The importance of intensive follow-up and achieving optimal chronic antithrombotic treatment in hospitalized medical patients with anemia: A prospective cohort study

BACKGROUND

Anemia is a global health concern, particularly among the elderly on chronic antithrombotic treatment. Close monitoring of hemoglobin (Hb) levels and achievement of an optimized treatment significantly enhance patients' quality of life. This study aimed to examine the impact of antithrombotic treatment on Hb levels and readmissions in hospitalized patients with anemia.

METHODS

This is a prospective cohort study of patients admitted to the Department of Internal Medicine of the University Hospital of Heraklion, Greece, from November 2021 to October 2022 with the diagnosis of anemia while receiving antithrombotic treatment. Data regarding demographics, past medical history, and laboratory and endoscopy findings were recorded. For those receiving inappropriate therapy according to international guidelines, antithrombotic treatment was optimized. Subsequent follow-ups occurred at one and six months post-discharge. Six- and twelve-month anemia-caused readmissions, as well as annual mortality, were evaluated.

RESULTS

In total, 104 patients were assessed. Among them, 34.6% were on antiplatelets, 56.7% were on anticoagulants, and 8.7% were on combination treatment. The mean age was 80 ± 8.2 years, and 54.8% were males. On admission, mean Hb levels were 6.86 ± 1.23 g/dL, while 56 (53.8%) patients had severe anemia. Gastroscopy and colonoscopy were performed in 75.0% and 41.4% of patients, respectively, confirming gastrointestinal bleeding in most of the cases. Treatment optimization was carried out for 56 patients. Follow-up revealed elevated Hb levels after one and six months post-discharge, while anemia-related readmissions stayed below 10%.

CONCLUSIONS

Most hospitalized anemic patients on antithrombotic treatment had endoscopic findings favoring gastrointestinal bleeding. Half received inappropriate antithrombotic therapy. Treatment optimization and regular follow-up improved Hb levels and reduced readmissions.

Tissue Remodeling for a More Homogenous Ablation in Transoral Outlet Reduction Using Suturing and Noncontact Argon Plasma Coagulation

The study is the first to assess the argon-plasma coagulation ArC Smart linear beam for mucosal ablation in transoral outlet reduction for weight regain after Roux-en-Y gastric bypass. The noncontact design of the linear beam can enhance tissue healing and remodeling of gastrojejunal anastomosis by causing a uniform scarring with minimal tissue injury. We followed patients for 45 days, during which none experienced gastrointestinal bleeding, stenosis, or ulcers, reporting 9.8% average of total body weight loss. The ArC Smart beam may offer a safer, more effective alternative to traditional argon-plasma coagulation for transoral outlet reduction, with better reduction in weight loss, although comparative studies are needed.

Flexible endoscopic treatment of Zenker's diverticulum: a retrospective study in a single center from Turkey

BACKGROUND/AIMS

We aimed to contribute to the literature by sharing the findings of patients treated by cricopharyngeal myotomy with a flexible endoscopic septal division.

METHODS

This retrospective study included patients with Zenker's diverticulum who underwent cricopharyngeal myotomy with a traditional flexible endoscopic septal division at our center. Clinical success was defined as a significant reduction in dysphagia score, and relapse was defined as an increase in dysphagia score occurring at any time over 1 month after the procedure.

RESULTS

Fifteen patients with symptomatic Zenker's diverticulum were treated with 16 cricopharyngeal myotomies. A dysphagia score of 100% indicated clinical success, but three (20%) of the patients experienced recurrence during follow-up.

CONCLUSIONS

While advances in interventional flexible endoscopy have opened doors for novel treatments, cricopharyngeal myotomy based on traditional flexible endoscopic septal division remains a reliable approach for treating Zenker's diverticulum.

Results of Endoscopic Treatment of Recurrent Malignant Biliary Obstruction in Patients with Self-Expanding Metal Stents

BACKGROUND AND AIM

Endoscopic biliary drainage with placement of a self-expanding metal stent (SEMS) is the preferred palliative treatment of malignant biliary obstruction. Recent advances in the treatment have prolonged survival, thus, increasing the chance of recurrent biliary obstruction (RBO) after SEMS placement. The aim of this study was to compare different endoscopic approaches in patients with a SEMS and RBO, regarding clinical success and time to RBO.

METHODS

This retrospective study included all patients with a SEMS placed because of malignant biliary strictures who underwent endoscopic retrograde cholangiopancreatography between January 2011 and December 2018. We evaluated the results of different endoscopic interventions to RBO, including insertion of a new SEMS, stent cleaning, and insertion of a plastic stent (PS).

RESULTS

From January 2011 to December 2018, 70 (22.4%) patients developed RBO requiring endoscopic reintervention (n = 105 sessions). From the 105 ERCPs, technical success, clinical success, and adverse events rates were 91,4%, 71,8%, and 7,8%, respectively. Younger age (OR = 1.11 95%CI: 1.03-1.19) and the finding of a patent SEMS (OR = 0.17 95%CI: 0.04-0.08) were predictors of clinical failure (P = 0.006 and P = 0.024, respectively). The mean patency time (in days) after endoscopic reintervention was greater for SEMSs than for PSs (417.2 [95% CI: 250.0-584.4] vs 175.2 [95% CI: 124.0-226.5], P = 0.002).

CONCLUSIONS

Correct identification and treatment of the causal factor of RBO typically lead to technical and clinical success. Placement of a second SEMS provides longer patency compared to a plastic stent if ingrowth (overgrowth) occurs.

Selection methods for endoscopic ultrasound‑guided biliary drainage cases that are appropriate for beginners

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is performed as a second drainage method when endoscopic retrograde cholangiopancreatography-guided biliary drainage fails. There are several severe adverse events in EUS-BD, and avoiding technical failure is desirable. Although EUS-BD is a skilled endoscopic treatment, the appropriate conditions for EUS-BD beginners are not well known. The present study aimed to clarify the appropriate cases for EUS-BD beginners. The present retrospective cohort study included patients with malignant biliary obstruction who underwent EUS-BD, which was performed by beginners between March 2005 and June 2024. Factors associated with successful EUS-BD performed by beginners were evaluated by multivariate logistic regression analysis. The performance of each factor was evaluated via a receiver operating characteristic (ROC) curve. According to multivariate analysis, the diameter of the punctured bile duct was associated with successful EUS-BD performed by beginners (odds ratio, 1.34; 95% CI, 1.03-1.75; P=0.031). The area under the ROC curve for the diameter of the punctured bile duct was 0.79, and the cutoff value was 6.7 mm (71% sensitivity and 81.8% specificity). The diameter of the punctured bile duct might be associated with successful EUS-BD procedures performed by beginners. When a beginner performs EUS-BD, a diameter of the targeted bile duct >6.7 mm might be desirable for successful procedures.

Ultrasound-assisted enhancement of bioactive compounds in hawthorn vinegar: A functional approach to anticancer and antidiabetic effects

In this study, the effects of ultrasound treatment on bioactive components and functional properties of hawthorn vinegar (Crataegus tanacetifolia) were investigated. Parameters such as total phenolic compound (TPC), total flavonoid content (TFC), ascorbic acid (AA), DPPH radical scavenging activity and CUPRAC reducing capacity were optimised by surface response method (RSM) and 14 min duration and 61.40 % amplitude were determined as the most suitable treatment conditions. The results showed that ultrasound treatment improved the antioxidant properties of hawthorn vinegar by increasing TPC, TFC, DPPH and CUPRAC values. In addition, it was observed that hawthorn vinegar samples exhibited anticancer effects in cell culture experiments. In experiments on A549 (lung), MCF-7 (breast) and HT-29 (colon) cancer cell lines, ultrasound-treated vinegar increased apoptotic effects, suppressed cell migration and reduced necrosis rates in some cell lines. In particular, ultrasound treatment of vinegar resulted in a reduction in the expression of anti-apoptotic genes (BCL-2 and XIAP) and an enhancement in the expression of pro-apoptotic genes (BAX). These findings suggest that ultrasound technology preserves and enhances the bioactive components of hawthorn vinegar, improves its anticancer properties and increases its potential for use as a functional food product.

