitis. A total of 13 patients with Ulcerative Colitis and 1 with Crohn's Disease were included.

RESULTS

CMV colitis recurrence occurred in 29% of patients at 12 months. A total of 43% of patients had changed their biologic dose at 6 months and 29% had escalated their biologic dose at 12 months. At 12 months, 36% of patients had been re-hospitalised, including three colectomies. Disease remission was only achieved by 29% of patients at 12 months.

CONCLUSIONS

IBD patients with CMV colitis have substantial rates of re-hospitalisation, failed medical therapy, and colectomy. These risks may be greater at <6 months from an index episode of CMV colitis.

Endoscopic segmentalized drainage of biliary tract obstruction complicated with duodenal stenosis

Biliary obstruction is a common gastrointestinal disorder with many etiological factors, such as benign and malignant diseases of the biliary tract, pancreas, and liver. Endoscopic ultrasound guided biliary drainage provides a new method for the treatment of biliary obstruction when ERCP cannula fails.

Endoscopic ultrasound in portal hypertension: navigating venous hemodynamics and treatment efficacy

Portal hypertension-related complications increase mortality in patients, irrespective of its etiology. Classically, endoscopic ultrasound (EUS) was used to assess the portal venous system and collaterals, considering size and hemodynamic parameters, which correlate with portal hypertension (PH) and related complications. Furthermore, therapeutic EUS guides treatment interventions, such as embolization of the gastric varices through coil placement and tissue adhesive injection, yielding encouraging clinical results. Recently, the direct measurement of portal pressure, emerging as an alternative to hepatic venous pressure gradient, has shown promise, and further research in this area is anticipated. In this review, we aimed to provide a detailed description of various possibilities for diagnosing vascular anatomy and hemodynamics in PH and actual knowledge on the EUS usefulness for PH vessel-related complications. Also, future promises for this field of endo-hepatology are discussed.

Increased needle passes for comparable diagnostic yield in endoscopic ultrasound-guided tissue acquisition for pancreatic stiff lesions measured by elastography

BACKGROUND/OBJECTIVES

Pancreatic cancer is characterized by tissue stiffness due to the high concentration of cancer-associated fibroblasts and extracellular matrix. Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is performed to diagnose pancreatic cancer but yields false-negative results attributed to inadequate specimens. EUS-elastography is a real-time assessment method to pancreatic tissue stiffness. This study aims to investigate the correlation between diagnostic yield and the number of needle passes based on the stiffness measured by elastography.

METHODS

Patients who underwent EUS-TA for pancreatic solid mass were retrospectively reviewed and included in this study. The number of needle passes during EUS-TA was determined based on macroscopic on-site evaluation. Tissue stiffness measurements were taken using EUS-elastography. The primary study outcome was the diagnostic yield. The secondary outcome included the number of needle passes required for a diagnosis.

RESULTS

A total of 652 patients were included. The average stiffness differed depending on the location of the tumor, and high-stiffness group had more malignant lesions. Although the diagnostic yield was not significantly different between groups, the number of needle passes was significantly higher in the high-stiffness group (3.6 ± 1.0 vs. 3.2 ± 0.9, p < 0.001).

CONCLUSIONS

The higher the stiffness of the pancreatic mass in EUS-elastography, the more needle passes are required to achieve a comparable diagnostic yield.

Submucosal injection fluid and tattoo agents

BACKGROUND AND AIMS

EMR and endoscopic submucosal dissection (ESD) are minimally invasive endoscopic techniques, developed for the removal of benign and early malignant lesions throughout the GI tract. Submucosal injection of a marking agent can help to identify lesions during surgery. Endoscopic resection frequently involves "lifting" of the lesions by injection of a substance within the submucosal space to create a cushion for safe resection. This review summarizes the current techniques and agents available for endoscopic marking and lifting of GI tract lesions.

METHODS

The MEDLINE database was searched through April 2023 for relevant articles related to the lifting and marking aspect of EMR by using key words such as "endoscopy" or "endoscopic" combined with "marking," "tattoo," and "lifting." The report was drafted, reviewed, and edited by the American Society for Gastrointestinal Endoscopy Technology Committee and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.

RESULTS

This technology review describes the techniques for endoscopic tattoo placement and submucosal lifting, along with currently available agents, safety, and costs.

CONCLUSIONS

Endoscopists performing EMR and ESD have several choices in submucosal injection materials for lifting and marking agents for tattoos. These may be commercially prepared agents or off-the-shelf materials with or without additives to facilitate visualization. A thorough understanding of the indications, techniques, properties of various agents, costs, and adverse events is necessary in choosing the appropriate materials and technique to optimize lesion resection in EMR and ESD.

