Optimizing bowel preparation quality for colonoscopy: consensus recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Artificial Intelligence Performance in Image-Based Cancer Identification: Umbrella Review of Systematic Reviews

BACKGROUND

Artificial intelligence (AI) has the potential to transform cancer diagnosis, ultimately leading to better patient outcomes.

OBJECTIVE

We performed an umbrella review to summarize and critically evaluate the evidence for the AI-based imaging diagnosis of cancers.

METHODS

PubMed, Embase, Web of Science, Cochrane, and IEEE databases were searched for relevant systematic reviews from inception to June 19, 2024. Two independent investigators abstracted data and assessed the quality of evidence, using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. We further assessed the quality of evidence in each meta-analysis by applying the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. Diagnostic performance data were synthesized narratively.

RESULTS

In a comprehensive analysis of 158 included studies evaluating the performance of AI algorithms in noninvasive imaging diagnosis across 8 major human system cancers, the accuracy of the classifiers for central nervous system cancers varied widely (ranging from 48% to 100%). Similarities were observed in the diagnostic performance for cancers of the head and neck, respiratory system, digestive system, urinary system, female-related systems, skin, and other sites. Most meta-analyses demonstrated positive summary performance. For instance, 9 reviews meta-analyzed sensitivity and specificity for esophageal cancer, showing ranges of 90%-95% and 80%-93.8%, respectively. In the case of breast cancer detection, 8 reviews calculated the pooled sensitivity and specificity within the ranges of 75.4%-92% and 83%-90.6%, respectively. Four meta-analyses reported the ranges of sensitivity and specificity in ovarian cancer, and both were 75%-94%. Notably, in lung cancer, the pooled specificity was relatively low, primarily distributed between 65% and 80%. Furthermore, 80.4% (127/158) of the included studies were of high quality according to the JBI Critical Appraisal Checklist, with the remaining studies classified as medium quality. The GRADE assessment indicated that the overall quality of the evidence was moderate to low.

CONCLUSIONS

Although AI shows great potential for achieving accelerated, accurate, and more objective diagnoses of multiple cancers, there are still hurdles to overcome before its implementation in clinical settings. The present findings highlight that a concerted effort from the research community, clinicians, and policymakers is required to overcome existing hurdles and translate this potential into improved patient outcomes and health care delivery.

TRIAL REGISTRATION

PROSPERO CRD42022364278; https://www.crd.york.ac.uk/PROSPERO/view/CRD42022364278.

Factors predicting insufflation-related events in peroral endoscopic myotomy procedures

BACKGROUND

Peroral endoscopic myotomy (POEM) has revolutionized the therapeutic landscape for esophageal achalasia, offering efficacy comparable to that of surgery with the convenience of an endoscopic approach. With the growing popularity of POEM, insufflation-related adverse events (AEs) present unique challenges that have been widely discussed in the literature. This study aimed to investigate the safety profiles and risk factors associated with insufflation-related events in patients undergoing POEM in endoscopy suites.

METHODS

This retrospective analysis included 100 consecutive patients with achalasia treated by POEM at our institute between March 2016 and October 2022. All procedures were performed in an endoscopy suite and employed carbon dioxide insufflation and general anesthesia with endotracheal intubation and positive-pressure ventilation. Variations in cardiopulmonary dynamics, intraprocedural AEs, and postoperative recovery were documented.

RESULTS

All procedures were successfully performed, with an average POEM duration of 92.3 min and an average anesthesia duration of 108.4 min. Of note, 1 major AE involving an esophageal leak and requiring endoscopic stenting was observed, along with a 27% incidence of minor AEs. Insufflation-related events, manifesting as capnoperitoneum, subcutaneous emphysema, or capnomediastinum, were identified in 48% of cases, but none required additional interventions or extended hospitalization. A peak inspiratory pressure increase of ≥20% was identified as the only predictor of insufflation-related events.

CONCLUSION

Performing POEM in an endoscopy suite can generally be considered safe from major AEs related to insufflation. Monitoring peak inspiratory pressure for a ≥20% increase may be an early indicator of other potential insufflation-related events.

Revealing autoimmune gastritis: Polypoid nodule scar development after endoscopic submucosal dissection for early gastric cancer

Endoscopic submucosal dissection (ESD), the standard treatment for early gastric cancer, typically results in homogeneous flat scars. However, in some cases, polypoid nodule scars (PNS) may develop, complicating the cancer recurrence assessment. This case report describes a 60-year-old man with a history of Helicobacter pylori infection who underwent two ESD procedures: first for early antral gastric cancer and then for gastric body adenoma. Subsequently, an erythematous protruding lesion developed at the antral ESD scar site. Lesion biopsy revealed regenerative and hyperplastic tissue growth, consistent with PNS. Despite H. pylori eradication therapy and discontinuation of potassium-competitive acid blockers and H2-receptor antagonists, the lesion continued to enlarge. PNS growth may be caused by excessive mucosal regeneration and enhanced antral peristalsis, suggesting that hypergastrinemia, which may enhance these effects, may be an underlying cause. Further, elevated serum gastrin levels, decreased pepsinogen levels, the presence of antiparietal cell antibodies, and consistent pathological findings confirmed autoimmune gastritis (AIG). This case highlights the diagnostic challenges of AIG, especially in cases of active or previous H. pylori infection because typical endoscopic features may be obscured. Persistent PNS after ESD warrants the consideration of excessive mucosal regeneration and enhanced peristalsis, with AIG as a potential cause because of its association with hypergastrinemia. To our knowledge, this is the first case report describing a potential link between AIG and PNS.

Clinicopathological evaluation of the efficacy of endoscopic treatment for sessile serrated lesions comparing endoscopic mucosal resection, cold snare polypectomy, and underwater endoscopic mucosal resection

OBJECTIVES

Recently, various endoscopic treatments for colorectal polyps have been reported, including cold snare polypectomy (CSP) and underwater endoscopic mucosal resection (UEMR), in addition to EMR. However, a precise treatment strategy for sessile serrated lesions (SSL) has not been established. In this study, we analyzed the clinicopathological features of SSL resected by EMR, CSP, and UEMR to determine the most suitable treatment for SSL.

METHODS

A total of 92 SSL resected via EMR (n = 11), CSP (n = 36), and UEMR (n = 45) were retrospectively enrolled between February 2021 and October 2022. To evaluate pathological findings, we examined SSL samples, which were stretched before formalin fixation and sectioned at 2-mm intervals. Primary outcomes were the R0 resection rate and thickness of submucosal (SM) tissue specimens for each treatment. In addition, we evaluated SSL with dysplasia (SSLD) and the inverted growth pattern which may affect the vertical margin.

RESULTS

The R0 resection rate significantly differed among the three groups (EMR, 73%; CSP, 42%; UEMR, 87%, p = 0.001). The median thickness of SM tissue resected by CSP (0 µm) was significantly less than that by EMR (362 µm) and UEMR (325 µm; p < 0.001). All four SSLDs were diagnosed endoscopically. Five SSLs with inverted growth patterns were pathologically diagnosed. Of these, two SSLs with inverted growth patterns could not be diagnosed endoscopically.

CONCLUSIONS

UEMR is considered to be a suitable treatment option for SSL. CSP results were pathologically insufficient. Therefore, surveillance to evaluate local recurrence is important, and the results of further multicenter prospective studies should be referred.

The latest evidence and guidance in lifestyle and surgical interventions to achieve weight loss in people with overweight or obesity

BACKGROUND

The prevalence of obesity and related co-morbidities has reached epidemic proportions. Effective evidence-based treatment approaches are therefore important. Lifestyle intervention remains the mainstay of the treatment strategy to manage obesity. Increased evidence has also emerged regarding the efficacy of metabolic bariatric surgery (MBS) to induce significant and sustained weight loss while also reducing the progression of obesity-related co-morbidities for people living with obesity.