Focal pancreatic parenchymal atrophy could be a precursor of pancreatic cancer

BACKGROUND/OBJECTIVES

We previously reported that focal pancreatic parenchymal atrophy (FPPA) indicates high-grade pancreatic intraepithelial neoplasia (HG-PanIN) or carcinoma in situ (CIS). Because HG-PanIN progresses into pancreatic ductal adenocarcinoma (PDAC), the relationship between FPPA and PDAC should be investigated.

METHODS

We included 54 patients with PDAC, whose previous computed tomography or magnetic resonance imaging were reviewed. The existence, positional relationship between FPPA and PDAC, and time between FPPA recognition and PDAC diagnosis were all examined. Of the 54 patients, 28 underwent surgery. The remaining 26 patients were histopathologically diagnosed with PDAC using endoscopic ultrasonography-guided fine needle aspiration.

RESULTS

Among the 54 patients included, 49 (83.3 %) had FPPA. The pancreatic head and body were the common sites of FPPA. In all patients with FPPA, PDAC developed near the FPPA, with an average distance of 7.93 mm between the edge of the FPPA and the center of the PDAC. The interval between FPPA recognition and PDAC diagnosis was 35.33 months, which was significantly shorter in the surgical group.

CONCLUSIONS

FPPA could be a precursor of PDAC and suggest the area at risk of PDAC.

Short-term outcome of endoscopic submucosal dissection using a clutch cutter for subepithelial lesions within the esophagogastric submucosa: a Japanese prospective observational study

BACKGROUND/AIMS

The efficacy and safety of endoscopic submucosal dissection using a clutch cutter (ESD-CC) for subepithelial lesions within the esophagogastric submucosa (SELEGSM) has not been investigated. This study aimed to assess the efficacy and safety of ESD-CC for the treatment of SELEGSM.

METHODS

This prospective study included 15 consecutive patients with 18 SELEGSMs diagnosed by endoscopic ultrasonography. The primary outcomes were short-term outcomes including en bloc resection rate, R0 resection rate, procedure time, and complication rate. The secondary outcome was final histological diagnosis.

RESULTS

Among the participants, 18 lesions were identified: 12 in the stomach (nine patients) and six in the esophagus (six patients). The en bloc resection rate was 94.4% (17/18). The R0 resection rate was 88.9% (16/18). The median operating time was 39 min, and no instances of perforation or bleeding were observed. The final diagnoses of SELEGSM included six neuroendocrine tumors (33.3%), six granular cell tumors (33.3%), two ectopic pancreases (11.1%), one inflammatory fibroid polyp (5.6%), one leiomyoma (5.6%), one lipoma (5.6%), and one leiomyosarcoma (5.6%).

CONCLUSIONS

ESD-CC appears to be a technically efficient and safe approach for SELEGSM resection, suggesting its potential as a valuable treatment option.

Management of Pancreatic Duct Strictures, Leaks, and Disconnected Pancreatic Duct Syndrome

Pancreatic duct (PD) strictures, leaks, and disconnected ducts are important morphologic consequences of inflammatory disease of the pancreas, resulting in abdominal pain, pancreatic ascites, pancreatic pleural effusion, and external pancreatic fistula. Traditionally, these PD complications were treated surgically, but a better understanding of their pathophysiology, along with advancement in endoscopic interventions, has transformed the therapy from morbid surgical interventions to minimally invasive, safe, and effective endoscopic treatment. This review discusses the current diagnostic and management strategies for PD strictures, leaks, and disconnected pancreatic ducts.

A case of gastric duplication cyst in an 18-year-old female

INTRODUCTION

Gastric duplication cysts (GDCs) are rare congenital anomalies, usually diagnosed in childhood, but can occasionally present in adults with non-specific symptoms such as abdominal pain, nausea, vomiting, and dysphagia. Advanced imaging, particularly endoscopic ultrasonography (EUS), plays a crucial role in diagnosis, while surgical or endoscopic resection is the definitive treatment.

PRESENTATION OF CASE

An 18-year-old female with no significant medical history presented with recurrent epigastric pain radiating to the back, abdominal fullness, heartburn, and difficulty swallowing solid foods for one month. Upper endoscopy revealed a gastric mass, and EUS identified a 30 - 28 mm cystic lesion adjacent to the stomach fundus. Fine-needle aspiration confirmed the diagnosis of a gastric duplication cyst. The patient underwent successful endoscopic unroofing, leading to symptom resolution.

CLINICAL DISCUSSION

GDCs in adults are uncommon and often present with vague gastrointestinal symptoms, making diagnosis challenging. Imaging modalities such as EUS and fine-needle aspiration are essential for differentiation from other gastric lesions, including gastrointestinal stromal tumors and pancreatic cysts. Traditional management involved surgical resection, but endoscopic approaches, such as unroofing, offer a less invasive alternative with favorable outcomes.

CONCLUSION

This case emphasizes the need for GDCs to be considered in the differential diagnosis of gastric masses. Early identification with EUS and minimally invasive intervention, such as endoscopic unroofing, can effectively resolve symptoms and prevent complications.

Lithobezoar and Phytobezoar Causing Intestinal Obstruction: A Report of Two Cases

Concretion or mass formed of exogenous undigested material in the gastrointestinal tract is called bezoar. Bezoar is a rare condition and can present with clinical features ranging from recurrent abdominal pain to acute presentation with obstruction or gastrointestinal bleeding. Preoperative diagnosis is usually done by imaging studies. They are treated with endoscopic or surgical removal of the bezoar along with treatment of complications and underlying illness. Here, we present two cases of bezoars: first, a case of a duodenal lithobezoar in 35-year-old male who presented with features of gastric outlet obstruction. He was found to have duodenal stricture and multiple small lithobezoars in the stomach and duodenum. The bezoars were removed by laparotomy and gastrotomy; and gastrojejunostomy was done to bypass the stricture. The second was a jejunal phytobezoar in 42-year-old male who presented with jejunal obstruction. Laparotomy and resection of the involved segment of jejunum and end-to-end anastomosis were done. Both the patients improved without postoperative complications.

Development and validation of a preoperative nomogram for predicting gallbladder adenoma

BACKGROUND

Gallbladder cholesterol polyp (GCP) and gallbladder adenoma (GA) are easily confused in clinical diagnosis. This study aims to establish a nomogram prediction model for preoperative prediction of the risk of GA patients.

STUDY DESIGN

We retrospectively collected clinical data of GCP or GA patients who underwent laparoscopic cholecystectomy (LC) between January 2020 and April 2023. We compared and analyzed the differences between the GCP group and the GA group. The data were divided into a training set and a validation set in a 7:3 ratio. Independent risk factors were determined using LASSO and Logistic regression analysis, and a nomogram model was established. The model was comprehensively validated and evaluated using the area under the ROC curve (AUC), Hosmer-Lemeshow test and clinical decision curve analysis (DCA).

RESULTS

This study ultimately included 497 patients. The independent predictors of the nomogram model include blood type (O-type blood, OR 2.00, 95% CI 1.02-3.94; P = 0.046), number of lesions (solitary, OR 2.11; 95% CI 1.08-4.12; P = 0.033), sessile polyp (OR 2.04; 95% CI 1.06-3.92; P = 0.033), age (OR 1.10; 95% CI 1.07-1.20; P < 0.001), diameter (OR 1.30; 95% CI 1.17-1.45; P < 0.001). For the training and validation set, the area under the ROC curve (AUC) was 0.843 and 0.837, respectively, and the P-value for the Hosmer-Lemeshow test was 0.056 and 0.300, respectively. In addition, the calibration curve and DCA curve indicate that the model has accurate predictive ability and reliable clinical practicality.

CONCLUSIONS

The blood type, number of lesions, sessile polyp, age and diameter are significant risk factors for GA. This nomogram model can use simple and readily available clinical data to predict the risk of having GA and can assist in guiding surgical decisions.

Balloon-assisted enteroscopy in the management of adult small-bowel intussusception: a comparative analysis of with and without double-balloon enteroscopy

BACKGROUND

Adult small-bowel intussusception (ASI) is a rare condition with pathological etiologies in most patients. Previously, surgical intervention was the primary treatment modality; however, the introduction of balloon-assisted enteroscopy (BAE) has allowed preoperative BAE in some cases to confirm the leading point, thereby guiding management and reducing surgical need. In this study, we investigated whether the introduction of BAE has altered the diagnostic and therapeutic strategies for ASI by retrospectively analyzing and comparing the clinicopathological features of patients before and after its introduction.