The Impact of Computer-aided Detection Technology in Adenoma Detection Rate Among Experienced Endoscopists in the Community Setting

Adenoma detection rate (ADR) is a key quality metric in screening colonoscopies. An adenoma detection rate of greater than 30% reduces the incidence of colorectal carcinoma (CRC). Furthermore, studies have demonstrated an inverse relationship between ADR and the incidence of CRC. Computer aided detection (CAD) can improve ADR, but these studies have largely been in major medical centers. In this retrospective single center observational study, screening colonoscopies in average-risk patients were compared among 5 experienced endoscopists in the year before and the year after implementation of the CAD (GI Genius). Training for GI Genius was completed in December 2021 and the technology was implemented the beginning of January 2022. We evaluated the adenoma detection rate (ADR) for 1838 screening colonoscopies in 2021 (before CAD incorporation) and 2629 screening colonoscopies in 2022 (after CAD incorporation) to assess efficacy of AI-assisted colonoscopy. Our study demonstrates that the incorporation of CAD technology in a group of experienced endoscopists in a community setting significantly improved ADR. The ADR of the entire group increased significantly (p < 0.05) following the implementation of CAD technology. The improvement in ADR was attributed to an increased detection of small (<6 mm) polyps. The clinical significance of improved detection of small polyps is uncertain, and further investigation should be done on the economical benefit of incorporating an AI model in the community setting.

Gastric and Rectal Phytobezoar From Sunflower Seed Ingestion: A Case Report and Review of the Literature

Seed bezoars are a subcategory of phytobezoars caused by undigested vegetable seeds or fruit pits. We report the case of a 48-year-old woman who was admitted due to severe constipation and rectal pain. Rectal examination was notable for numerous sunflower seeds at the anal verge. Initial CT imaging revealed fecal impaction with a rectal bezoar which was managed with manual evacuation. Repeat CT imaging was notable for a gastric bezoar which was successfully managed by dissolution therapy with Coca-Cola. Most seed bezoars can be managed conservatively and life-threatening complications are rare.

Opening the doors of precision medicine: novel tools to assess intestinal barrier in inflammatory bowel disease and colitis-associated neoplasia

Mounting evidence underscores the pivotal role of the intestinal barrier and its convoluted network with diet and intestinal microbiome in the pathogenesis of inflammatory bowel disease (IBD) and colitis-associated colorectal cancer (CRC). Moreover, the bidirectional association of the intestinal barrier with the liver and brain, known as the gut-brain axis, plays a crucial role in developing complications, including extraintestinal manifestations of IBD and CRC metastasis. Consequently, barrier healing represents a crucial therapeutic target in these inflammatory-dependent disorders, with barrier assessment predicting disease outcomes, response to therapy and extraintestinal manifestations.New advanced technologies are revolutionising our understanding of the barrier paradigm, enabling the accurate assessment of the intestinal barrier and aiding in unravelling the complexity of the gut-brain axis. Cutting-edge endoscopic imaging techniques, such as ultra-high magnification endocytoscopy and probe-based confocal laser endomicroscopy, are new technologies allowing real-time exploration of the 'cellular' intestinal barrier. Additionally, novel advanced spatial imaging technology platforms, including multispectral imaging, upconversion nanoparticles, digital spatial profiling, optical spectroscopy and mass cytometry, enable a deep and comprehensive assessment of the 'molecular' and 'ultrastructural' barrier. In this promising landscape, artificial intelligence plays a pivotal role in standardising and integrating these novel tools, thereby contributing to barrier assessment and prediction of outcomes.Looking ahead, this integrated and comprehensive approach holds the promise of uncovering new therapeutic targets, breaking the therapeutic ceiling in IBD. Novel molecules, dietary interventions and microbiome modulation strategies aim to restore, reinforce, or modulate the gut-brain axis. These advancements have the potential for transformative and personalised approaches to managing IBD.

Endoscopic assessment of minor papilla morphology: Predictors of successful cannulation and procedural pancreatitis risk in minor papilla endotherapy

BACKGROUND

We evaluated for predictors of successful cannulation and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in minor papilla endotherapy (MPE), emphasizing endoscopic minor papilla morphology.

METHODS

We retrospectively analyzed 232 MPEs in 65 patients, assessing minor papilla morphology based on three features: bulge as "prominent" or "subtle," mucosal appearance as "papilla-like" resembling the main papilla or "SMT-like" akin to a gastrointestinal submucosal tumor, and orifice visibility as "clear" or "unclear." Cannulation success was evaluated in 65 enrolled patients, with PEP risk assessed in all 232 MPEs.

RESULTS

Minor papilla morphology was categorized as prominent/subtle bulge in 42/23 patients, papilla-like/SMT-like mucosal appearance in 42/23, and clear/unclear orifice visibility in 24/41. Cannulation succeeded in 54/65 patients (83%). A papilla-like appearance and clear orifice visibility was significantly associated with cannulation success. PEP incidence was 5.2% and predominantly mild. A papilla-like appearance significantly decreased PEP incidence, while precutting technique and orifice dilation significantly increased PEP risk.