AIMS & METHODS

This article aims to bring together current evidence, guidance and best practice for the prevention and management of people living with overweight or obesity by means of lifestyle and behavioural intervention, as well as by MBS.

RESULT

Lifestyle intervention encompasses dietary strategies, physical activity and behavioural intervention. Discussion on MBS will focus on current indications, comparison between different MBS procedures, novel endoscopic techniques, potential complications and pre-operative management.

PLAIN LANGUAGE SUMMARY

The number of people living with excess weight and complications associated with being overweight is alarmingly quite high. Effective treatment approaches that are supported by clinical studies are therefore important. Lifestyle changes remain very important to manage excess weight. Increased evidence has also shown the benefits of weight loss surgery to produce significant weight loss which could be sustained, while also reducing the risk of developing medical conditions associated with excess weight. This article aims to bring together current evidence, guidance and best practice for the prevention and management of people living with excess weight by means of lifestyle and behavioural changes, as well as by weight loss surgery. Lifestyle intervention encompasses dietary strategies, physical activity and behavioural intervention. Discussion on weight loss surgery will focus on current criteria for suitability, comparison between different weight loss surgery procedures, new techniques, possible complications and appropriate management prior to weight loss surgery.

A rare unifocal gastric gastrointestinal stromal tumor in a young NF1 patient: A case report

INTRODUCTION AND IMPORTANCE

Gastrointestinal stromal tumors (GISTs) are the most prevalent mesenchymal neoplasms of the gastrointestinal tract, predominantly associated with mutations in the KIT and PDGFRA genes. Neurofibromatosis type 1 (NF1) increases the risk of developing GISTs, particularly in younger individuals, and often presents with atypical features.

CASE PRESENTATION

A 16-year-old female with a known diagnosis of NF1 presented with severe anemia, hematemesis, and melena. Physical examination revealed multiple café-au-lait spots and cutaneous nodular masses. A contrast-enhanced CT scan showed a large mass arising from the stomach's greater curvature, consistent with GIST. The patient underwent a sleeve gastrectomy, and histopathological evaluation confirmed high-grade spindle cell GIST. Immunohistochemistry was positive for CD117, CD34, and DOG-1. Postoperative PET-CT showed no residual disease.

CLINICAL DISCUSSION

GIST in NF1 patients typically presents with a multifocal pattern, but our patient exhibited a rare unifocal GIST in the stomach. The diagnosis was complicated by atypical presentation and required multimodal imaging and histopathological confirmation. NF1-associated GISTs generally lack KIT and PDGFRA mutations, rendering targeted therapies like imatinib ineffective, emphasizing surgical management as the primary treatment.

CONCLUSION

This case highlights the unique clinical and pathological characteristics of NF1-associated GISTs, stressing the need for vigilant assessment in NF1 patients with gastrointestinal symptoms.

ACG Clinical Guideline: Diagnosis and Management of Gastric Premalignant Conditions

Gastric premalignant conditions (GPMC) are common and include atrophic gastritis, gastric intestinal metaplasia, dysplasia, and certain gastric epithelial polyps. GPMC have an increased risk of progression to gastric adenocarcinoma. Gastric cancer (GC) in the United States represents an important cancer disparity because incidence rates are 2- to 13-fold greater in non-White individuals, particularly early-generation immigrants from regions of high GC incidence. The US 5-year survival rate for GC is 36%, which falls short of global standards and is driven by the fact that only a small percentage of GC in the US is diagnosed in the early, curable stage. This document represents the first iteration of American College of Gastroenterology guidelines on this topic and encompasses endoscopic surveillance for high-risk patients with GPMC, the performance of high-quality endoscopy and image-enhanced endoscopy for diagnosis and surveillance, GPMC histology criteria and reporting, endoscopic treatment of dysplasia, the role of Helicobacter pylori eradication, general risk reduction measures, and the management of autoimmune gastritis and gastric epithelial polyps. There is insufficient evidence to make a recommendation on upper endoscopic screening for GC/GPMC detection in US populations deemed high-risk for GC. Surveillance endoscopy is recommended for individuals at high risk for GPMC progression, as defined by endoscopic, histologic, and demographic factors, typically every 3 years, but an individualized interval may be warranted. H. pylori testing, treatment, and eradication confirmation are recommended in all individuals with GPMC. Extensive high-quality data from US populations regarding GPMC management are lacking, but continue to accrue, and the quality of evidence for the recommendations presented herein should be interpreted with this dynamic context in mind. The GPMC research and education agendas are broad and include high-quality prospective studies evaluating opportunistic endoscopic screening for GC/GPMC, refined delineation of what constitutes "high-risk" populations, development of novel biomarkers, alignment of best practices, implementation of training programs for improved GPMC/GC detection, and evaluation of the impact of these interventions on GC incidence and mortality in the US.

Accidental Ingestion of an Open Safety Pin by a Two-Year-Old Male Child: A Case Report

Accidental foreign body (FB) ingestion is common in the pediatric age group between six months and five years. Most ingested FBs pass easily through the esophagus, into the stomach, and are expelled from the body without complications. However, some of these foreign bodies may get stuck in any part of the gastrointestinal (GI) tract, and endoscopic removal may be required to avoid complications. We present a case involving the endoscopic removal of an open safety pin from the duodenum of a two-year-old boy. The safety pin went unnoticed until the mother realized one was missing, leading to an incidental diagnosis.

A Rare Case of Massive Gastrointestinal Hemorrhage Caused by an Ileal Gastrointestinal Stromal Tumor

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors of the gastrointestinal tract. Although gastrointestinal bleeding is a common complication of GISTs, life-threatening hemorrhage is rare, particularly with intestinal GISTs. We report a rare case of an ileal GIST in a 71-year-old female patient who presented with massive lower gastrointestinal bleeding. Initial CT angiography (CTA) demonstrated a brisk gastrointestinal bleed in the ileal region. Despite embolization of the associated distal ileal artery branches, the patient experienced persistent hemoglobin drops and hematochezia. Repeat CTA revealed a hyper-enhancing exophytic lesion in the proximal ileum. This 4.7cm ileal tumor had to be excised, and histopathology confirmed a low-grade GIST. This case highlights the diagnostic complexity of ileal GISTs and the importance of imaging modalities such as CTA in managing active gastrointestinal bleeding.

The Role of Artificial Intelligence for Advanced Endoscopy

Artificial intelligence (AI) application in gastroenterology has grown in the last decade and continues to evolve very rapidly. Early promising results have opened the door to explore its potential application to advanced endoscopy (AE). The aim of this review is to discuss the current state of the art and future directions of AI in AE. Current evidence suggests that AI-assisted endoscopic ultrasound models can be used in clinical practice to distinguish between benign and malignant pancreatic diseases with excellent results. AI-assisted endoscopic retrograde cholangiopancreatography models could also be useful in identifying the papilla, predicting difficult cannulation, and differentiating between benign and malignant strictures.

Novel minimally invasive strategies for achieving source control in intra-abdominal infections

PURPOSE OF REVIEW

To provide an overview of recent advancements in minimally invasive intra-abdominal source control techniques.

RECENT FINDINGS

There have been multiple recent advances in minimally invasive techniques for managing intra-abdominal infection or sepsis. Endoscopic based interventions include stenting, suturing, clip placement, and endoscopic vacuum therapy. Robotic surgery is becoming progressively more popular in emergency general surgery and offers comparable results compared to laparoscopic surgery with lower rates of conversion to open.

SUMMARY

Endoscopic based interventions and minimally invasive surgery offer comparable outcomes to more invasive interventions with less morbidity for patients, though the ability to perform these techniques may not be limited to tertiary and quaternary health centers. Providers must use their clinical judgment to determine the best course of action.

