Endoscopy International Open最新文献

Background and study aims: Although endoscopic resection is recommended for management of complex benign colon polyps, patients are routinely referred for surgical resection. Little is known about the effects of these elective colectomies on patient outcomes. We sought to determine trends, surgical outcomes, and costs of elective colectomy for benign colon polyps.

Patients and methods: We performed a retrospective cohort analysis of veterans nationwide using the National Veterans Affairs Surgical Quality Improvement Program (VASQIP) database linked to the national VA Corporate Data Warehouse database. We included all veterans (N = 7,102) undergoing elective colectomy for benign polyps from 2000 to 2015. Outcomes of interest were rates of colectomy, surgical pathology findings, morbidity, mortality, and costs.

Results: Colectomy for benign polyps increased significantly from 6% of all colectomies in 2000 to 18% in 2014, and the percent of colectomies for colon cancer decreased from 40% to 31%. The 30-day mortality rate was 1.2% and the complication rate was 19.7%. Based on pathology, 80% of patients (n = 514) underwent right hemicolectomy, mean polyp size was 2.7 cm (± 1.7 cm), and 60.1% of resected polyps were adenomas. Median cost of colectomy was $22,712 for open and $20,697 for laparoscopic colectomy. Costs increased if a complication occurred.

Conclusions: Rates of colectomy for benign adenomas significantly increased from 2000 to 2014. Colectomy was associated with significant mortality, morbidity, and cost. Development of strategies to improve endoscopic management of benign large colon neoplasms is urgently needed.

Background and study aims: Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has been proposed as a minimally invasive alternative to surgery for treatment of both functional (F-) and non-functional (NF-) pancreatic neuroendocrine tumors (PanNETs). We performed a large prospective multicenter study to evaluate safety and effectiveness of EUS-RFA in patients with F- and NF-PanNETs.

Patients and methods: Patients with F- (≤ 2 cm) and NF-PanNETs (15 mm-25 mm) were prospectively enrolled over a 43-month period. The primary aim was safety, defined as rate of adverse events (AEs). The secondary aim was effectiveness defined as complete disappearance of the hormonal secretion syndrome in F- PanNETs, whereas for NF-PanNETs, complete response was defined as absence of enhancing tissue and of detectable lesion at magnetic resonance imaging/computed tomography scan and Gallium-positron emission tomography, respectively. The EUSRA 19G needle was used in all patients. After treatment completion, follow-up was performed for 1 year.

Results: During the study period, a total of 60 patients were enrolled, 30 with insulinomas and 30 with NF-PanNETs (mean lesion size 14.5 ± 4.5 mm). In 78.3% of patients, a single RFA session was performed. Overall, AEs occurred in nine of 60 patients (15%), in four patients (13.3%) with insulinomas and in five (16.7%) with NF-PanNETs, with only one severe AE. Complete insulin hypersecretion symptom resolution was obtained in 29 of 30 patients (96.7%) with insulinomas, whereas for NF-PanNETs, complete radiological response was obtained in 22 of 25 patients (88%) with long-term follow up.

Conclusions: Our prospective international multicenter study demonstrated that EUS-RFA is highly safe and effective for the treatment for both F- and NF-PanNETs.

Background and study aims: Roux-en-Y gastric bypass (RYGB) is an effective long-term weight loss operation with improvements in metabolic diseases. Nutritional deficiencies, however, are highly prevalent despite supplementation, largely due to exclusion of the proximal small bowel. In RYGB patients who require pancreaticobiliary access, the EUS-directed transgastric ERCP (EDGE) procedure provides a stable gastro-gastric (GG) fistula using a lumen-apposing metal stent (LAMS). The metabolic and nutritional effects of temporary food diversion remain unknown.

Methods: We conducted a review of 60 consecutive RYGB patients from two tertiary centers who underwent EDGE. Nutritional and metabolic parameters were assessed before LAMS placement and after removal.

Results: Mean age was 63.2 ± 11.05 years; 23% were male. Significant improvements were observed in serum hemoglobin (mean difference (MD) 1.1 g/dL; P = 0.004), vitamin B12 levels (MD 204.4 pg/mL; P = 0.021), iron (MD 57.9 mcg/dL; P = 0.017), albumin (MD 0.4 g/dL; P = 0.013), and magnesium levels (MD 0.24 mg/dL; P = 0.016). In addition, serum folate (MD 2.2 μg/mL; P = 0.873), and ferritin levels (MD 315.5 μg/mL; P = 0.335), showed improvement trends, but these did not reach statistical significance. No significant changes were observed in total body weight, body mass index, serum glucose, hemoglobin A1c, serum triglycerides, low-density lipoprotein, or high-density lipoprotein ( P > 0.05 for all).