CONCLUSION

Evaluating minor papilla morphology may help predict cannulation success and PEP risk in MPE. A papilla-like mucosal appearance prognosticates cannulation success and reduced PEP risk, with clear orifice visibility serving as a success predictor. These findings provide practical guidance for preprocedural planning by emphasizing the importance of minor papilla morphology evaluation.

Linear endoscopic ultrasound: Current uses and future perspectives in mediastinal examination

This editorial elaborates on the current and future applications of linear endoscopic ultrasound (EUS), a substantial diagnostic and therapeutic modality for various anatomical regions. The scope of endosonographic assessment is broad and, among other factors, allows for the evaluation of the mediastinal anatomy and related pathologies, such as mediastinal lymphadenopathy and the staging of central malignant lung lesions. Moreover, EUS assessment has proven more accurate in detecting small lesions missed by standard imaging examinations, such as computed tomography or magnetic resonance imaging. We focus on its current uses in the mediastinum, including lung and esophageal cancer staging, as well as evaluating mediastinal lymphadenopathy and submucosal lesions. The editorial also explores future perspectives of EUS in mediastinal examination, including ultrasound-guided therapies, artificial intelligence integration, advancements in mediastinal modalities, and improved diagnostic approaches for various mediastinal lesions.

Impact of timing of ERCP on long term outcomes of ERCP for acute cholangitis - A single center retrospective study

INTRODUCTION

Acute cholangitis is a critical medical emergency. The association between the timing of ERCP and clinical outcomes of acute cholangitis is still debated. The current study aims to evaluate whether ERCP within 48 h (urgent) is associated with improved long term clinical outcomes.

METHODS

This study is a single-center retrospective analysis of a prospectively maintained database. All patients admitted with acute cholangitis as per Tokyo guidelines at AIG Hospitals, Hyderabad between January 2022 to December 2022 were included. We evaluated the association between urgent ERCP and length of hospital stay, need for reintervention and readmissions, and mortality.

RESULTS

A total of consecutive 301 patients underwent ERCP for acute cholangitis; of which 217 patients (31.3 % females; mean age 54.02 ± 14.9 years) underwent urgent ERCP. The remaining 84 (32.1 % females; mean age 56.56 ± 13.9 years) underwent routine ERCP. Fifty-eight (26.7 %) and 22 (26.2 %) patients with Grade III underwent urgent and routine ERCP respectively. The median (IQR) hospital stay for urgent ERCP was 8.00 (6.00 - 11.00) days and for routine ERCP was 11.00(8.00 - 15.00; p value 0.0001), with similar hospital stay post ERCP (p 0.26). There was no significant difference in mortality upto one year between patients who underwent urgent (22.1 %;48/217) or routine ERCP (31.0 %;26/84, p 0.135). The cox proportional hazard model showed that mortality is independently associated with older age (HR 1.034;95 %CI: 1.013 - 1.054; p 0.001) and malignancy (HR 8.64;95 %CI:4.728 - 15.790; p 0.0001). There was no significant difference between two groups in terms of need for reinterventions and readmissions.

CONCLUSIONS

Urgent ERCP for acute cholangitis is associated comparable overall mortality, need for reinterventions, and readmissions with decreased total length of hospital stay. There is an unmet need to confirm these findings by randomized controlled studies.

Efficacy and safety of endoscopic nasobiliary drainage versus percutaneous transhepatic cholangial drainage in the treatment of advanced hilar cholangiocarcinoma: a systematic review and meta-analysis

OBJECTIVE

To evaluate and compare the efficacy and safety of Endoscopic Nasobiliary Drainage (ENBD) and Percutaneous Transhepatic Cholangiography Drainage (PTCD) in patients with advanced Hilar Cholangiocarcinoma (HCCA) through a meta-analysis of clinical studies.

METHODS

We searched Chinese and English databases, including China National Knowledge Infrastructure (CNKI), Wanfang database, PubMed, Embase, Scopus, and Web of Science, for relevant literatures on PTCD and ENBD for advanced HCCA clinical trials. Two investigators independently screened the literatures, and the quality of the included studies was evaluated using the Newcastle-Ottawa Scale (NOS). The primary endpoint was the success rate of biliary drainage operation, while secondary endpoints included Total Bilirubin (TBIL) change, acute pancreatitis, biliary tract infection, hemobilia, and other complications. R software was used for data analysis.