A targeted endoscopic band ligation technique for management of acute esophageal variceal bleeding

BACKGROUND/AIMS

Endoscopic band ligation (EBL) standard therapy is traditionally performed with banding from the distal esophagus upwards. However, esophageal varices (EV) with stigma of recent bleeding are not consistently banded at the first attempt. We aimed to compare conventional banding in acute variceal bleeding (AVB) vs targeted banding of EV in patients with stigma of recent bleeding (white nipple sign).

METHODS

This case-control study included patients treated in our hospital from December 2016 to September 2019 with endoscopic signs of recent variceal bleeding. The targeted technique involves deploying the first band at the recent bleeding stigmata and then completing the procedure with standard variceal banding technique. The conventional group included patients treated with standard EBL.

RESULTS

We analyzed 92 patients, 54 (58.7%) in conventional technique and 38 (41.3%) in the targeted group. Active bleeding during endoscopy occurred in 11 (20.0%) of conventional and two (6.5%) of the targeted group (p=0.021). Although procedure time was longer in the conventional group (24.3min SD 11.58) compared to the targeted group (21.52min SD 8.73) this difference was not significant. One detached band episode was documented in targeted group and none in the conventional group (p=0.418). TIPS were not used during this study due to health system policy. There were no significant differences in mortality, rebleeding or transfusion requirements between groups.

CONCLUSIONS

The targeted technique for EV with stigma of recent bleeding had a low band detachment incidence and fewer bleeding events during endoscopy, however, the limitations of the study should be considered.

Development and feasibility study of a piezoresistive pressure sensor-based automated system for monitoring and controlling gastric pressure in endoscopy

Maintaining precise intragastric pressure during gastrointestinal endoscopy is critical for patient safety and diagnostic accuracy, yet current methods relying on manual adjustments pose risks of improper insufflation. This study aimed to develop an automated gastric pressure control system for flexible endoscopy, addressing these challenges with a piezoresistive pressure sensor that can be integrated into a 7.3 mm diameter flexible endoscope. The system, incorporating air and suction pumps controlled by a microcontroller, was calibrated in an acrylic chamber and validated through comprehensive testing in both an endoscopy simulator and a porcine specimen. Testing scenarios included normal breathing, coughing, belching, and combined events, assessing accuracy, stability, and real-time pressure regulation under conditions mimicking physiological responses. Results demonstrated high accuracy (R2 = 0.9999), minimal bias (0.23 mmHg), and strong agreement with reference standards, confirming effective pressure management. Simulated clinical scenarios in simulator and porcine specimen further showed the system's ability to maintain target pressure with minimal errors, indicating robustness under dynamic conditions. These findings suggest that the automated pressure control system significantly improves safety and procedural efficiency in endoscopy, with potential applicability to other minimally invasive procedures. Further animal model testing is recommended to validate the clinical performance under realistic physiological conditions.

Gastrointestinal stromal tumor causing bleeding and intussusception: A case report

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors that originate from interstitial cells of Cajal. They most commonly occur in the stomach, followed by the small bowel. Jejunal GISTs are particularly rare and often present with nonspecific symptoms. However, they can also present with gastrointestinal bleeding and intussusception, complicating diagnosis and treatment.

PRESENTATION OF CASE

We report a case of a 58-year-old male who presented with melena and anemia due to a bleeding intussuscepting jejunal gastrointestinal stromal tumor (GIST). The patient underwent jejunal resection and anastomosis. The postoperative course was uncomplicated, and the patient made a full recovery.

DISCUSSION

Gastrointestinal stromal tumors (GISTs) can present with melena and acute or chronic anemia due to gastrointestinal bleeding. The bleeding typically results from ulceration or erosion of blood vessels within the tumor. The diagnosis is often challenging, as the symptoms are nonspecific. Imaging techniques such as CT scans are essential for identifying the tumor, and surgical resection is the primary treatment, providing favorable outcomes for localized, low-risk cases.

CONCLUSION

Gastrointestinal stromal tumors (GISTs), although rare, should be considered in the differential diagnosis of patients presenting with gastrointestinal bleeding and anemia.

Multicenter evaluation of the impact of COVID-19 on the uptake of endoscopic skills by gastroenterology trainees

BACKGROUND AND AIMS

The COVID-19 pandemic significantly decreased procedural volume in 2020, thus limiting training opportunities. First-year fellows (1YF) are particularly susceptible to reduction in endoscopic volume as they build foundational endoscopic skills. We used an objective validated tool, the Assessment of Competency in Endoscopy (ACE), to determine the effect of the pandemic on endoscopy competency in gastroenterology fellows.

METHODS

This was a prospective cohort study conducted across two fellowship programs in New York City. Our primary outcome was the comparison of ACE scores of fellows starting gastroenterology fellowships in 2020 to the scores of those starting in 2016-2018. Our secondary outcome was to compare colonoscopy quality metrics and endoscopy volume between these cohorts.

RESULTS

ACE scores were available from 11 pandemic and 10 pre-pandemic 1YFs, and five pandemic and 19 pre-pandemic second (2YF) and third-year fellows (3YF). ACE scores for 1YFs showed significantly higher rating in the pre-pandemic cohort for 4 domains including knowledge of indications and medical issues (p = 0.03), effective and efficient use of air, water, and suction (p = 0.04), pathology identification (p = 0.001), and overall hands-on skills (p = 0.004). 2YFs showed no significant differences. 3YFs showed significantly lower scores in the pandemic cohort in the effective and efficient use of air, water, and suction (p = 0.03), fellows' knowledge of therapeutic tools (p = 0.05), and fellows overall cognitive skills (p = 0.05). There were no significant differences in quality metrics between the cohorts, except longer procedure time for the pandemic cohort (p < 0.01).

CONCLUSION

Following the COVID-19 pandemic, there was a decline in multiple aspects of endoscopic competency both at the beginning and the end of fellowship training. These trends are likely the result of a decrease in overall procedure volume early in training and highlight the need for supplementing trainee education with other modalities.

Endoscopic features of gastric neuroendocrine tumors

OBJECTIVES

The endoscopic features of gastric neuroendocrine tumors (G-NETs) remain unclarified. The present study investigated the endoscopic features of G-NETs in relation to the clinicopathological findings.

METHODS

This retrospective study analyzed consecutive patients with G-NETs who received endoscopic or surgical treatment between January 2005 and December 2023. The endoscopic and clinicopathological findings of the lesions were analyzed to provide diagnostic information.

RESULTS

Among 29 patients, the characteristic endoscopic findings of G-NETs on white-light images were reddish color (66%), dilated vessels (83%), submucosal tumor-like marginal elevation (59%), and central depression (48%). The gross appearance of G-NETs was classified into two macroscopic subtypes: reddish polypoid lesions (n = 17) and submucosal tumor-like lesions (n = 9). Magnifying narrow-band imaging endoscopy revealed an absent microsurface pattern plus an irregular microvascular pattern in all cases of reddish polypoid lesions with central depressions (100%, 9/9). The findings of a reddish polypoid lesion and an absent microsurface pattern plus an irregular microvascular pattern corresponded to the subepithelial NET component close to the non-neoplastic surface epithelium. Additionally, reddish polypoid lesions were significantly more frequent in type 1 G-NETs than in type 3 G-NETs (80% vs. 11%, p < 0.001), while submucosal tumor-like lesions were significantly more frequent in type 3 G-NETs than in type 1 G-NETs (78% vs. 10%, p < 0.001).

CONCLUSIONS

These endoscopic features should increase the index of suspicion and help clinicians to correctly diagnose G-NETs through the pathological examination of biopsy specimens.

Adverse events in patients with obstructive sleep apnea undergoing procedural sedation in ambulatory settings: An updated systematic review and meta-analysis

OBJECTIVE

Patients with obstructive sleep apnea (OSA) may be at increased risk for adverse events during procedural sedation, however, there remains a gap in the literature quantifying these risks. This systematic review and meta-analysis aimed to evaluate the risk of peri-procedural adverse events in OSA patients undergoing procedural sedation in ambulatory settings, compared to those without OSA.