METHODS

Fifty-three patients with ASI, initially diagnosed via abdominal computed tomography scanning at Korea University Guro Hospital from 2000 to 2023, were included in our study. Patients were grouped based on double-balloon enteroscopy (DBE) usage, and clinicopathological outcomes were compared retrospectively.

RESULTS

Of the 53 patients, 38 (71.7%) had enteroenteric-type intussusception and 15 (28.3%) had enterocolic-type intussusception. Among the patients with enteroenteric-type intussusception, 15.8% had a malignant cause, whereas in the enterocolic type, 60% had a malignant cause (p = 0.001). Of 38 patients with enteroenteric ASI, 15 (39.5%) underwent preoperative DBE. The surgical resection rate was significantly lower in the DBE group (40%) than in the non-DBE group (73.9%) (p = 0.037). Pathological diagnoses of patients who underwent surgical resection without preoperative DBE revealed 17.6% malignancies and 82.4% benign causes, including idiopathic intussusception (four cases) and Peutz-Jeghers syndrome (two cases). No morbidity, mortality, or recurrence was observed.

CONCLUSION

Preoperative BAE is a valuable diagnostic and therapeutic modality for ASI, particularly in cases of low-grade small-bowel obstruction, reducing surgical resection rates in most ASI cases. The introduction of the BAE has significantly improved ASI management, achieving high successful reduction rates and few surgical interventions. BAE should be considered a first-line diagnostic and therapeutic tool for ASI management.

Utility of endoscopy in paediatric gastroenterology and hepatology-Review and updates

Paediatric endoscopy has been an integral part of the diagnostic evaluation and management of gastroenterology and hepatology diseases in children. This area of clinical medicine has made meteoric advancements since it was first introduced conserving it's traditional roles of gastroscopy and colonoscopy but broadening significantly it's clinical utility and diagnostic accuracy with new and emerging technology. This article aims to explore and review the current utility and emerging applications of diagnostic and therapeutic endoscopy for the practicing paediatric gastroenterologist and hepatologist.

Diagnostic ability and adverse events of mucosal incision-assisted biopsy for gastric subepithelial tumors: Systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to evaluate the diagnostic ability and examine the efficacy of countermeasures to adverse events of mucosal incision-assisted biopsy (MIAB) for gastric subepithelial tumors (SETs).

METHODS

We performed a literature search and identified 533 relevant articles. Eleven articles, including 339 lesions, were ultimately used in the meta-analysis. The primary end-point was the pathological diagnostic rate of MIAB for gastric SETs, and the secondary end-point was the incidence of adverse events. The efficacy of acid secretion inhibitors in preventing postoperative bleeding and that of local injection before incision to prevent perforation were also examined.

RESULTS

Nine studies were conducted in Japan and two in South Korea, of which only two were prospective studies. The pooled pathological diagnostic rate of MIAB for gastric SETs was 87.8% (95% confidence interval [CI] 80.2-94.0; I2 = 68.7%). The adverse event rate of the pooled population was 0.2% (95% CI 0-1.4; I2 = 0%). The acid secretion inhibitors significantly reduced postoperative bleeding (odds ratio 0.06, 95% CI 0.01-0.66, P = 0.02). Perforation occurred in 0% and 2.6% of the local and nonlocal injection cohorts, respectively, and the pathological diagnostic rates were 50% and 66.7%, respectively.

CONCLUSIONS

MIAB is a reliable technique with a favorable diagnostic rate and few adverse events. Acid secretion inhibitors may effectively prevent postoperative bleeding; however, the efficacy of local injection remains unclear. This technique could be an option for tissue sampling in gastric SETs.

Safety, efficacy and post-endoscopic retrograde cholangiopancreatography survival in nonagenarians: a retrospective cohort study

BACKGROUND

Increasing numbers of older patients with pancreatobiliary disease are undergoing endoscopic retrograde cholangiopancreatography (ERCP). Older patients may be at higher risk of ERCP-related adverse events due to their age and comorbidities; however, data are sparse.

AIMS

This study aimed to evaluate long-term mortality, procedural outcomes and safety of ERCP in nonagenarians.

METHODS

We retrospectively evaluated consecutive patients aged ≥90 years who underwent ERCP at a tertiary hospital over 12 years. The primary outcome was survival. Secondary outcomes included procedural success and adverse events. Logistic regression was used to analyse procedural outcomes, and factors predictive of survival were identified using a Cox proportional hazard model visualised by Kaplan-Meier plot.

RESULTS

A total of 159 consecutive ERCPs were performed in 115 nonagenarian patients. The mean age of the cohort was 92.3 (standard deviation ± 2.1) years. Choledocholithiasis (78.6%) was the most common indication, followed by malignant biliary obstruction (MBO, 18.9%) and bile leak (2.5%). Survival following ERCP for MBO at 30 days, 3 months and 1 year was 78%, 52% and 9%, respectively, compared to 98%, 94% and 89% for choledocholithiasis (P < 0.001). Procedural success was achieved in 91% of ERCPs (benign or malignant). ERCPs performed for MBO were more likely to fail (P < 0.001). Adverse events occurred in 5% of procedures.

CONCLUSION

Therapeutic ERCP in select nonagenarians is a clinically relevant intervention for both malignant and benign pathology. Age does not constitute a barrier to the performance of ERCP in appropriately selected patients. Nonagenarians may be counselled for a success and adverse event rate equivocal to younger populations.

Inpatient Outcomes of Gastrointestinal Bleeding in Advanced CKD and Kidney Transplant Recipients: A National Analysis 2016-2019

Key Points

Advanced CKD and ESKD are independent risk factors for gastrointestinal bleeding hospitalizations, angiodysplasia bleeding, and in-hospital mortality. Patients with ESKD with gastrointestinal bleeding exhibit significantly higher rates of adverse outcomes compared with those without CKD. Patients with advanced CKD and ESKD had lower rates of early endoscopy and higher rates of delayed endoscopy, with delayed endoscopy linked to increased mortality.

Background

Patients with kidney disease are at increased risk for gastrointestinal bleeding (GIB). This study aimed to investigate the incidence, causes, interventions, and inpatient outcomes of GIB in patients with advanced CKD (ACKD), ESKD, and kidney transplant (KT) recipients, compared with those without CKD (NCKD).

Methods

This retrospective study used the Nationwide Inpatient Sample database to identify adult patients admitted nonelectively with GIB from 2016 to 2019. Patients were stratified into five groups: ACKD (CKD stages 4 or 5), ESKD, KT, NCKD, and others (including CKD stages 1–3 and unspecified CKD). We compared outcomes across these groups and conducted subgroup analyses within the ACKD and ESKD groups to explore the association between mortality and the timing of endoscopic evaluation. Multivariate logistic regression (for binary outcomes) and linear regression (for continuous outcomes) models were used to analyze the dependent variables.

Results

A total of 2,163,929 patients were included. The incidence of GIB hospitalizations was higher in the ACKD (3.2%) and ESKD (3.4%) groups and lower in the KT group (2.1%) compared with the NCKD group (2.2%). All-cause in-hospital mortality was increased in ACKD, ESKD, and KT (3.0%, 3.1%, and 2.0%, respectively) compared with NCKD (1.7%). ESKD patients had higher rates of mechanical ventilation, vasopressor support, and blood transfusion, along with prolonged and costly hospitalizations (P < 0.001). ACKD and ESKD groups had lower rates of early endoscopy (<24 hours) and higher rates of delayed endoscopy (>48 hours), with delayed endoscopy linked to increased mortality. ACKD and ESKD were independent risk factors for angiodysplasia bleeding, while KT was a risk factor for diverticular and esophageal bleeding.

Conclusions

ACKD and ESKD are independent risk factors for GIB hospitalizations and in-hospital mortality, with delayed endoscopy further worsening outcomes. Tailored treatment plans are essential to improve outcomes in this complex population.