RESULTS

A comprehensive database search, based on predefined inclusion and exclusion criteria, yielded 26 articles for this study. Analysis revealed that PTCD had a significantly higher success rate than ENBD [OR (95% CI) = 2.63 (1.98, 3.49), Z=6.70, P<0.05]. PTCD was also more effective in reducing TBIL levels post-drainage [SMD (95%CI) =-0.13 (-0.23, -0.03), Z=-2.61, P<0.05]. While ENBD demonstrated a lower overall complication rate [OR (95%CI) = 0.60 (0.43, 0.84), Z=-2.99, P<0.05], it was associated with a significantly lower incidence of post-drainage biliary hemorrhage compared to PTCD [OR=3.02, 95%CI: (1.94-4.71), Z= 4.89, P<0.01].

CONCLUSIONS

This meta-analysis compares the efficacy and safety of ENBD and PTCD for palliative treatment of advanced HCCA. While both are effective, PTCD showed superiority in achieving successful drainage, reducing TBIL, and lowering the incidence of acute pancreatitis and biliary infections. However, ENBD had a lower risk of post-drainage bleeding. Clinicians should weigh these risks and benefits when choosing between ENBD and PTCD for individual patients. Further research is needed to confirm these findings and explore long-term outcomes.

Efficacy and safety of vonoprazan versus proton pump inhibitors in the treatment of peptic ulcer disease: a systematic review and network meta-analysis for randomized controlled trails

Background and aims

Vonoprazan, a novel acid suppressant, has been employed in the treatment of peptic ulcer disease in recent years. However, the efficacy and safety of vonoprazan versus proton-pump inhibitors remains controversial. To address this gap, a systematic review and network meta-analysis were conducted to evaluate the efficacy and safety of vonoprazan in comparison with various proton-pump inhibitors.

Methods

Randomized controlled trials that met selection criteria in PubMed (Medline), EMBASE and the Cochrane Library were searched up to July 15, 2024. The primary outcome was ulcer healing rate. Secondary outcomes were treatment-emergent adverse events and drug-related adverse events. Effect size on outcomes is presented as odds ratios with 95% confidence intervals.

Results

Thirty-five randomized controlled trials containing 9,544 participants were included. In terms of the healing rate at 2 weeks, lansoprazole 30 mg ranked first, followed by vonoprazan 20 mg and ilaprazole 10 mg. In terms of the healing rate at 4 weeks, pantoprazole 40 mg ranked first, with rabeprazole 10 mg and lansoprazole 30 mg ranking second and third, respectively. Regarding the healing rate at 8 weeks, lansoprazole 30 mg is demonstrated to be the most efficacious regimen. Moreover, subgroup analysis indicated that lansoprazole 30 mg is the optimal regimen in the treatment of artificial gastric ulcer at 4 and 8 weeks. Importantly, lansoprazole 30 mg has fewer adverse reactions and higher safety.

Conclusion

The optimal regimen for the treatment of peptic ulcer disease may be lansoprazole 30 mg at 2 and 8 weeks, while pantoprazole 40 mg has demonstrated superior performance at the 4-week when compared to vonoprazan 20 mg. Furthermore, lansoprazole 30 mg has shown to be superior in terms of safety outcomes. These findings, derived from a network meta-analysis, necessitate further research for validation.

Optimal bowel preparation for colonoscopy

There is robust evidence to indicate a strong correlation between the bowel preparation status and adenoma detection rate (ADR), which directly impacts the incidence and mortality rate of postcolonoscopy colorectal cancer. Therefore, improving bowel preparation has been of increasing interest. In Japan, commercially available bowel preparation agents include polyethylene glycol, oral sodium sulfate, sodium picosulfate-magnesium citrate, magnesium citrate, and oral sodium phosphate; each has its own strengths and limitations. The timing of administration can also influence the efficacy of bowel preparation and patient tolerability. Furthermore, meta-analyses have suggested predictive factors for inadequate bowel preparation. A detailed understanding of these factors could contribute to reducing the need for repeat colonoscopy within 1 year, as recommended for patients with inadequate bowel preparation. Recent advancements, such as oral sulfate tablets, present promising alternatives with higher patient satisfaction and ADRs than traditional methods. Achieving optimal bowel preparation requires enhanced instructions, individualized regimens, and a comprehensive understanding of patient backgrounds and the characteristics of various bowel preparation agents. This article provides a concise overview of the current status and advancements in bowel preparation for enhancing the quality and safety of colonoscopy.

Comparing Endoscopic Treatment Modalities for Gastric Antral Vascular Ectasia: Efficacy, Safety, and Outcomes in a Network Meta-analysis

OBJECTIVE

Gastric antral vascular ectasia (GAVE) is characterized by vascular ectasias accounting for 4% of nonvariceal upper gastrointestinal bleeds, which can range from occult bleeds to severe acute upper gastrointestinal bleeding. In turn, GAVE can lead to severe morbidity and recurrent hospitalization. Current endoscopic treatments for GAVE include argon plasma coagulation (APC), endoscopic band ligation (EBL), and radiofrequency ablation. With this significant burden in mind, a systematic review and network meta-analysis were conducted to compare the efficacy and safety of various modalities in the treatment of GAVE.