METHODS

Four databases were systematically searched for studies published from January 1, 2011 to January 4, 2024. The inclusion criteria were: adult patients with OSA undergoing procedural sedation in ambulatory settings, peri-procedural adverse events reported, and control group included. The primary outcome was the incidence of peri-procedural adverse events amongst patients with vs without OSA.

RESULTS

Nineteen studies (27,973 patients) were included. The odds of respiratory adverse events were significantly increased for patients with OSA (OR 1.65, 95 % CI 1.03-2.66, P = 0.04). Furthermore, the odds of requiring an airway maneuver/intervention were significantly greater for patients with OSA (OR 3.28, 95 % CI 1.43-7.51, P = 0.005). The odds of cardiovascular adverse events were not significantly increased for patients with OSA.

CONCLUSION

Patients with OSA undergoing procedural sedation in ambulatory settings had 1.7-fold greater odds of respiratory adverse events and 3.3-fold greater odds of requiring airway maneuvers/interventions.

Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Endoscopic ultrasound-guided bite-on-bite biopsy and endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of gastric tumors with negative malignant endoscopy biopsies: a retrospective cohort study

BACKGROUND

Specific types of gastric tumors, including gastric linitis plastica and lymphoma, may cause extensive deep-layer infiltration, impeding an accurate diagnosis with endoscopic biopsy. This study aims to evaluate the efficacy of endoscopic ultrasound (EUS)-guided bite-on-bite biopsy and EUS-guided fine-needle aspiration (EUS-FNA) in diagnosing gastric malignancies with negative endoscopic biopsies.

METHODS

We retrospectively analyzed suspicious malignant gastric lesion cases in our hospital from October 2017 to August 2023. Clinical manifestations, radiographical examinations, endoscopic examinations, histopathological results, and therapeutic strategies were recorded and analyzed.

RESULTS

Forty malignant gastric tumor cases with negative endoscopic biopsies were incorporated into our study. EUS-guided bite-on-bite biopsy was performed in 16 cases exclusively, whereas 17 patients received EUS-FNA exclusively, and seven patients underwent both simultaneously. Among the 23 patients who received the EUS-guided bite-on-bite biopsy, 22 (95.7%) were diagnosed with malignancies. Among the 24 patients who received EUS-FNA, a total of 19 cases with malignancies (79.2%) were confirmed by EUS-FNA (p = 0.11): 13 gastric adenocarcinomas, five metastatic malignancies, and one malignant stromal tumor. No adverse events were observed in any of the cases.

CONCLUSIONS

EUS-guided bite-on-bite biopsy and EUS-FNA possess their advantages and disadvantages. EUS-guided bite-on-bite biopsy could serve as a reliable diagnostic method for shallow lesions with negative malignant endoscopic biopsies.

Understanding Portosystemic Collateral Anatomy

Portosystemic collateral pathways are a significant concern in interventional radiology, frequently manifesting in patients with cirrhosis or portal vein thrombosis. These pathways can lead to severe clinical complications, including gastrointestinal bleeding, hepatic encephalopathy, and liver failure. A thorough understanding of the anatomy, hemodynamic alterations, and clinical implications of these shunts is crucial for interventional radiologists to provide effective treatment while minimizing risks. This article reviews the clinical presentations associated with portosystemic shunts, explores the anatomical variants and altered flow dynamics, and discusses the latest endovascular treatment strategies to optimize patient outcomes.

Technical review of endoscopic ultrasound-guided drainage/anastomosis and trans-endosonographically created route procedures for the treatment of pancreatic diseases

Endoscopic ultrasound (EUS)-guided pancreatic duct drainage includes two procedures: EUS-guided drainage/anastomosis (EUS-D/A) and trans-papillary drainage with EUS-assisted pancreatic rendezvous. EUS-guided pancreatogastrostomy is the most common EUS-D/A procedure and is recommended as a salvage procedure in cases in which endoscopic retrograde cholangiopancreatography fails or is difficult. However, initial EUS-D/A is performed in patients with surgically altered anatomy at our institution. It is one of the most difficult interventional EUS procedures and has a high incidence of adverse events. The technical difficulties differ according to etiology, and the incidence of adverse events varies between initial EUS-D/A and subsequent trans-endosonographically/EUS-guided created route procedures. Hence, it is important to meticulously prepare a procedure based on the patient's condition and the available devices. The technical difficulties in EUS-D/A include: (1) determination of the puncture point, (2) selection of a puncture needle and guidewire, (3) guidewire manipulation, and (4) dilation of the puncture route and stenting. Proper technical procedures are important to increase the success rate and reduce the incidence and severity of adverse events. The complexity of EUS-D/A is also contingent on the severity of pancreatic fibrosis and stricture. In post-pancreatectomy cases, determination of the puncture site is important for success because of the remnant pancreas. Trans-endosonographically/EUS-guided created route procedures following initial EUS-D/A are also important for achieving the treatment goal. This article focuses on effective strategies for initial EUS-D/A, based on the etiology and condition of the pancreas. We mainly discuss EUS-D/A, including its indications, techniques, and success-enhancing strategies.

Efficacy and safety of oral sulfate solution versus polyethylene glycol for colonoscopy: A systematic review and meta-analysis of randomized controlled trials

Background

Colonoscopy is the gold standard for early detection and monitoring of colorectal cancer. Procedural effectiveness is dependent on optimal bowel preparation. Traditional polyethylene glycol (PEG) solutions are difficult to tolerate, whereas newer low-volume alternatives, including PEG with ascorbic acid and oral sulfate solutions (OSS), offer improved efficacy and tolerability. The meta-analysis was performed to evaluate the efficacy and safety of OSS compared to PEG for bowel preparation in colonoscopy.

Methods

Studies were identified by searching PubMed, Embase, Cochrane CENTRAL, and clinicaltrials.gov from inception until June 2024. Only randomized controlled trials comparing OSS with PEG were included. Data was analyzed using R version 4.4.0 using a random effects model to calculate risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs).

Results

Twenty-one studies with 6346 participants met the inclusion criteria. OSS significantly improved adenoma detection (RR, 1.13; 95% CI, 1.04-1.22; p-value <0.01; I2 = 0%) and polyp detection rates (RR, 1.16; 95% CI, 1.06-1.26; p-value <0.01; I2 = 0%), and had a higher Boston Bowel Preparation Scale (BBPS) score (MD, 0.31; 95% CI, 0.13-0.50; p-value <0.01; I2 = 81%). PEG was associated with more sleep disturbances (RR, 0.45; 95% CI, 0.25-0.82; p-value = 0.03; I2 = 0%). However, other adverse effects were similar between both solutions.

Conclusion

OSS demonstrated superior adenoma and polyp detection rates. When compared to PEG, patients utilizing OSS achieved higher BBPS scores. Data gleaned support enhanced cleansing efficacy and safety of OSS as a bowel preparation regimen.

Association of frailty with outcomes in patients with large vessel occlusion stroke undergoing mechanical thrombectomy

PURPOSE

Frailty is a clinical syndrome characterized by reduced physiological reserve and increased vulnerability to adverse health outcomes, potentially impacting patients undergoing mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion (LVO). This study aimed to evaluate the influence of frailty on in-hospital outcomes in these high-risk patients.

METHODS

We conducted a retrospective analysis of the National Inpatient Sample (2016-2021), identifying patients with large vessel occlusion stroke undergoing mechanical thrombectomy. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses. Propensity score matching (PSM) was applied to create balanced cohorts for primary analysis.