Conclusions: Temporary partial-reversal of RYGB using a LAMS improves key nutritional parameters without compromising metabolic benefits of RYGB. These findings may support a therapeutic role for iatrogenic GG fistulas as a minimally invasive option for RYGB patients with refractory nutritional deficiencies.

Background and study aims: Multiple therapeutic modalities, including surgery and rigid and flexible endoscopy, have been adopted to manage Zenker's diverticulum (ZD). Relief from symptoms such as dysphagia and regurgitation is the main goal of therapy in symptomatic ZD. This study was the first large cohort that aimed to assess efficacy with time and safety of endoscopic diverticulotomy using the Clutch Cutter.

Patients and methods: Cricopharyngeal myotomy was performed in 43 patients at Hospital Saint Joseph de Paris, a tertiary referral center. Symptoms were analyzed before and at 3, 6, and 12 months post-intervention using an extensive questionnaire about dysphagia, odynophagia, regurgitation, chronic cough, state of health, and complications. Procedure details such as duration, complications, and technical success were recorded.

Results: Mean size of ZD was 25.6 mm. Mean procedure time was 48 minutes. No major complications (e.g., perforation, mediastinitis) occurred, although one patient suffered from a sinus piriform wound. Follow-up was performed at 3, 6, and 12 months. During follow-up consultations, patients rated improvement in their symptoms as a percentage. At 12 months, 97% of patients reported 100% improvement.

Conclusions: In patients with treatment-naïve ZD, the Clutch Cutter technique is safe, fast, and provides durable symptom remission.

Background and study aims: Reporting of colorectal polyp morphology using the Paris classification is often inaccurate. Multimodal large language models (M-LLMs) may support morphological assessment. This study aimed to evaluate the accuracy of an M-LLM (GPT-4o) in classifying colorectal polyp morphology compared with expert and non-expert endoscopists.

Patients and methods: We used the SUN dataset of colonoscopy videos from 100 unique colorectal polyps, each labeled with the validated Paris classification. An M-LLM (GPT-4o) classified five representative frames per lesion. Three expert and three non-expert endoscopists, blinded to one another, performed the same task. The primary outcome was accuracy in differentiating non-polypoid (IIa/IIc) from polypoid (Is/Ip/Isp) lesions. The secondary outcome was accuracy in differentiating sessile (Is) from pedunculated (Ip/Isp) lesions. Given the exploratory design, no multiplicity correction was applied; point estimates are presented with 95% confidence intervals (CIs), and P values are interpreted descriptively.

Results: M-LLM accuracy for differentiating non-polypoid from polypoid lesions was 73% (95% CI 63%-81%), comparable to experts (75%, 65%-83%; P = 0.84) and non-experts (77%, 68%-85%; P = 0.52), with similar sensitivity and specificity. Accuracy for differentiating sessile from pedunculated lesions was 55% (95% CI 42%-67%), lower than experts (76%; P = 0.02) and non-experts (77%; P = 0.01), primarily due to poor specificity (12% vs. experts 82% and non-experts 88%; P < 0.01 for both comparisons).

Conclusions: M-LLMs performed comparably to endoscopists in distinguishing non-polypoid from polypoid lesions but failed to reliably identify pedunculated morphology.

Background and study aims: The aim of this study was to validation the accuracy of major guidelines and their adopted unfavorable histologic factors for lymph node metastasis (LNM) in pT1 colorectal cancer (CRC). National Comprehensive Cancer Network (NCCN), Japanese Society for Cancer of the Colon and Rectum (JSCCR), European Society for Medical Oncology (ESMO), and French Intergroup Clinical Practice Guidelines (FICPG) were included.

Patients and methods: Retrospectively, 519 cases receiving oncological resection with lymphadenectomy were included. Factors and four pathological parameters--histological differentiation grades (HDG), lymphovascular invasion (LVI), depth of submucosal invasion (DSI)(>1000μm), and tumor budding (TB)--were analyzed for their impact on LNM incidence individually and in combination as defined by the guidelines.

Results: HDG, LVI, TB, and gender (female) are risk factors for LNM in multivariate analysis. All guidelines have significant ability to predict LNM ( P <0.001). NCCN and ESMO have similar performance, in terms of sensitivity (63.8%/68.1%) and specificity (62.7%/69.5%). JSCCR and FICPG had similar performance in terms of good sensitivity (100%/100%) and low specificity (25.6%/25.2%). The JSCCR/FICPG group had higher sensitivity and lower specificity and accuracy than the NCCN/ESMO group.

Conclusions: HDG, LVI, TB, and gender (female) are independent risk factors for LNM of T1 CRC. DSI is an excellent negative predictor, although not an independent risk factor. The NCCN/ESMO guideline has medium sensitivity and requires improvement. The JSCCR/FICPG guideline has perfect sensitivity but low specificity, thus exposing patients to many unnecessary surgeries. There is revision potential for current guideline factors, including those beyond current pathological ones, to improve LNM prediction accuracy.