Small bowel obstruction due to migrated oesophageal metal stent

INTRODUCTION AND IMPORTANCE

Endoscopic oesophageal stents have numerous applications, including palliative management for unresectable oesophageal cancer, treatment of benign strictures and blocking early oesophageal perforations. However a significant limitation of fully covered self-expandable metallic stents (FC-SEMs) is their risk of migration. While oesophageal stenting is generally safe, it carries risks of mainly minor complications and a few major complications like tracheoesophageal fistulae, intestinal perforation, and, very rarely, intestinal obstruction due to stent migration. We hereby describe an instance of the last complication.

CASE PRESENTATION

A 48-year-old male with chronic kidney disease and hypertension presented with Boerhaave's syndrome which was successfully managed with FC-SEMs placement. He was lost to follow-up, but returned 8 months later presented with features of intestinal obstruction. Imaging revealed migrated FC-SEMs in the mid-jejunum with features of small bowel obstruction. After conservative management failed, he underwent exploratory laparotomy and stent retrieval. He had an uneventful post-operative recovery.

CLINICAL DISCUSSION

Boerhaave syndrome, a rare spontaneous oesophageal perforation, has seen evolving management strategies, from surgical repair to minimally invasive endoscopic interventions like self-expandable metallic stents (SEMs). While SEMs effectively manage perforations, migration remains a major complication, influenced by stent type and placement location. In this case, a migrated stent caused small bowel obstruction, necessitating surgical retrieval. This highlights the need for careful stent selection, close follow-up, and individualized management to prevent severe complications.

CONCLUSION

Migrating, covered SEMs, placed for oesophageal perforation, may cause intestinal obstruction necessitating surgical retrieval.

EUS‑guided antegrade stenting for malignant jaundice following Roux‑en‑Y reconstruction: the treatment of multiple biliary strictures

Multiple malignant biliary strictures are rare, and the application of multiple stents can achieve better drainage. EUS-guided biliary drainage (EUS-BD) can be offered as an alternative technique when ERCP unsuccessful. We applied Endoscopic ultrasonic guided antegrade stenting technique to treat a case of multiple biliary strictures following Roux-en-Y reconstruction.

Endoscopic vacuum therapy for gastrointestinal transmural defects: a literature review

Endoscopic vacuum therapy (EVT) has emerged as a transformative approach for managing gastrointestinal (GI) transmural defects, offering a less invasive and more promising alternative to surgery. Initially developed to address anastomotic leaks after rectal surgery, the application of EVT has expanded to include other locations within the GI tract. This review investigated the principles, indications, procedures, outcomes, challenges, and future perspectives of EVT for the management of GI transmural defects. In conclusion, EVT has demonstrated favorable outcomes in GI defect closure, with reduced complications, shortened hospital stay, and decreased morbidity rates as compared with conventional treatments. Although EVT faces challenges in some specific anatomical locations and in managing severe complications such as major bleeding, ongoing advancements in technology and standardization efforts offer promise for broader indications and better outcomes. Future perspectives include exploring novel EVT devices, refining patient selection criteria and pre-emptive applications, and standardizing procedural protocols.

Endoscopic ultrasound-guided fine-needle aspiration and fine-needle biopsy in the diagnosis of gastrointestinal lymphomas

INTRODUCTION

The role of endoscopic ultrasound-guided fine-needle aspiration and fine-needle biopsy (EUS-FNA/B) in the clinical management of gastrointestinal lymphoma has not been extensively studied. This study investigates the use of EUS-FNA/B in the diagnosis of first-time and recurrent gastrointestinal lymphomas at a large academic institution.

MATERIALS AND METHODS

A total of 40 patients who had final diagnosis of lymphoma according to the World Health Organization (WHO) classification of tumors of hematopoietic lymphoid tissues who underwent EUS-FNA/B were included in the study. Cases with concurrent forceps mucosal biopsies or lost to clinical follow-up were excluded. The diagnostic accuracy and clinical use of EUS-FNA/B was investigated by comparing EUS-FNA/B diagnosis with the final diagnosis.

RESULTS

EUS-FNA/B diagnoses were concordant with the final WHO diagnosis for as high as 72.5% of the cases. Of the remaining 27.5%, 17.5% had enough cytologic features for lymphoma diagnosis with incomplete phenotyping, while the remaining 10.0% showed features suspicious for lymphoma. Cell block and flow cytometry quality significantly affected diagnostic accuracy. Number of passes between 1 and 5 yielded better diagnostic accuracy than 6 or more passes during FNA; however, no difference was identified during procedures that used FNB alone or combined with FNA. There is no significant difference in onsite adequacy diagnostic performance of EUS-FNA performed by cytopathologists or cytotechnologists.

CONCLUSIONS

EUS-FNA/B with concurrent ancillary studies such as immunocytochemistry in cell block and flow cytometry can be helpful in efficient first and recurrent diagnoses of gastrointestinal lymphomas.

Endoscopic submucosal excavation for gastric muscularis propria tumours less than 10 mm in diameter: What are the risk factors responsible for perforation?

OBJECTIVE

To explore the risk factors for perforation during endoscopic submucosal excavation (ESE) for gastric muscularis propria tumours less than 10 mm in diameter. This study provides clinical guidance for preventing the occurrence of intraoperative adverse events.

METHODS

Samples of gastric muscularis propria tumours less than 10 mm in diameter were removed via ESE at Shenzhen Second People's Hospital and were collected from June 2023 to August 2024. The general clinical characteristics of the patients, location, size, growth pattern, and pathology of the tumours, operation time, resection time, perforation incidence and bleeding incidence were analysed, and logistic regression was used to calculate the risk factors for perforation and bleeding.

RESULTS

A total of 102 patients were included in this study. The tumours were successfully removed from all patients. The mean age was 52.28 ± 11.84 years. There were 34 (33.33%) males. The mean size was 6.96 ± 1.82 mm. 89 (87.25%) tumours exhibited an intraluminal growth pattern. In total, 79 (77.45%) tumours were in the gastric body, and 23 (22.55%) tumours were in the gastric fundus. The mean operation time was 35.26 ± 23.15 min, and the mean resection time was 27.88 ± 21.77 min. A total of 55 (53.92%) tumours were leiomyoma, and 43 (42.16%) tumours were GIST. There were 4 (3.92%) tumours classified as other lesions. 41 (40.20%) patients experienced intraoperative bleeding, all of which had minor bleeding and successful haemostasis under endoscopy.There were 27 (26.47%) concurrent perforation, of which,24(88.89%) were diagnosed as GIST, and 3(11.11%) were diagnosed as leiomyoma. All perforations were successfully managed with an endoscopic suture. According to the multivariate regression analysis, a pathologic diagnosis was a risk factor for perforation. When the pathological diagnosis is GIST, the risk of perforation increases (PE = 18.632, 95% CI 4.571 ~ 75.941; p < 0.001). Gender,age,tumor size, growth pattern, location, and resection time were not found to be risk factors for perforation.all of observed factors were not the risk factors for bleeding.

CONCLUSION

ESE is an effective removal method for gastric muscularis propria tumours less than 10 mm in diameter.Intraoperative bleeding and perforation are common.However, these complications are controllable.GIST is an independent risk factor for the perforation.When the tumour is diagnosed as a GIST, the incidence of perforation is significantly increased.

Is the Transverse Colon Overlooked? Establishing a Comprehensive Colonoscopy Database from a Multicenter Cluster-Randomized Controlled Trial

Background and Study Aim: Colonoscopy holds the highest volume of all endoscopic procedures, allowing for large colonoscopy databases to serve as valuable datasets for quality assurance. We aimed to build a comprehensive colonoscopy database for quality assurance and the training of future AIs. Materials and Methods: As part of a cluster-randomized controlled trial, a designated, onsite medical student was used to acquire procedural and patient-specific data, ensuring a high level of data integrity. The following data were thereby collected for all colonoscopies: full colonoscopy vides, colonoscope position (XYZ-coordinates), intraprocedural timestamps, pathological report, endoscopist description, endoscopist planning, and patient-reported discomfort. Results: A total of 1447 patients were included from the 1st of February 2022 to the 21st of November 2023; 1191 colonoscopies were registered as completed, 88 were stopped due to inadequate bowel cleansing, and 41 were stopped due to patient discomfort. Of the 1191 completed colonoscopies, 601 contained polypectomies (50.4%), and 590 did not (49.6%). Comparing colonoscopies with polypectomies to those without the withdrawal time (caecum to extubating the scope) was significantly longer for all parts of the colon (p values < 0.001), except the transverse colon (p value = 0.92). The database was used to train an AI, automatically and objectively evaluating bowel preparation. Conclusions: We established the most thorough database in colonoscopy with previously inaccessible information, indicating that the transverse colon differs from the other parts of the colon in terms of withdrawal time for procedures with polypectomies. To further explore these findings and reach the full potential of the database, an AI evaluating bowel preparation was developed. Several research partners have been identified to collaborate in the development of future AIs.