METHODS

All studies that involved adults and children with endoscopic characteristics of GAVE undergoing treatment with APC, EBL, radiofrequency ablation, or a combination of 2 treatment modalities were included.

RESULTS

There was no statistical difference in the rate of adverse events and the number of red blood cell transfusions across all 3 groups (APC, EBL, and APC + EBL). However, statistical differences were noted for outcomes of bleeding recurrence, length of hospitalization, and change in hemoglobin status. EBL exhibited a significant decrease in bleeding recurrence when compared with APC. Moreover, shorter hospitalization stays were seen in APC + EBL and EBL groups compared with APC, and a beneficial change in hemoglobin status was also more often seen in APC + EBL and EBL groups compared with APC.

CONCLUSIONS

Based on this study, EBL was found to have superior efficacy when compared with APC for the treatment of GAVE; however, there was no significant difference in rates of adverse events between APC, EBL, and combination therapy.

Post-colonoscopy appendicitis: A systematic review

Post-colonoscopy appendicitis is an infrequent complication of colonoscopy. This systematic review aimed to summarize the literature's current notions, clinical features, and management of post-colonoscopy appendicitis. PubMed and Embase were searched from inception until December 31, 2023. Two reviewers independently screened titles/abstracts and full-text papers for any study design about post-colonoscopy appendicitis and abstracted data. 56 articles with a total of 67 patients were included in the systematic review. The median age was 54.9 years (range 24-84), with more male individuals affected (64.2 %). The main indication of colonoscopy was investigation (37.3 %). Forty-three patients had colonoscopy with additional procedures (64.2 %). Most patients (79.1 %) presented with symptoms within two days after the colonoscopy. The clinical manifestation was the same as acute appendicitis. The diagnosis of post-colonoscopy appendicitis was confirmed in 70.2 % of the cases, mainly with abdominal computed tomography or, alternatively, ultrasound. Most patients were successfully treated with surgery (88.1 %), either open (56.8 %) or laparoscopic appendectomy (31.3 %). The conversion rate of laparoscopic appendectomy was 19.2 %. Non-operative management with intravenous antibiotics was attempted in 17 patients with a success rate of 41.2 %. Histopathology revealed acute appendicitis in 30 cases (44.8 %) and complicated appendicitis in 29 (49.2 %). Fecalith was found in 21 cases (31.3 %). Post-colonoscopy appendicitis is an infrequent but potential complication of colonoscopy. The onset of symptoms, especially pain, fever, nausea, and vomiting after a colonoscopy, should raise suspicion of this entity. A satisfactory outcome depends on timely diagnosis and appropriate management.

Comparative Analysis of ERCP and PTBD for Biliary Interventions for Readmission Rates and Patient Outcomes

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are interventions used to relieve biliary obstruction. The utility of ERCP compared with PTBD is not fully understood from a utilization outcome standpoint. Our study compares readmission rates and hospitalization outcomes in ERCP and PTBD.

METHODS

Using the National Readmission Database (NRD) 2016 to 2020, we identified all patients with an ERCP or PTBD completed during admission. The study cohort was first analyzed by 3 weighted study arms including those admitted with cholangitis, biliary/pancreatic malignancy, and choledocholithiasis. Second, we analyzed the cohort by a 1:1, unweighted propensity match. The primary outcome was 30 day, 90 day, and 6 month readmission. Secondary outcomes were readmission/overall mortality, cost, and length of stay. Outcomes were analyzed using multivariate analysis.

RESULTS

A total of 621,735 admissions were identified associated with 589,796 ERCP and 31,939 PTBD. In the propensity matched cohort, PTBD had a higher readmission rate at 30 days (20.38% vs. 13.71% P<0.0001), 90 days (14.63% vs. 13.14%, P<0.0001) but lower rate at 6 months (8.50% vs. 9.67%, P=0.0003). Secondary outcomes included increased PTBD-associated hospital length of stay (9.01 d vs. 6.74 d, P<0.0001), hospitalization cost ($106,947.97 vs. $97,602.25, P<0.0001), and overall mortality (6.86% vs. 4.35%, P<0.0001). No major differences were found for mortality among readmissions at 30 days (7.19% vs. 6.88%, P=0.5382), 90 day (6.82% vs. 6.51%, P=0.5612), and 6 months (5.08% vs. 5.91%, P=0.1744).