RESULTS

In propensity-matched analysis, frail patients had higher in-hospital mortality (12.06% vs. 9.90%, P = 0.004), seizures (2.35% vs. 1.65%, P = 0.048), major adverse cardiac events (MACE) (15.29% vs. 13.51%, P = 0.044), pulmonary embolism (2.38% vs. 1.62%, P = 0.031), and hospital-acquired pneumonia (6.10% vs. 4.80%, P = 0.023). Sensitivity analysis using multivariable logistic regression confirmed similar trends, with frailty remaining an independent predictor of mortality (aOR 1.24, 95% CI: 1.04-2.23, P = 0.04).

CONCLUSION

Frailty is associated with significantly worse outcomes, including higher mortality, MACE, and pneumonia in patients undergoing mechanical thrombectomy for LVO. These findings emphasize the need for frailty screening as part of pre-procedural risk stratification and tailored management strategies to improve patient outcomes.

Case Report: Fish bone-induced duodenal perforation leading to bile duct stones and portal vein thrombosis

We present a case of duodenal perforation caused by accidental ingestion of a fishbone, presenting with right upper abdominal pain and jaundice. Imaging studies revealed duodenal perforation, common bile duct stones, and portal vein thrombosis. By reviewing the patient's clinical presentation, diagnostic process, treatment measures, and prognosis, we analyzed the potential mechanisms underlying this complex pathological condition and proposed appropriate clinical management strategies. Duodenal perforation caused by foreign bodies is a rare but potentially fatal condition that may lead to severe complications. Foreign body-induced duodenal and bile duct perforation can act as potential triggers for common bile duct stones and portal vein thrombosis. Its intricate pathophysiology requires heightened vigilance and comprehensive evaluation. Prompt diagnosis and individualized treatment strategies are critical for improving patient outcomes.

Endoscopic mucosal resection with an over-the-scope clip for colorectal tumors (with video)

Background

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection may result in complications or may be unsuitable for tumors that are difficult to treat endoscopically. We investigated the usefulness of a newly developed endoscopic resection technique-EMR with an over-the-scope clip (EMR-O)-for difficult-to-treat lesions.

Method

We retrospectively examined patients who underwent EMR-O for colorectal tumors between September 2017 and January 2024. Patient and lesion characteristics, technical success rates, en bloc resection rates, R0 resection rates, procedure time, histopathology, and the clinical course were evaluated.

Results

EMR-O was performed for 18 patients. Indications for EMR-O included residual or recurrent lesions (seven patients; 38.9%), diverticulum lesions (five patients; 27.8%), appendiceal orifice lesions (three patients; 16.7%), T1 cancers (two patients; 11.1%), and subepithelial tumors (one patient; 5.5%). The median lesion size was 11 mm. The rates of technical success, en bloc resection, and R0 resection were 100%, 86.7%, and 86.7%. The median procedure time was 10 min. The only adverse event was diverticulitis (one patient; 5.5%). Intraoperative and delayed perforation and bleeding were not observed. The pathological resection depths were full-thickness for three patients (16.7%), muscularis resection for four patients (22.2%), and deep submucosal resection for 11 patients (61.1%).

Conclusion

Although EMR-O is limited by the target lesion size, it shortens the procedure time, prevents perforation, and avoids the need for surgery. EMR-O may be a minimally invasive treatment option for small lesions that are difficult to treat endoscopically.

Does endoscopic management have a role in chronic radiation proctopathy: A systematic review

AIM

Chronic radiation proctopathy (CRP) is a significant side-effect of radiotherapy, and poses a challenge in clinical management, necessitating effective and standardized therapeutic approaches. The aim of this review is to investigate the role of endoscopic interventions for CRP, focusing on argon plasma coagulation (APC) and formalin application.

METHOD

A literature search was undertaken for studies that investigated the clinical responses to endoscopic management in patients with CRP. A systematic review was performed in accordance with PRISMA guidelines, and a meta-analysis of proportions was conducted with a random-effects model. ROBINS-I and the Cochrane Collaboration's tool were used to assess risk of bias in cohort studies and randomized control trials, respectively.

RESULTS

A total of 82 studies met the inclusion criteria, including 11 randomized control trials, 20 systematic reviews, one cohort study and 50 case series. A robust 89% (95% CI 84%-92%, p < 0.01 and 95% CI 84%-93%, p = 0.03) pooled response rate was demonstrated for both APC and formalin therapies, respectively. Adverse effects were generally minimal.

CONCLUSION

Endoscopic therapies, particularly APC and formalin, exhibit commendable clinical response rates in the management of CRP. However, the lack of standardized treatment protocols highlights the need for larger prospective studies. Clear guidelines, informed by defined outcomes and quality-of-life assessments, are imperative for enhancing patient outcomes and minimizing the morbidity associated with CRP.

Linked color imaging and upper gastrointestinal neoplasia

White light imaging (WLI) can sometimes miss early upper gastrointestinal (UGI) neoplasms, particularly minimal changes and flat lesions. Moreover, endoscopic diagnosis of UGI neoplasia is strongly influenced by the condition of the surrounding mucosa. Recently, image-enhanced endoscopy techniques have been developed and used in clinical practice; one of which is linked color imaging (LCI), which has an expanded color range for better recognition of slight differences in mucosal color and enables easy diagnosis and differentiation of noncancerous mucosa from carcinoma. LCI does not require magnified observation and can clearly visualize structures using an ultrathin scope; therefore, it is useful for screening and surveillance endoscopy. LCI is particularly useful for detecting gastric cancer after Helicobacter pylori eradication, which accounts for most gastric cancers currently discovered, and displays malignant areas in orange or orange-red surrounded by intestinal metaplasia in lavender. Data on the use of convolutional neural network and computer-aided diagnosis with LCI for UGI neoplasm detection are currently being collected. Further studies are needed to determine the clinical role of LCI and whether it can replace WLI.

Efficacy of Magnifying Texture and Color Enhancement Imaging With Indigo Carmine as an Alternative to Crystal Violet for Colorectal Tumors

BACKGROUND

Pit pattern diagnosis using crystal violet staining for colorectal tumors is useful for qualitative and depth diagnosis. However, due to its reported carcinogenic potential, the use of crystal violet has been restricted. This study was aimed at investigating the efficacy of texture and color enhancement imaging (TXI) magnification in pit pattern diagnosis.

METHODS

This study enrolled consecutive patients with consent obtained and with colonic tumors indicated for magnifying endoscopy in which all modalities' images (magnified observation with crystal violet staining (CV), magnified white light observation with indigo carmine (IC-WLI), and magnified TXI observation with indigo carmine (IC-TXI)) were evaluable between July 2020 and January 2023. The visibility of the pit pattern using a 5-point Likert scale and its diagnostic accuracy were compared (IC-TXI vs. IC-WLI, reference: CV, by three experts).

RESULTS

A total of 145 colorectal tumors from 145 patients were included. Visibility scores for the pit pattern were significantly higher with IC-TXI compared to IC-WLI (all three experts, p < 0.0001). The pit pattern match rate (Type II/III/IV/V) of IC-TXI compared to CV was also superior to IC-WLI (72.9% vs. 59.7%; p = 0.02).

CONCLUSIONS

IC-TXI provided reasonably good and higher visibility and diagnostic accuracy than IC-WLI for pit pattern diagnosis of colorectal tumors compared to CV, suggesting it as an alternative to CV.

Role of Artificial Intelligence for Endoscopic Ultrasound

Endoscopic ultrasound (EUS) is widely used for the diagnosis of biliopancreatic and gastrointestinal tract diseases, but it is one of the most operator-dependent endoscopic techniques, requiring a long and complex learning curve. The role of artificial intelligence (AI) in EUS is growing as AI algorithms can assist in lesion detection and characterization by analyzing EUS images. Deep learning (DL) techniques, such as convolutional neural networks, have shown great potential for tumor identification; the application of AI models can increase the EUS diagnostic accuracy, provide faster diagnoses, and provide more information that can be helpful also for a training program.