Accuracy of Visual Estimation for Measuring Colonic Polyp Size: A Systematic Review and Meta-Analysis

INTRODUCTION

Measurement of colorectal polyps is typically performed through visual estimation, which is prone to bias. Studies have evaluated the accuracy of visual estimation and utility of assistive tools, but results have been mixed. The aim of this study was to clarify the accuracy of visual estimation as a measurement tool and the benefits of artificial intelligence.

METHODS

MEDLINE and Embase were searched through October 2024. Extraction and quality assessment were performed independently by 2 authors. The primary outcome was the pooled absolute mean difference in size between visual estimation and control. Secondary outcomes included subgroup analysis of expert vs trainee status, accuracy of artificial intelligence, study origin (East vs West), comparator type, definition of accuracy, polyp size, direction of estimation, and image type.

RESULTS

Thirty-five studies with 42,964 polyp measurements were included in our analysis. All studies were of high quality, and there was no evidence of publication bias. The pooled absolute mean difference from comparator was 1.68 mm (confidence interval 1.21-2.15) with high variability explained by differences in the comparator, direction of estimation, image type, and size of the polyp. Overall accuracy was 60% with high variability as well, with increased accuracy with video displayed over photographs. Artificial intelligence improved accuracy with an odds ratio of 7.46.

DISCUSSION

Visual estimation is an inaccurate and imprecise way to measure colorectal polyps. Further research is needed to determine the impact on clinical outcomes related to colorectal cancer. Investment in new technology to aid in polyp measurement is an important next step.

Single-stage laparoendoscopic management of cholecystocholedocholithiasis: A retrospective study comparing starting with ERCP versus with laparoscopic cholecystectomy

Backgrounds/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) remains the most common therapeutic strategy used for cholecystocholedocholithiasis (CCL). Recently, single-stage ERCP + LC has gained popularity for treating CCL due to patient satisfaction and financial considerations. In this study, we aimed to compare the feasibility and efficacy of the two variants of single-stage ERCP + LC (starting with ERCP followed by LC versus starting with LC followed by ERCP) for treatment of CCL.

Methods

A total of 115 patients who underwent single-stage ERCP + LC for CCL from January 2021 to December 2023 were enrolled in a retrospective comparative cohort study. These patients were divided into two groups: Group A (ERCP-first approach) and Group B (LC-first approach).

Results

Patients in Group A had a common bile duct clearance rate of 88.2%, which was comparable to the 95.7% observed in Group B (p = 0.163). The mean duration of the ERCP procedure was comparable between the two groups (43.3 ± 11.8 vs 39.5 ± 13.5 minutes; p = 0.112). However, the mean duration of the LC procedure was significantly longer in Group A than in Group B (41.2 ± 8.98 vs 37.2 ± 12.2 minutes; p = 0.045). The mean total operative time for the combined ERCP + LC was significantly longer in Group A compared to Group B (81.9 ± 16.7 vs 75.1 ± 19.3 minutes; p = 0.046). Post-ERCP pancreatitis occurred in 4 patients in Group A and in 2 patients in Group B (p = 0.701).

Conclusions

Both LC-1st approach and ERCP-1st approach are feasible and highly effective for treating CCL through single-stage ERCP + LC. However, the LC-1st approach has the advantage of a shorter operative time.

Efficacy-cost analysis of endoscopic mucosal resection and cold snare polypectomy: A propensity score matching analysis

BACKGROUND

Although substantial evidence supports the advantages of cold snare polypectomy (CSP) in terms of polypectomy efficacy and reduced postoperative adverse events, few studies have examined the cost differences between CSP and traditional endoscopic mucosal resection (EMR) for the treatment of intestinal polyps.

AIM

To compare the efficacy-cost of EMR and CSP in the treatment of intestinal polyps.

METHODS

A total of 100 patients with intestinal polyps were included in the retrospective data of our hospital from April 2022 to May 2023. According to the treatment methods, they were divided into EMR (n = 46) group and CSP (n = 54) group. The baseline data of the two groups were balanced by 1:1 propensity score matching (PSM), and the cost-effectiveness analysis was performed on the two groups after matching. The recurrence rate of the two groups of patients was followed up for 1 year, and they were divided into recurrence group and non-recurrence group according to whether they recurred. Multivariate logistic regression analysis was used to screen out the influencing factors affecting the recurrence of intestinal polyps after endoscopic resection.

RESULTS

Significant disparities were observed in the number of polyps and smoking background between the two groups before PSM (P < 0.05). Following PSM, the number of polyps and smoking history were well balanced between the EMR and CSP groups. The direct cost incurred by the CSP group was markedly higher than that incurred by the EMR group. Concurrently, the cost-effectiveness ratio in the CSP group was substantially reduced when juxtaposed with that in the EMR group (P < 0.05). Upon completion of the 1-year follow-up, the rate of recurrence after endoscopic intestinal polypectomy was 38.00%. Multivariate methods revealed that age ≥ 60 years, male sex, number of polyps ≥ 3, and pathological type of adenoma were risk factors for recurrence after endoscopic intestinal polypectomy (all P < 0.05).

CONCLUSION

CSP was more cost-effective for the treatment of intestinal polyps. An age ≥ 60 years, male sex, having a number of polyps ≥ 3, and pathological type of adenoma are independent influencing factors for recurrence.

Overview of endoscopic biliary stenting in malignant obstructive jaundice

This article discusses Wang et al’s essay. Endoscopic biliary stenting, a less invasive alternative to surgery, is effective for malignant obstructive jaundice. This article summarizes the pathophysiology of biliary obstruction, the technical aspects of stenting, and the clinical outcomes. By comparison of endoscopic stenting with percutaneous biliary drainage, improvements and complications are focused on. Additionally, patient selection for stenting and future advancements in stent technology are important. Overall, endoscopic biliary stenting is a valuable palliative option for patients with malignant jaundice, especially those ineligibles for surgery.

Diagnosing and Managing Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in Adults: Review of Evidence 2017-2023

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening reactions associated with long-term disabling sequelae. In the acute phase, the best supportive care in expert centers is the cornerstone of treatment. The follow-up is prolonged and multidisciplinary, according to the patient's needs. In this paper, we review the evidence from 2017 to 2023 for the diagnosis and management of SJS/TEN in adults. On the basis of this review and our own experience, we present recommendations for the diagnosis of SJS/TEN in adults, management in the acute phase (best supportive care; prevention of infections; skin, ocular, and other mucosa management; intensive care measures; and etiological treatment), and follow-up. The most frequent sequelae are cutaneous, ocular, and psychological. High-quality studies assessing the efficacy of immunomodulating agents (eg, cyclosporine, corticosteroids, intravenous Igs, and anti-TNF agents) in accelerating healing and reducing mortality are still lacking. In addition, we propose avenues for future studies.

Real-world effectiveness and safety of 1L polyethylene glycol and ascorbic acid for bowel preparation in patients aged 80 years or older

Background and study aims

Clinical trials and real-world studies show a 1L polyethene glycol and ascorbic acid solution (1L PEG-ASC) to be an effective and safe bowel preparation for colonoscopy in the general population. Here, the effectiveness and safety of 1L PEG-ASC were evaluated in patients aged 80 years or older in a real-world setting.

Patients and methods

A post-hoc analysis of an observational, multicenter, retrospective study assessed the effectiveness and safety of 1L PEG-ASC on outpatients aged ≥ 80 years old undergoing colonoscopy at eight centers in Spain and Portugal. Cleansing quality was assessed using the Boston Bowel Preparation Scale, with overall scores ≥ 6 and all segmental scores ≥ 2 considered adequate colon cleansing, and overall scores ≥ 8 or 3 in the right colon considered high-quality cleansing. Cecal intubation rate, withdrawal time, polyp and adenoma detection rates (ADR), and adverse events (AEs) were also monitored.