CONCLUSIONS

ERCP demonstrated superior results compared with PTBD for readmission rates, length of stay and overall mortality. For failed ERCP cases, emerging data for Endoscopic ultrasound guided-biliary drainage (EUS-BD) offers potential over PTBD and may provide additional options for the future in tertiary referral centers with experience.

Gastrointestinal pharmacoradiology, an updated review of medications and gastrointestinal contrasts in abdominal imaging

The purpose of this article is to review commonly used medications in abdominal radiology including their indications, mechanisms of action, dosages, contraindications, precautions, and adverse reactions. We will clarify common inquiries and address frequently asked questions by patients and clinicians related to their use. In addition, we will explore the indications, advantages and disadvantages, dosages, and contraindications of enteric contrast agents used for CT and fluoroscopic examinations.

Endoscopic submucosal dissection vs. endoscopic mucosal resection in the treatment of early Barrett's neoplasia: Systematic review and meta-analysis

OBJECTIVES

Endoscopic resection is the preferred approach to treat early Barrett's neoplasia, reducing the need for surgical interventions. However, the best choice between endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) remains unclear. The study aimed to compare the efficacy and safety of EMR vs. ESD for early Barrett's neoplasia.

METHODS

An electronic search was conducted in MEDLINE, Central Cochrane, EMBASE, and LILACS until November 2023. Studies comparing ESD vs. EMR in the treatment of patients with early Barrett's neoplasia were included. This study was performed according to the Preferred Report Items for Systematic Reviews and Meta-Analyses guidelines. The ROBIN-I tool was used to analyze the risk of bias and GRADE to measure the quality of the evidence.

RESULTS

A total of 9352 patients from 15 observational studies were included. Patients undergoing ESD had significantly higher rates of en-bloc (odds ratio [OR] 25.96, 95% confidence interval [CI] 13.82, 48.74; I2 = 52%; P < 0.00001) and R0 (OR 5.10, 95% CI 3.29, 7.91; I2 = 73%; P < 0.00001) with a higher risk of adverse events, including bleeding, stricture formation, and perforation. In a subgroup analysis of patients who did not receive radiofrequency ablation, ESD had a lower recurrence rate than EMR (OR 0.22, 95% CI 0.05, 0.94; I2 = 88%; P = 0.04).

CONCLUSION

Endoscopic submucosal dissection is more effective than EMR in treating early Barrett's neoplasia at the expense of higher adverse events rates.

Neoadjuvant radiation target volume definition in esophageal squamous cell cancer: a multicenter recommendations from Chinese experts

BACKGROUND

This study aimed to establish a consensus on the delineation of target volumes for neoadjuvant radiation therapy (nRT) in esophageal squamous cell carcinoma (ESCC) within China.

METHODS

From February 2020 to June 2021, nine ESCC patients who received nRT were retrospectively selected from Sun Yat-sen University Cancer Center and Shandong Cancer Hospital. A panel from eight cancer radiotherapy centers performed two rounds of nRT target volume delineation for these patients: the first round for cases 1-6 and the second for cases 7-9. Online meetings were held after each delineation round to discuss findings. The consistency of delineations across centers was compared using mean undirected Hausdorff distances (Hmean), dice similarity coefficients (DSC), and total volumes, analyzed with the Mann-Whitney U test.

RESULTS

The second round of delineations showed improved consistency across centers (total clinical target volume (CTVtotal): mean DSC = 0.76-0.81; mean Hmean = 2.11-3.14 cm) compared to the first round (CTVtotal: mean DSC = 0.63-0.64; mean Hmean = 5.66-7.34 cm; DSC and Hmean: P < 0.050 between rounds), leading to the formation of a consensus and an atlas for ESCC nRT target volume delineation. A proposal was reached through evaluating target volume delineations, analyzing questionnaire survey outcomes, and reviewing pertinent literature.

CONCLUSIONS

We have developed guidelines and an atlas for target volume delineation in nRT therapy for ESCC in China. These resources are designed to facilitate more consistent delineation of target volumes in both clinical practice and clinical trials.

Causes, management, and prognosis of severe gastrointestinal bleedings in critically ill patients with pancreatic cancer: A retrospective multicenter study

BACKGROUND

Gastrointestinal (GI) bleeding is a leading cause of intensive care unit (ICU) admission in pancreatic cancer patients.

AIMS

To analyze causes, ICU mortality and hemostatic treatment success rates of GI bleeding in pancreatic cancer patients requiring ICU admission.

METHODS

Retrospective multicenter cohort study between 2009 and 2021. Patients with a recent pancreatic resection surgery were excluded.