Behind the Ink: Unmasking Asymptomatic Micro-perforations Following Endoscopic Tattooing

Endoscopic tattooing is a valuable tool for identifying gastrointestinal lesions following initial discovery during endoscopy. Although generally considered safe, with minimal complications, routine post-procedure imaging is not practiced, and the detection of micro-perforation after tattooing is even rarer. We present a case of a 49-year-old male who underwent a colonoscopy for a workup of anemia, revealing a malignant-appearing mass in the ascending colon. The lesion was tattooed for further assessment. A follow-up CT scan for evaluation of metastatic disease incidentally demonstrated acute inflammatory changes and trace gas, consistent with micro-perforation. The patient was asymptomatic and hemodynamically stable on supportive treatment, with subsequent successful recovery. Therefore, close observation without additional interventions could be considered in patients with incidental micro-perforations and no symptoms. A large-scale study is needed to further demonstrate the correlation between endoscopic tattooing and micro-perforations to avoid unnecessary extensive evaluation.

Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Endoscopic Papillary Balloon Dilation Versus Small Endoscopic Sphincterotomy for Endoscopic Retrograde Cholangiopancreatography-Related Adverse Events in Patients With Non-Dilated Distal Bile Duct

OBJECTIVE

Endoscopic papillary balloon dilation (EPBD), small endoscopic sphincterotomy (EST), and small EST plus EPBD are commonly used as rescue techniques to remove bile duct stones. However, we often encountered challenging cases with non-dilated distal bile ducts, especially in those undergoing EPBD. We aimed to explore the reasons by assessing whether patients without the dilated bile duct had a higher risk of early complications and whether it was impacted by the rescue techniques.

METHODS

We performed a retrospective cohort study by frequency matching design in patients diagnosed with stones in non-dilated distal bile duct who received rescue techniques from July 2016 to June 2022. Besides, patients with stones and without dilatation of the distal bile duct (DDBD) were divided into 3 subgroups according to the rescue technique received. Outcomes were compared between the subgroups.

RESULTS

The non-DDBD group was more likely to develop post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and hyperamylasemia (HP) than the DDBD group ( P < 0.05). Some cases had mild or moderate pancreatitis, but no one in either group developed severe pancreatitis. For subgroup analysis, each technique resulted in complete stone removal; the EPBD group had a higher HP rate than the other subgroups and reached statistical significance: the EPBD group versus the small EST group ( P = 0.013) and the EPBD group versus the EPBD plus small EST group ( P = 0.008). Although there was no statistical significance, PEP incidence in the EPBD group was 13.7% higher than in other subgroups ( P > 0.05/3).

CONCLUSION

Non-DDBD patients have a higher risk for endoscopic retrograde cholangiopancreatography-related pancreatic inflammation. EPBD should be used cautiously due to the significant association with increased rates of PEP and HP. Conversely, small EST and combination therapy are suitable for non-dilated bile duct stones because of their high safety profile and efficacy.

Impact of advanced endoscopy training on colonoscopy quality and efficiency

Objectives

Few reports have detailed improvements in the quality of colonoscopies with continuous training post-fellowship completion. We examined the changes in colonoscopy performance among trainees during our advanced endoscopy training program.

Methods

Screening or surveillance colonoscopies performed by 11 trainees who participated in our 3-year advanced endoscopy training program between April 2015 and March 2020 were retrospectively analyzed. Quality and efficiency metrics of colonoscopies were evaluated annually.

Results

Altogether, 297, 385, and 438 colonoscopies were enrolled in the first, second, and third training years, respectively. The mean insertion times were 8.6, 7.6, and 6.9 min in the first, second, and third training years, respectively, with significant improvement from the first to second year (p = 0.03) and from the first to third year (p < 0.01). The adenoma detection rate, proximal adenoma detection rate, and mean number of adenomas per patient exhibited a tendency to improve annually; however, the difference was not significant. Polypectomy efficiency was 10.5%, 11.2%, and 13.0%, with significant improvements from the first to third year (p < 0.01) and from the second to third year (p = 0.02). Insertion time and polypectomy efficiency showed significant improvements, especially among trainees experienced with <500 colonoscopies.

Conclusions

Through our advanced endoscopy training program, there has been an improvement in the quality and efficiency of colonoscopy for trainees who have completed their fellowships, particularly those with <500 colonoscopies.

Multi-Institutional Analysis of Pancreaticoduodenectomy for Nonfamilial Periampullary Adenoma: A Novel Risk Score to Guide Shared Decision-Making

BACKGROUND

Pancreaticoduodenectomy (PD) may occasionally be indicated for complete removal of periampullary (duodenal and ampullary) adenomas (PAs). As compared with malignant indications, PD for benign or premalignant disease is often associated with increased morbidity. Although the Spigelman classification assesses malignancy risk for familial adenomatous polyposis (FAP)-related duodenal adenomas, no malignancy risk score (MRS) exists for non-FAP-related PAs. We developed an MRS for non-FAP-related PAs undergoing PD to weigh the risk of malignancy and postoperative morbidity.

STUDY DESIGN

We retrospectively analyzed patients with non-FAP-related PA who underwent PD at 8 institutions (2010 to 2022). Patient and lesion factors associated with final malignant pathology were identified using multivariable logistic regression to create MRS. Postoperative complications were assessed according to MRS.

RESULTS

Of 127 patients, 59 (46.5%) had evidence of malignancy on final pathology. The odds of malignancy were higher in patients aged 65 years or older (odds ratio [OR] 3.2, p = 0.01), having bile duct 9 mm or more (OR 3.3, p = 0.009), having preoperative symptoms (OR 7.7, p = 0.002), and having high-grade dysplasia (OR 7.5, p < 0.001). A MRS was derived ranging from 0 to 6: age 65 years or older = 1, bile duct 9 mm or more = 1, symptomatic = 2, and high-grade dysplasia = 2. Patients were stratified into low-risk (MRS 1 to 2, n = 26), intermediate-risk (MRS 3 to 4, n = 59), and high-risk groups (MRS 5 to 6, n = 26), with malignancy rates increasing with MRS (10.3%, 44.1%, and 88.2%, p < 0.001). Patients in the no- or low-risk group (MRS 0 to 2) had higher odds of major postoperative complications compared with patients in the intermediate- or high-risk group (MRS 3 or higher, OR 2.9, p = 0.047).

CONCLUSIONS

This novel MRS stratifies the risk of malignancy in non-FAP-related PAs managed with PD. This score can be used to counsel patients who may require PD for complete tumor removal about their risk of harboring malignancy and their risk of major postoperative complications.

Beyond visualizing the bird beak: esophagram, timed barium esophagram and manometry in achalasia and its 3 subtypes

Achalasia is a rare esophageal motility disorder characterized by lack of primary peristalsis and a poorly relaxing lower esophageal sphincter. This disease process can be examined several ways and these evaluations can offer complementary information. There are three manometric subtypes of achalasia, with differing appearances on esophagram. Differentiating them is clinically important, because treatment for the subtypes varies. Timed barium esophagram (TBE) is a simple test to quantitatively evaluate esophageal emptying. TBE can be used to diagnose achalasia and assess treatment response. Considerable variation in the TBE protocol exist in the literature. We propose a standardized approach for TBE to allow for comparison across institutions.

A systematic review and meta-analysis of factors associated with esophageal stent migration and a comparison of antimigration techniques

BACKGROUND

Esophageal stents are effective in managing various pathologies. However, they are limited by their most common complication: migration. This study aimed to present the largest comprehensive review of the risk factors associated with stent migration and the interventions leveraged to prevent stent migration.

METHODS

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were primary data sources (no systematic reviews), ≥18 years of age, esophageal stent placement, and reported indication for intervention, site of placement, and migration rate. A total of 162 studies met the inclusion criteria. Proportions experiencing migration were pooled using a random-effects model with a DerSimonian-Laird estimator to account for potential heterogeneity, and forest plots were used to visualize the treatment effects across studies.