Results

Data were analyzed from 423 patients aged ≥ 80 years; mean age 83.5 years (±3.2) and 49.2% males. The adequate colon cleansing success rate was 88.9%, with high-quality cleansing of the overall and right colon achieved in 54.1% and 46.1% of patients, respectively. Colonoscopy was complete in 94.1% of cases and the ADR was 51.3%. At least one AE was experienced by 4.5% of participants, the most frequent being mild dehydration (2.8%) and nausea (1.2%).

Conclusions

This post-hoc analysis confirms 1L PEG-ASC to be an effective and safe bowel cleansing preparation for patients aged 80 years or older in a real-world setting.

Technological integration in timing of endoscopy: Predictive modeling for acute upper gastrointestinal bleeding outcomes

BACKGROUND

Technological advancements have revolutionized the management of acute upper gastrointestinal bleeding (AUGIB). However, the impact of endoscopic timing on treatment outcomes remains a critical area of exploration.

OBJECTIVE

This study evaluated the role of endoscopic timing in improving treatment outcomes for AUGIB and introduces a predictive model incorporating clinical and technological insights.

METHODS

A retrospective analysis of AUGIB patients treated between December 2020 and December 2023 was conducted. Logistic regression identified significant predictors of outcomes, and receiver operating characteristic (ROC) analysis evaluated their predictive value. A predictive model was developed based on these findings.

RESULTS

Among 145 patients, 35 (24.1%) experienced rebleeding. Key predictors included endoscopic timing, active bleeding, shock on admission, and bleeding volume (p < 0.05). The predictive model demonstrated robust performance (C-index: 0.885, 95% CI: 0.810-0.956), emphasizing the clinical relevance of precise timing in endoscopic intervention.

CONCLUSION

This study underscores the importance of integrating technology with clinical practice to optimize endoscopic timing and improve AUGIB outcomes. The predictive model offers a valuable tool for risk stratification and clinical decision-making in modern healthcare settings.

Reporting Quality of AI Intervention in Randomized Controlled Trials in Primary Care: Systematic Review and Meta-Epidemiological Study

BACKGROUND

The surge in artificial intelligence (AI) interventions in primary care trials lacks a study on reporting quality.

OBJECTIVE

This study aimed to systematically evaluate the reporting quality of both published randomized controlled trials (RCTs) and protocols for RCTs that investigated AI interventions in primary care.

METHODS

PubMed, Embase, Cochrane Library, MEDLINE, Web of Science, and CINAHL databases were searched for RCTs and protocols on AI interventions in primary care until November 2024. Eligible studies were published RCTs or full protocols for RCTs exploring AI interventions in primary care. The reporting quality was assessed using CONSORT-AI (Consolidated Standards of Reporting Trials-Artificial Intelligence) and SPIRIT-AI (Standard Protocol Items: Recommendations for Interventional Trials-Artificial Intelligence) checklists, focusing on AI intervention-related items.

RESULTS

A total of 11,711 records were identified. In total, 19 published RCTs and 21 RCT protocols for 35 trials were included. The overall proportion of adequately reported items was 65% (172/266; 95% CI 59%-70%) and 68% (214/315; 95% CI 62%-73%) for RCTs and protocols, respectively. The percentage of RCTs and protocols that reported a specific item ranged from 11% (2/19) to 100% (19/19) and from 10% (2/21) to 100% (21/21), respectively. The reporting of both RCTs and protocols exhibited similar characteristics and trends. They both lack transparency and completeness, which can be summarized in three aspects: without providing adequate information regarding the input data, without mentioning the methods for identifying and analyzing performance errors, and without stating whether and how the AI intervention and its code can be accessed.

CONCLUSIONS

The reporting quality could be improved in both RCTs and protocols. This study helps promote the transparent and complete reporting of trials with AI interventions in primary care.

Cytological Diagnosis by Fine-Needle Aspiration or Core Biopsy with Touch Preparation for Renal Cystic or Solid Lesions: A Single-Center Clinicopathological Analysis

INTRODUCTION

A retrospective study analyzed real-life data from a single-center cohort of renal fine-needle aspiration (FNA) and core biopsy (CB) with touch preparation (TP) procedures over an 18-year period and aimed to provide a comprehensive overview of the evaluation of cytological diagnostic performance, challenges, and accuracy concerning renal cystic, solid, and mixed cystic-solid lesions.

METHODS

All percutaneous ultrasound-guided FNA and CT-guided CB with TP performed at our institution from 2006 to 2024 were identified.

RESULTS

A total of 89 renal cytology procedures were performed during the study period. Sixty-two (69.7%) lesions displayed cystic radiological features, 20 (22.5%) lesions presented solid mass, and only 7 (7.8%) lesions exhibited mixed cystic-solid radiological features. Of the procedures performed, seventy-five (84.3%) were ultrasound-guided FNA biopsies, while 14 (15.7%) were CT-guided CB with TP. Of the 62 renal cystic lesions, 54 (87.1%) were simple renal cysts. Twelve (60%) in 20 solid lesions were malignant, mainly involving clear cell renal cell carcinoma (RCC), urothelial carcinoma, and collecting duct carcinoma. Cytological diagnoses of renal mixed cystic-solid lesions mainly involved tuberculosis and clear cell RCC. However, only 22 cases had corresponding histopathological specimens available for comparison. The concordance rate between cytological diagnoses and surgical pathology specimens for cystic, solid, and mixed cystic-solid renal lesions was 100%, 92.3%, and 80%, respectively.

CONCLUSION

In our series, FNA or CB with TP demonstrates significant diagnostic utility in the evaluation of renal lesions. The diagnostic accuracy of FNA cytology for renal lesions has been enhanced through the application of immunocytochemical staining on cell blocks.

Effectiveness of glucocorticoids in preventing esophageal stricture and predictors of stricture after esophageal ESD: 5 years of experience in a single medical center

Background

Esophageal stricture is one of the major complications after endoscopic submucosal dissection (ESD) of the esophagus. However, even with steroid prophylaxis, stenosis still occurs in up to 45% of patients. Accordingly, the aim of this study was to evaluate the efficacy and safety of steroid therapy in preventing esophageal strictures after ESD, as well as to assess the predictors of esophageal strictures after the application of steroids.

Methods

Between February 2018 and March 2023, 207 patients who underwent esophageal ESD at Southeast University Affiliated Zhongda Hospital were retrospectively enrolled. We evaluated stenosis rate, number of endoscopic dilations after ESD, the interval between the first endoscopic dilatation after ESD and explored risk factors for strictures after steroid prophylaxis.

Results

In the control group, the oral steroids group, and the combined group, the stenosis rates were 83/87 (95.4%), 44/53 (83.0%), and 56/67 (83.6%), respectively; the number of endoscopic dilations were 3.43 (±2.22), 2.34 (±2.17), and 1.52 (±1.25), respectively; the time intervals between first endoscopic dilation and ESD procedure were 38.36 (±6.87), 68.18 (±9.49), and 96.82 (±8.41) days, respectively; all these indicators were significantly better in the oral and combined groups than in the control group (p < 0.05). Multivariate analysis identified lesion circumference ≥ 5/6th and submucosal injection of solution were two independent factors on esophageal stricture formation (p < 0.05).

Conclusion

Steroid prophylaxis is effective and safe in preventing esophageal stenosis. Moreover, lesion circumference and submucosal injection of sodium hyaluronate were two independent factors on esophageal stricture formation even with steroids administration.

Endoscopic retrograde cholangiopancreatography consultation after digestive tract reconstruction and risk factors for complications

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) has been widely used in the diagnosis and treatment of biliary and pancreatic diseases, and its success rate and therapeutic effect are considerable, and its use in patients with gastrointestinal tract reconstruction is also increasing. The anatomical structure of the digestive tract has been changed in these patients, which makes the use of endoscopic retrograde cholangiopancreatography technically more challenging. The aim of this study was to investigate the efficacy of transendoscopic retrograde cholangiopancreatography in patients after gastrointestinal reconstruction and its risk factors for postoperative complications.