RESULTS

Ninety-five patients were included (62 % males, 67 years-old). Fifty-one percent presented hemorrhagic shock, 41 % required mechanical ventilation. Main GI bleeding causes were gastroduodenal tumor invasion (32 %), gastroesophageal varices (21 %) and arterial aneurysm (12 %). Arterial aneurysms were more frequent in patients with previous pancreatic resection (36 % vs 2 %, p < 0.001). Hemostatic procedures included gastroduodenal endoscopy in 81 % patients and arterial embolization in 28 % patients. ICU mortality was 19 %. Multivariate analysis identified four variables associated with mortality: performance status >2 (OR 9.34, p = 0.026), mechanical ventilation (OR 14.14, p = 0.003), treatment success (OR 0.09, p = 0.010), hemorrhagic shock (OR 11.24, p = 0.010). Treatment success was 46 % and was associated with aneurysmal bleeding (OR 29.89, p = 0.005), ongoing chemotherapy (OR 0.22, p = 0.016), and prothrombin time ratio (OR 1.05, p = 0.001).

CONCLUSION

In pancreatic cancer patients with severe GI bleeding, early identification of aneurysmal bleeding (particularly in case of previous resection surgery) and coagulopathy management may increase the treatment success and reduce mortality.

LAMB3: Central role and clinical significance in neoplastic and non-neoplastic diseases

Recently, topics related to targeted gene therapy and diagnosis have become increasingly important in disease research. The progression of many diseases is associated with specific gene signaling pathways. Therefore, the identification of precise gene targets in various diseases is crucial for the development of effective treatments. Laminin subunit beta 3 (LAMB3), a component of laminin 5, functions as an adhesive protein in the extracellular matrix and plays a vital role in regulating cell proliferation, migration, and cell cycle in certain diseases. Previous studies have indicated that LAMB3 is highly expressed in numerous tumorous and non-tumorous conditions, including renal fibrosis; squamous cell carcinoma of the skin, thyroid, lung, pancreatic, ovarian, colorectalr, gastric, breast, cervical, nasopharyngeal, bladder, prostate cancers; and cholangiocarcinoma. Conversely, it is underexpressed in other conditions, such as hepatocellular carcinoma, epidermolysis bullosa, and amelogenesis imperfecta. Consequently, LAMB3 may serve as a molecular diagnostic and therapeutic target for various diseases through its involvement in critical gene signaling pathways. This paper reviews the research status of LAMB3 and its role in related diseases.

Behcet's Disease Presenting as Pancolonic Ulcerations in a Patient With Kikuchi-Fujimoto Disease: A Rare Gastrointestinal Manifestation

Kikuchi-Fujimoto disease (KFD) is a rare and self-limiting disorder characterized by cervical lymphadenopathy and fever. In this report, we present a case of a 24-year-old man with known history of KFD who presented with lower gastrointestinal bleeding and acute blood loss anemia. Further evaluation with colonoscopy showed widespread ulcerations in the colon and terminal ileum with suspicion for Behcet's disease. Biopsy from the colonic mucosa and ileocecal valve demonstrated focal ulcer with cryptitis and lymphoid aggregates that can be seen in Behcet's syndrome; however, it lacks specificity and Behcet's disease is a clinical diagnosis. This case emphasizes the importance of including gastrointestinal bleeding as a potential manifestation due to Behcet's disease in patients diagnosed with KFD.

Safe outpatient discharge after gastrointestinal endoscopy with sedation and analgesia: a systematic literature review

Sedation and analgesia during gastrointestinal (GI) endoscopy increase procedural quality, contributing at the same time to greater patient satisfaction and willingness to undergo the procedure. Although sedation use has been optimized by the advent of efficacious and safe medications, data regarding the minimal criteria for discharge after outpatient endoscopy remain scant. Moreover, the time of discharge after endoscopy can be highly variable, depending not only on the type of procedure and anesthesia administered, but also on postprocedural complications and the patient's comorbidities. To make things even more conflicting, there is neither consensus among various endoscopic societies, concerning the most appropriate discharge strategy, nor a universally established tool that could be incorporated into everyday clinical practice, allowing patients' safe discharge as well as ability to drive. In this context, we conducted a systematic review, aiming to summarize the evidence regarding the available discharge scoring systems after outpatient GI endoscopy with sedation and analgesia administration.

Duodeno-ileal diversion with self-forming magnets in a sutureless neodymium anastomosis procedure (SNAP) for weight recidivism after sleeve gastrectomy: feasibility and 9-month results

BACKGROUND

The sleeve gastrectomy (SG) has become the most common bariatric procedure worldwide. However, insufficient weight loss or weight recidivism is frequent, which may require effective and safe revisional procedures.

OBJECTIVE

To determine the technical feasibility and safety of a minimally invasive, duodeno-ileal side-to-side anastomosis using a Sutureless Neodymium Anastomosis Procedure (SNAP) for patients with weight recidivism or inadequate weight loss following SG.