RESULTS

A total of 14,092 patients were included in the analysis. The mean migration rate across all studies and stent types was 17.2%, and the mean reintervention rate was 83.2%. Cancerous indications, benign strictures, history of esophageal surgery, stent diameter of <20 mm, plastic stents, and fully covered stents were associated with significantly higher migration rates. There was a trend toward stents using antimigration technology having lower migration rates (effect size [ES] = 0.15; 95% CI, 0.10-0.20) than those that did not (ES = 0.33; 95% CI, 0.18-0.48). However, this difference was not significant. There were no statistically significant differences among the stent fixation strategies (clips, sutures, wire hooks, and Shim technique).

CONCLUSION

Several risk factors are associated with stent migration. However, no currently available solutions can significantly reduce stent migration. Further optimization of these devices or the creation of new technology to prevent migration is required.

Neuroendocrine tumors and diabetes mellitus: which treatment and which effect

Diabetes mellitus (DM) and neuroendocrine tumors (NET) can exert unfavorable effects on each other prognosis. In this narrative review, we evaluated the effects of NET therapies on glycemic control and DM management and the effects of anti-diabetic therapies on NET outcome and management. For this purpose, we searched the PubMed, Science Direct, and Google Scholar databases for studies reporting the effects of NET therapy on DM as well as the effect of DM therapy on NET. The majority of NET treatments appear to impair glycaemic control, both inducing hypoglycemic or, more commonly, hyperglycemia and even new-onset DM. However, glucose metabolism imbalance can be effectively managed by modulating anti-diabetic therapy and adopting an appropriate nutritional approach. On the other hand, the effects of anti-diabetic treatment, like insulin, sulfonylureas, thiazolidinediones, ipeptidyl-peptidase-4 inhibitors, Glucagon-like peptide-1 receptor agonists, and Sodium-glucose cotransporter-2 inhibitors on NET are unclear. Recently, metformin has been investigated in patients with gastroenteropancreatic NET resulting in improved progression free survival suggesting a potential antineoplastic role. Finally, the management of DM in patients with NET is of great clinical relevance to correctly perform radiological procedures and even more functional imaging procedures, as well as to optimize the therapy and avoid treatment withdrawal or discontinuation. In conclusion, understanding the mechanisms underlying therapy-induced DM and implementing appropriate monitoring and management strategies of DM are essential for optimizing NET patient outcome and quality of life.

A Rare Case of Gastric Fundal Vascular Ectasia: A Unique Presentation and Diagnostic Challenge

A 75-year-old male patient was admitted with a two-week history of melena on a background of psoriatic arthritis and chronic iron-deficiency anaemia. Initial bloods confirmed acute-on-chronic anaemia with evidence of ongoing bleeding as the hemoglobin consistently dropped to 77g/L from 84g/L. After resuscitation which included giving a unit of blood transfusion, an urgent endoscopy revealed moderate gastric fundal vascular ectasia (GFVE) with active bleeding from three points and mild gastric antral vascular ectasia with no bleeding. Pulsed Argon-Plasma coagulation was successfully applied during endoscopy immediately, achieving haemostasis. Small Grade-2 oesophageal varices without bleeding were also noted. Subsequent imaging confirmed new liver cirrhosis with CHILD-PUGH scoring of 6 falling into category A, which was under investigation as outpatient. The patient's haemoglobin stabilized post-endotherapy with significant symptoms improvement and he was also given intravenous iron infusion. No further gastrointestinal bleeding event was noted until the writing of this article.

The role of four-dimensional flow MRI as an adjunct to endoscopy for predicting variceal bleeding in patients with cirrhosis

BackgroundNon-invasive approach other than conventional endoscopy could be effectively used for screening and monitoring esophageal variceal bleeding (EVB).PurposeTo retrospectively investigate the role of four-dimensional (4D) flow magnetic resonance imaging (MRI) as an add-on tool to endoscopy for predicting EVB in cirrhotic patients with esophageal varices (EVs).Material and MethodsA cohort of 109 cirrhotic patients with EVs was divided into four groups: A = negative red color [RC] sign, no EVB, n = 60; B = negative RC sign, EVB, n = 13; C = positive RC sign, no EVB, n = 10; and D = positive RC sign, EVB, n = 26. All patients underwent laboratory assessments and 4D flow MRI using a 3-T scanner to analyze hemodynamic parameters within the main portal vein (PV), splenic vein, and superior mesenteric vein. Comparative analysis of 4D flow parameters among the groups was performed using the Mann-Whitney U-test, and diagnostic accuracy was assessed through the area under the receiver operator characteristic curve (AUC).ResultsIn the main PV, all 4D flow parameters were significantly lower in patients with a positive RC sign compared to those with a negative RC sign (P < 0.05). Patients with EVB had lower parameters than those without EVB (P < 0.05). The AUC values predicting actual variceal bleeding was 0.762 for endoscopy alone and 0.770-0.787 for 4D flow MRI. Integrating the endoscopic classification with the 4D flow MRI significantly improved the AUC value to 0.871 (P < 0.05).ConclusionFour-dimensional flow MRI may be useful as an add-on tool to endoscopy for predicting actual bleeding in cirrhotic patients with EVs.

Lumen-apposing metal stents provide early and late clinical benefits for the management of benign gastrointestinal strictures: Is there a role for definitive therapy?

Objectives

This study aimed to characterize the clinical outcomes, safety, and efficacy of lumen-apposing metal stents (LAMS) in treating benign gastrointestinal strictures.

Methods

A single-center retrospective review of all patients who underwent LAMS placement for benign strictures from June 2017 to July 2023. Primary outcomes were technical success, early clinical success, late clinical success (LCS), and sustained post-LAMS clinical success (SPLCS). Secondary outcomes included stent dwell time, stenosis changes, adverse events, reintervention rates, and symptomatology evaluation.

Results

Thirty-five patients underwent placement of 42 LAMS (74% female, mean age: 54.2 ± 11.7 years). Anastomotic strictures accounted for 64% of cases (N = 27, 45% at the gastrojejunal anastomosis). The median STD was 91.0 days (interquartile range [IQR]: 55.0-132.0). Technical success was obtained in all cases. Early clinical successand LCS were achieved in 80% of cases overall. SPLCS was achieved in 45% (n = 15) of cases. The overall reintervention rate was 63%, with a median time to reintervention being 50.5 days (IQR: 24-105). adverse events occurred in 28% (n = 12) overall, with a 24% migration rate (n = 10). Follow-up was completed in 83% of cases with a median duration of 629 days (range: 192.0-1297.0). Overall symptom improvement occurred in 79% (n = 27) during indwelling LAMS versus 58% and 56% at 30- and 60-days post-removal, respectively.

Conclusions

LAMS for benign gastrointestinal strictures are associated with high technical and early clinical success/LCS rates, positive quality-of-life metrics, and a tolerable adverse event rate. Overall, recurrence of symptoms and high reintervention rates post-LAMS removal reinforce the difficulty in managing benign gastrointestinal strictures but also argue for LAMS as a definitive therapy in select cases.

Impact of HPV status on oropharyngeal cancer detection via gastrointestinal endoscopy: a retrospective study

BACKGROUND

Gastrointestinal endoscopy (GIE) performed by gastroenterologists is essential for the early detection of pharyngeal cancer. Human papillomavirus (HPV) is a significant cause of oropharyngeal squamous cell carcinoma (OPSCC). However, the prevalence of HPV-related OPSCC detected by GIE remains unclear.

AIM

This study aims to evaluate the differences in detection rates, patient characteristics, and treatment approaches between HPV-positive and HPV-negative OPSCCs, with a focus on the role of GIE in early diagnosis.

METHODS

We retrospectively analyzed 207 OPSCCs from 2018 to 2022, where HPV infection was diagnosed by p16 immunohistochemistry. We compared detection modalities and evaluated the proportion of lesions detected by GIE in both p16-positive and p16-negative cases.