METHODS

A retrospective analysis was conducted on clinical data of 522 patients who underwent ERCP for diagnostic and therapeutic purposes after gastrointestinal reconstruction surgery at Zhongnan Hospital, Wuhan University, from January 2017 to December 2023. Univariate analysis, multicollinearity testing, and binary logistic regression were performed to explore the factors associated with ERCP efficacy and complications.

RESULTS

A total of 522 patients were included in the study. The success rate of intubation was 96.93% (506/522), the success rate of cannulation was 91.09% (466/506), and the therapeutic success rate was 95.28% (444/466). Multivariate logistic regression analysis of failed intubation showed that independent risk factors included total gastrectomy (P = 0.000, OR = 7.114, 95% CI 2.454-20.622), gastrojejunostomy (P = 0.000, OR = 46.881, 95% CI 10.250-214.423), and the use of a forward-viewing endoscope (P = 0.010, OR = 2.322, 95% CI 1.228-4.389). Post-ERCP complications included hyperamylasemia in 67 cases (12.84%), acute pancreatitis in 13 cases (2.49%), acute cholangitis in 3 cases (0.57%), bleeding in 3 cases (0.57%), and perforation in 2 cases (0.38%). Univariate analysis of the complications showed that a history of cholecystectomy (P = 0.042, OR = 1.800, 95% CI 1.015-3.193) was an independent risk factor for hyperamylasemia; difficult cannulation (P = 0.000, OR = 47.619, 95% CI 13.317-170.275) was an independent risk factor for acute pancreatitis; and a history of pancreatitis (P = 0.040, OR = 42.75, 95% CI 3.399-537.620) was an independent risk factor for bleeding.

CONCLUSIONS

ERCP performed in patients after gastrointestinal reconstruction at our hospital achieved a high success rate. Total gastrectomy, gastrojejunostomy, and the use of a forward-viewing endoscope were independent risk factors for failed intubation. A history of cholecystectomy, recurrent cannulation, and a history of pancreatitis were identified as independent risk factors for hyperamylasemia, acute pancreatitis, and bleeding, respectively.

The Role of Fractional Exhaled Nitric Oxide and Oscillometry in Pediatric Asthma

Diagnosing pediatric asthma is challenging and requires the evaluation of symptoms, inflammation, and lung function. Spirometry, which is commonly used to evaluate lung function in asthma, is difficult to obtain from young pediatric patients and frequently not possible to obtain from patients under 5 years of age. This is also true for the fraction of exhaled nitric oxide (FENO) measurement, which can indicate type 2 airway inflammation in asthma, and controversy has existed regarding the appropriate use of FENO measurement in asthma diagnosis and monitoring. Impulse oscillometry can be used to evaluate lung function and may be easier to perform than spirometry for pediatric patients. This narrative review evaluates the recent guidelines for diagnosis and monitoring of pediatric asthma. It also provides an overview of the use of FENO measurement and impulse oscillometry in pediatric asthma. A panel discussion of the role of FENO measurement and impulse oscillometry in pediatric asthma concludes this article.

Endoscopic ultrasound guided liver biopsy and portal pressure gradient: when, why and how? Can it become the standard of care in endo-hepatology?

INTRODUCTION

The armamentarium of 'Endo-hepatology' is proliferating with the advancements in techniques and availability of new devices in the field of endoscopic ultrasound (EUS). This has resulted in the merger of multitude of diagnostic and therapeutic interventions, such as EUS-liver biopsy (LB), EUS-angioembolization of gastric varices, EUS-portal pressure gradient (PPG) measurement, and others into a 'one-stop-shop' for efficient patient management. Lack of standardization of these techniques forms a major hinderance in their widespread adoption.

AREAS COVERED

A comprehensive literature search was undertaken across various databases on EUS-LB and EUS-PPG till November 2024 for reviews, observational studies, and randomized trials on EUS-LB and EUS-PPG, describing its indications, technique, and data of safety and efficacy, detailing its role in day-to-day clinical practice.

EXPERT OPINION

EUS-LB and EUS-PPG have shown promise in the ever-growing field of endo-hepatology. EUS-LB has exhibited excellent safety profile and comparable tissue yield compared to its percutaneous counterpart. On the other hand, EUS-PPG seems to be a viable alternative although it needs to be standardized further. From a patient and hospital perspective, they might prove to be convenient and cost-effective. Nevertheless, more evidence is warranted before they can be labeled as the new standard of care.

Pancreatic cancer: Future challenges and new perspectives for an early diagnosis

This editorial is a commentary on the case report by Furuya et al focusing on the challenging diagnosis of early pancreatic adenocarcinoma and new tools for an earlier diagnosis. Currently, pancreatic cancer still has a poor prognosis, mainly due to late diagnosis in an advanced stage. Two main precancerous routes have been identified as pathways to pancreatic adenocarcinoma: The first encompasses a large group of mucinous cystic lesions: intraductal papillary mucinous neoplasm and mucinous cystic neoplasm, and the second is pancreatic intraepithelial neoplasia. In the last decade the focus of research has been to identify high-risk patients, using advanced imaging techniques (magnetic resonance cholangiopancreatography or endoscopic ultrasonography) which could be helpful in finding "indirect signs" of early stage pancreatic lesions. Nevertheless, the survival rate still remains poor, and alternative screening methods are under investigation. Endoscopic retrograde cholangiopancreatography followed by serial pancreatic juice aspiration cytology could be a promising tool for identifying precursor lesions such as intraductal papillary mucinous neoplasm, but confirming data are still needed to validate its role. Probably a combination of cross-sectional imaging, endoscopic techniques (old and new ones) and genetic and biological biomarkers (also in pancreatic juice) could be the best solution to reach an early diagnosis. Biomarkers could help to predict and follow the progression of early pancreatic lesions. However, further studies are needed to validate their diagnostic reliability and to establish diagnostic algorithms to improve prognosis and survival in patients with pancreatic cancer.

Respiratory Support Strategies for Surgical Neonates: A Review

Neonates with congenital conditions which require surgical management frequently experience respiratory distress. This review discusses the management of pulmonary complications and the respiratory support strategies for four conditions: oesophageal atresia-tracheoesophageal fistula (OA-TOF), congenital diaphragmatic hernia (CDH), congenital lung malformations (CLM), and anterior abdominal wall defects (AWD). Mechanical ventilation techniques which can reduce the risk of ventilator-induced lung injury (VILI) are discussed, as well as the use of non-invasive respiratory support modes. While advances in perioperative respiratory support have improved outcomes in infants with OA-TOF, managing respiratory distress in premature OA-TOF neonates remains a challenge. In CDH infants, a randomised trial has suggested that conventional ventilation may improve outcomes compared to high-frequency ventilation. Echocardiographic assessment is essential in the management of CDH infants with pulmonary hypertension. Lung-protective ventilation settings may lower the rate of postoperative complications in symptomatic CLM infants, but there remains debate regarding the choice of expectant versus surgical management in neonates with asymptomatic CLMs. Infants with AWDs can require ventilation due to pulmonary hypoplasia, but the effects of this on their long-term respiratory health are poorly understood. As surgical techniques continue to evolve and novel ventilation techniques become available, prospective multi-centre studies will be required to define the optimal respiratory support strategies for neonatal surgical conditions that affect lung function.

Safe removal of an Allurion swallowable intragastric balloon using an EUS aspiration needle at a non-specialist centre

Intragastric balloons (IGBs) are an increasingly popular management strategy for obesity. The Allurion IGB is a swallowable balloon that spontaneously degrades after residing in the stomach for 4 months. We describe a technique for safe retrieval of an Allurion IGB using endoscopic accessories available at hospitals without a dedicated bariatric service. Nausea and pain are often encountered following IGB insertion. Infrequent but serious adverse events have been noted by NICE. As it does not normally require endoscopic removal, a specific endoscopic kit has not been designed for the Allurion IGB. Devices designed for other types of IGBs have previously been used to extract the Allurion balloon. We achieved a similar outcome using an endoscopic ultrasound (EUS) aspiration needle. Although general anaesthetic for IGB removal remains contentious, we felt this represented the safest strategy given the risk of aspiration as well as the lack of prior experience at our centre.