METHODS

This is a prospective, single-arm, open-label pilot study that enrolled patients with obesity to assist in weight reduction following an SG performed > 12 months prior. For the SNAP, self-assembling magnets were deployed into the ileum (laparoscopically) and duodenum (per-oral endoscopy). Magnets were coupled under laparoscopic and fluoroscopic guidance to create a compression anastomosis. The primary endpoints were technical feasibility, weight loss, and rate of serious adverse events (SAEs).

RESULTS

Successful duodeno-ileal diversions were created with SNAP in 27 participants (mean age: 50.6 ± 9.1, mean BMI: 38.1 ± 4.6 kg/m2) with no device-related serious adverse events. Upper endoscopy at 3 months confirmed patent, healthy anastomoses in all patients. At 9 months, patients (n = 24) experienced 11.9 ± 6.2%, 14.5 ± 10.8%, and 17.0 ± 13.9% TBWL at 3, 6, and 9 months, respectively. There were no device-related SAEs.

CONCLUSION

The SNAP is technically feasible and relatively safe, with all patients presenting widely patent anastomosis at 3 months. Patients experienced a progressive, clinically meaningful weight loss. Further studies are needed to confirm our findings.

Endoscopic repair of duodenal perforations, a scoping review

BACKGROUND

There is a discrepancy in the surgical and endoscopic literature for managing duodenal perforations. Although often managed conservatively, surgical repair is the standard treatment for duodenal perforations. This contrasts with the gastroenterology literature, which now recommends endoscopic repair of duodenal perforations, which are more frequently iatrogenic from the growing field of advanced endoscopic procedures. This study aims to provide a scoping review to summarize the current literature content and quality on endoscopic repair of duodenal perforations.

METHODS

The protocol for performing this scoping review was outlined by the Joanna Briggs Institute. All studies that reported primary outcomes of patients who had undergone endoscopic repair of duodenal perforations before February 2022, regardless of perforation etiology or repair type were reviewed, with studies after 1999 meeting inclusion criteria. The study excluded articles that did not report clinical outcomes of endoscopic repair, articles that did not describe where in the gastrointestinal tract the endoscopic repair occurred, pediatric patients, and animal studies.

RESULTS

7606 abstracts were screened, with 474 full articles reviewed and 152 studies met inclusion criteria. 560 patients had duodenal perforations repaired endoscopically, with a technical success rate of 90.4% and a survival rate of 86.7%. Most of these perforations (74.5%) were iatrogenic from endoscopic procedures or surgery. Only one randomized control trial (RCT) was found, and 53% of studies were case reports.

CONCLUSION

These results suggest that endoscopic repair could emerge as a viable first-line treatment for duodenal perforation and highlight the need for more high-quality research in this topic.

The Underrecognized Role of Cannabis in the Etiology of Acute Pancreatitis

Cannabis-induced pancreatitis (CIP) is an emerging clinical entity that presents unique challenges in diagnosis and management. This narrative review explores the current understanding of CIP, synthesizing evidence from epidemiological, pathophysiological, and clinical studies. The rising prevalence of cannabis use worldwide has been paralleled by an increase in reported cases of CIP, particularly among younger populations. Pathophysiological mechanisms involve the interaction of exogenous cannabinoids with pancreatic cannabinoid receptors, potentially disrupting normal pancreatic function and triggering inflammation. Clinical presentation of CIP often mimics other forms of acute pancreatitis (AP), necessitating a high index of suspicion and thorough history-taking for accurate diagnosis. Management strategies align with established protocols for AP, with an emphasis on supportive care and cannabis cessation to prevent recurrence. While short-term outcomes are generally favorable, the risk of progression to chronic pancreatitis in cases of continued cannabis use underscores the importance of long-term follow-up and abstinence counseling. This review also highlights significant knowledge gaps, including the need for standardized diagnostic criteria, a better understanding of dose-response relationships, and potential interactions with other risk factors. Future research directions should focus on elucidating precise pathophysiological mechanisms, developing targeted therapies, and investigating the impact of different cannabis formulations and consumption methods on pancreatic health. As cannabis use continues to increase globally, a comprehensive understanding of its effects on pancreatic function is crucial for improving patient outcomes and informing public health policies.

Bilio-Cecal Stent Migration Presenting as Massive Rectal Bleeding

Endoscopic biliary stenting is a well-established intervention for the treatment of biliary, hepatic, and pancreatic disorders. The common indications include strictures, neoplasms, stones, infections, and bile leaks. Stents can be occluded, predisposing patients to ascending cholangitis and biliary sepsis. Distal stent migration is another known complication of endoscopic stenting and is usually spontaneous. Bowel perforation, abscesses, bleeding, and pancreatitis are rare complications of distal stent migration and are usually limited to the duodenum. Herein, we describe an extremely rare case of bilio-cecal stent migration presenting as rectal bleeding.