RESULTS

Out of the 207 patients, 92 (44.4%) were p16-positive. p16-positive cases had significantly lower rates of alcohol use, smoking, and history of esophageal or head/neck squamous cell carcinoma (all p < 0.001). Only 4.3% of p16-positive cases were detected by GIE, compared to 44.3% of p16-negative cases (p < 0.001). In addition, p16-positive patients were often diagnosed at advanced stages and underwent transoral resection less frequently (2.2% vs. 31.3%, p < 0.001). In cT1 cases, GIE and laryngoscopy revealed that p16-positive lesions were typically protruding and white to normal-colored, while p16-negative lesions were predominantly flat and erythematous.

CONCLUSIONS

HPV-related OPSCC cases are rarely detected by GIE, and few cases are treated with minimally invasive transoral resection. These findings highlight the need for enhanced detection strategies for HPV-positive OPSCC.

Recognition of refractory benign esophageal strictures at index endoscopy: creation of a predictive model

BACKGROUND AND AIMS

Refractory benign esophageal strictures (RBESs) are defined by an inadequate response to dilation. Early recognition of RBESs allows for earlier initiation of aggressive therapy, potentially leading to less morbidity and cost. We sought to establish a predictive model for RBESs.

METHODS

Patients who underwent EGD with esophageal dilation at Mayo Clinic Rochester were identified. In addition, a cohort of patients from a clinical database of patients with RBESs managed with self-dilation was identified. Malignant strictures, Schatzki's rings, and previously treated strictures were excluded. RBES was defined by the inability to maintain a diameter ≥14 mm over 5 dilation sessions. Multivariable logistic regression models were built to predict RBESs.

RESULTS

Of 128 identified patients with an index EGD and esophageal dilation, 25 met the RBES criteria. An additional 63 RBES patients were identified from the self-dilation cohort for a total of 88 RBES and 103 non-RBES patients. Multivariable analysis yielded a strong predictive model, with a c-statistic of .85, identifying stricture length ≥2 cm, diameter ≤7 mm, and proximal or diffuse stricture location as associated with a higher risk for RBESs. Patients without any of these risk factors had a 2% risk of RBESs, whereas those with all 3 risk factors had a risk of 73% for RBESs.

CONCLUSIONS

Risk of RBESs can be predicted at the index EGD based on stricture features. A predictive model for RBESs was created based on readily available risk factors, which may guide an individualized therapeutic approach to patients with benign esophageal strictures, potentially reducing morbidity and cost.

Effect of Cholecystectomy on Bubble Formation and Endoscopic Visualization: A Retrospective Cohort Study

PURPOSE

This study aimed to evaluate the association between cholecystectomy and colonic bubble formation during colonoscopy, METHODS: A single-center retrospective cohort study was conducted at Staten Island University Hospital. Researchers reviewed 348 colonoscopy reports, comparing patients with (n = 56) and without (n = 292) a history of cholecystectomy. Colonic bubble formation was assessed using a 0-3 scale (0 = no bubbles, 3 = severe bubbles). Secondary endpoints included polyp and adenoma detection, withdrawal and procedure times, bowel preparation quality, and repeat procedures. Statistical analysis included t-tests, Mann-Whitney U tests, and χ2 tests.

RESULTS

Patients with prior cholecystectomy had significantly higher incidence of severe bubble formation (score 3; 28.6% vs. 12%, p = 0.001), longer withdrawal times (18 ± 8 vs. 15 ± 5 min, p = 0.024), and increased need for repeat colonoscopies (10.7% vs. 2.1%, p = 0.001). No significant differences were found in adenoma detection, polyp detection, or bowel preparation quality between the two groups.

CONCLUSION

Cholecystectomy is associated with increased colonic bubble formation during colonoscopy, leading to longer withdrawal times and higher rates of repeat procedures. While this study did not find a difference in adenoma detection rates, the impaired visualization caused by bubbles may necessitate tailored bowel preparation strategies for patients with a history of cholecystectomy to optimize colonoscopy effectiveness.

Aetiology and Feasibility of Endoscopic Interventions for Massive Upper Gastrointestinal Bleeding in Makurdi, North-Central Nigeria

Introduction

Massive upper gastrointestinal bleeding (UGIB) is a life-threatening emergency with high mortality. Emergency upper gastrointestinal (GI) endoscopy, endotherapy, interventional radiology, and surgery are necessary to control the bleeding source and restore normal physiology. However, these interventions are suboptimal in most centres in Nigeria, contributing to the dismal mortality observed in this condition.

Objectives & Methodology

We aimed to determine the aetiology, feasibility of endoscopic intervention, and outcome of management of massive UGIB in Madonna Hospital, Makurdi, over a 30-month-period by retrospectively reviewing the medical and procedural records of patients presenting with hypotension from an endoscopically diagnosed upper GI bleeding source.

Result

A total of 39 patients were identified, with a mean age of 49.3 ± 17.7 years. Among them, 27 were males (69.2%) and 12 were females (30.8%). Bleeding peptic ulcers were the cause of massive UGIB in 21 cases (53.8%), followed by variceal bleeding, observed in 10 (25.6%) cases. Most of these cases were amenable to endoscopic treatment using adrenaline injection, endoclips, endoscopic variceal band ligation, and diathermy fulguration. Thirty-three (84.6%) patients survived, while the in-hospital mortality following initial endoscopic intervention was 6 out of 39 patients (15.4%), which is comparable to figures from more advanced climes.

Conclusion & Recommendation

Endoscopic management of massive UGIB is feasible in a low-resource setting. However, timely access to emergency endoscopy is vital to reduce mortality. Strategies to reduce risk factors for peptic ulcers and oesophageal varices are necessary to reduce the incidence of massive UGIB in Makurdi, Nigeria.

Evaluation of the Susceptibility of Bangladeshi University Students to Gastroesophageal Reflux Disease (GERD) and Its Associated Factors: A Cross-Sectional Study

Background and Aims

Gastroesophageal reflux disease (GERD) is a highly prevalent clinical condition all over the world. The study was conducted to determine the GERD prevalence among Bangladeshi university students using the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG) score and to find out what factors are linked to the disease.

Methods

The study was based on descriptive cross-sectional analysis. After a comprehensive literature review, a questionnaire was developed with some pre-structured options kept in the sociodemographic, dietary, and lifestyle sections along with the FSSG parameters. The tool was disseminated among students of different universities in Bangladesh. After receiving the responses, all the data was analyzed using SPSS software (version 26.0).

Results

After scrutiny, 402 responses of the study participants were subjected to statistical analysis, and among participants, 57.2% (N = 230) were female and 42.8% (N = 172) were male. The GERD prevalence was 45.5% (N = 183), which indicated the FSSG score was more than 8 among 45.5% of the individuals. Logistic regression analysis revealed that eating beyond fullness (OR = 2.859, CI = 1.811-4.515), consumption of painkillers (OR = 2.237, CI = 1.370-3.653), anxiety (OR = 2.349, CI = 1.529-3.611), being stressed (OR = 2.255, CI = 1.456-3.494), quick eating habit (OR = 1.845, CI = 1.240-2.745), poor sleep quality (OR = 1.760, CI = 1.183-2.620), fast food consumption (OR = 1.613, CI = 1.082-2.404), eating sour and spicy food regularly (OR = 1.610, CI = 1.073-2.415), female gender (OR = 1.595, CI = 1.068-2.381), less interval between dinner and sleep (OR = 1.561, CI = 1.020-2.389), being alone most of the time (OR = 1.514, CI = 1.016-2.257), were significantly associated with the occurrence of GERD symptoms.

Conclusion

GERD symptoms were seen among a large number of university students. Various sociodemographic, dietary, and lifestyle-related factors had an impact on the disease; these contributing factors should be positively modified to alleviate the burden of GERD symptoms.