Short-term and long-term management of caustic-induced gastrointestinal injury: An evidence-based practice guidelines

The Indian Society of Gastroenterology has developed an evidence-based practice guideline for the management of caustic ingestion-related gastrointestinal (GI) injuries. A modified Delphi process was used to arrive at this consensus containing 41 statements. These statements were generated after two rounds of electronic voting, one round of physical meeting, and extensive review of the available literature. The exact prevalence of caustic injury and ingestion in developing countries is not known, though it appears to be of significant magnitude to pose a public health problem. The extent and severity of this preventable injury to the GI tract determine the short and long-term outcomes. Esophagogastroduodenoscopy is the preferred initial approach for the evaluation of injury and contrast-enhanced computed tomography is reserved only for specific situations. Low-grade injuries (Zargar grade ≤ 2a) have shown better outcomes with early oral feeding and discharge from hospital. However, patients with high-grade injury (Zargar grade ≥ 2b) require hospitalization as they are at a higher risk for both short and long-term complications, including luminal narrowing. These strictures can be managed endoscopically or surgically depending on the anatomy and extent of stricture, expertise available and patients' preferences. Nutritional support all along is crucial for all these patients until nutritional autonomy is established.

The Impact of Immunomodulatory Components Used in Clinical Nutrition-A Narrative Review

BACKGROUND

Malnutrition is a clinical condition that leads to unfavourable changes in health. It affects 35-55% of hospitalized patients, and in the case of cancer, this prevalence rises to 40-90% of patients. Screening nutritional status is essential for preventing undernutrition, which is crucial as its treatment. Undernutrition in patients after severe injuries significantly increases catabolic changes. Cytokines and hormones, such as epinephrine, glucagon, and cortisol, are released, which can increase energy expenditure by 50%. Properly conducted nutritional treatment aims to maintain or improve the nutritional status of patients whose nutrition with a natural diet is insufficient, moreover, in some cases, treatment of the underlying disease.

METHODS

This study is a narrative review focused on immunonutrition. The search for source articles, mainly from the last 10 years, was conducted in the PubMed and Google Schoolar databases, as well as in printed books. The key words used were "malnutrition", "inflammation", "clinical nutrition", "immunomodulatory components", "nutritional status assessment", "enteral nutrition", "parenteral nutrition", and their combinations.

RESULTS

Providing substances such as omega-3 fatty acids, glutamine, arginine, nucleotides, antioxidants, and prebiotic fiber has a beneficial impact on immunological and anti-inflammatory pathways. The above-mentioned ingredients may inhibit the secretion of pro-inflammatory cytokines, activate anti-inflammatory cytokines, stimulate immune cells, and have a beneficial effect in allergic diseases, respiratory infections, or wound healing.

CONSLUSION

Immunonutrition can be administrated via oral, enteral, and parenteral routes. It is crucial to highlight the importance of proper nutritional status in patients. The relationship between inflammation and malnutrition creates a vicious cycle, where one negatively affects the other due to increased metabolic demand, loss of appetite, weakened immune system, and gut dysbiosis.

How Early Can Pancreatic Tumors Be Detected Using NMR-Based Urine Metabolic Profiling? Identification of Early-Stage Biomarkers of Tumor Initiation and Progression in an Orthotopic Xenograft Mouse Model of Pancreatic Cancer

Background: Pancreatic cancer is the most lethal of all human cancers. The disease has no obvious symptoms in its early stages and in the majority of cases, the cancer goes undetected until it has advanced to the point that surgery is no longer a viable option or until it has metastasized to other organs. The absence of reliable and sensitive biomarkers for the early detection of pancreatic cancer contributes to the poor ability to detect the disease before it progresses to an untreatable stage. Objectives: Here, an orthotopic xenograft mouse model of pancreatic cancer was investigated to determine if urinary metabolic biomarkers could be identified and used to detect the early formation of pancreatic tumors. Methods: The orthotopic xenograft mouse model of pancreatic cancer was established by injecting human MiaPaCa-2 cells, derived from a male patient aged 65 years with pancreatic adenocarcinoma, into the pancreata of severe combined immunodeficient mice. Orthotopic pancreatic tumors, allowed to grow for eight weeks, were successfully established in the pancreata in 15 out of 20 mice. At the time of sacrifice, tumors were excised and histologically analyzed and the masses and volumes recorded. Urine samples were collected prior to injection, at one-week post injection, and every two weeks afterwards for eight weeks. Results: NMR-based metabolic profiling of the urine samples indicated that 31 metabolites changed significantly over the course of tumor initiation and growth. Longitudinal metabolic profiling analysis indicated an initial increase in activity of the metabolic pathways involved in energy production and/or cell synthesis by cancer cells as required to support tumor growth that was followed by a diminished difference between control and orthotopic mice associated with tumor senescence as the tumors reached 7-8 weeks post injection. Conclusions: The results indicate that NMR-based urinary metabolic profiling may be able to detect the earliest stages of pancreatic tumor initiation and growth, highlighting the potential for translation to human clinical studies.

Virtual Reality and Augmented Reality Use Cases in Gastroenterology

PURPOSE OF REVIEW

Virtual reality (VR) and augmented reality (AR) are emerging technologies with significant potential in medical education and therapeutic interventions, particularly within gastroenterology. This review aims to explore the current applications of VR and AR in enhancing endoscopy training, procedural skills, and patient comfort, while also identifying their role in non-pharmacological pain management and pre-procedure education.

RECENT FINDINGS

Extensive research has been conducted on the use of VR and AR in surgical and neurological fields, but their application in gastroenterology is still evolving. VR simulators provide realistic training environments, contributing to improved procedural skills and patient care. Additionally, VR has been shown to reduce patient discomfort and serve as an alternative to sedation during procedures like colonoscopies. AR, specifically in colonoscopies, has demonstrated potential in enhancing polyp detection by overlaying real-time digital information, leading to better diagnostic accuracy. Studies also suggest that VR can improve patient outcomes in functional gastrointestinal disorders and enhance pre-procedure education, increasing patient satisfaction. VR and AR hold significant promise in gastroenterology by advancing both educational and procedural practices. These technologies offer cost-effective, patient-friendly solutions that improve diagnostic accuracy and patient outcomes. Continued research is essential to fully realize the benefits of VR and AR in gastroenterology, as these tools become more prevalent in clinical practice.

[Thinking out of the tube: endoscopic findings in oral cavity, pharynx and larynx during flexible esophagogastroduodenoscopy]

During a flexible esophagogastroduodenoscopy (EGD), the oral cavity and significant regions of the pharynx (oropharynx, hypopharynx), as well as the larynx, can usually be examined with a high resolution. Numerous benign and malignant findings of considerable clinical relevance can occur in this region of the digestive tract, which can be inspected during a gastroscopy and treated subsequently. Remarkably, head and neck tumors represent a heterogeneous group of malignant diseases and account for ca. 4 % of cancers diagnosed in men in Germany.This review presents benign and malignant findings assessed during routine endoscopy in the oral cavity, pharynx and larynx discussing them in the context of an extensive literature review.Common benign and malignant findings in the oral cavity, oropharynx, hypopharynx and larynx are easy to diagnose visually with a reasonable amount of additional time and histological confirmation is possible in selected cases. We describe a proposal for a structured examination procedure.Careful routine inspection of the oral cavity, oropharynx, hypopharynx and larynx during gastroscopy can reveal pathological findings and diagnose them at an early stage, especially in people at risk, but also in the general population.

Ergonomic endoscopy - Fundamentals of ergonomics and interventions for endoscopy-related musculoskeletal disorders

Recently, musculoskeletal disorders (MSDs) among endoscopists have attracted considerable attention. MSDs are caused by prolonged static postures, forceful manual exertions, and repetitive twisting maneuvers. Basic knowledge of ergonomics is useful for improving the posture, movements, and work environment of endoscopists, as well as developing equipment to prevent MSDs. This review discusses problematic endoscopic tasks from an ergonomic perspective, issues with MSD definitions, the prevalence of MSDs, local site interpretations, risk factors including working time and environment, and ergonomic evaluations. The evidence highlights the importance of multifaceted strategies for risk avoidance using the Hierarchy of Controls. Additionally, this review summarizes global trends and introduces the Ergonomic Endoscopy 7 Tips for MSD prevention, emphasizing a systems approach through collaboration with various stakeholders. Thus, it may serve as a guide for gastroenterologists and staff engaged in endoscopic procedures for prolonged periods.