Gastrointestinal endoscopy最新文献

Background and aims: Difficult biliary cannulation is an independent risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP); however, there is a noticeable lack of studies focusing on the incidence and risk factors of PEP among patients undergoing easy cannulation. Therefore, we aimed to systematically investigate the risk factors for PEP in patients who underwent easy cannulation.

Methods: We prospectively enrolled patients with naïve major papillae who underwent diagnostic or therapeutic ERCP between June 2018 and June 2023. The primary endpoint was to determine the incidence of PEP in patients with easy cannulation; the secondary endpoints included identifying PEP risk factors and evaluating procedure-related adverse events (AEs).

Results: Overall, 1,930 patients were included, with 1,061 (54.9%) undergoing easy cannulation. Within this cohort, PEP incidence was 3.0%, whereas 2.9% experienced procedure-related AEs, excluding PEP. A history of acute pancreatitis (odds ratio [OR] 95% confidence interval [CI]: 6.75 [1.83-20.14], P=0.001) and acute cholangitis upon admission (OR [95% CI]: 2.25 [1.07-5.08], P=0.039) were identified as independent risk factors for PEP in patients with easy cannulation. Endoscopic sphincterotomy and biliary stent placement were independent factors for procedure-related AEs.

Conclusions: Our findings underscore the importance of assessing patient- and procedure-related factors to mitigate the risk of PEP in patients undergoing easy cannulation. Despite the low incidence of PEP, the potential for the occurrence of severe cases emphasizes the need for cautious intervention, particularly in patients with a history of acute pancreatitis and acute cholangitis upon admission.

Background and aims: Liver transplantation (LT) is a curative treatment for end-stage liver disease. Anastomotic biliary strictures (ABS) are more common in living donor LT (LDLT). However, the success rate of endoscopic retrograde cholangiopancreatography (ERCP) for ABS remains unsatisfactory. This study aimed to evaluate the efficacy of single-operator cholangioscopy (SOC) for ABS treatment in LDLT recipients where standard ERCP failed to access the stricture.

Methods: This prospective study included 40 LDLT patients undergoing ERCP with SOC (SpyGlass™ DS II) to treat ABS when guidewire placement across the ABS was difficult during conventional ERCP (cannulation time >10 min) between October 2021 and May 2023. Our primary endpoint was technical success defined as successful guidewire placement across the ABS and/or subsequent treatment. The secondary endpoints were rates of clinical success, complication, and re-intervention.

Results: The mean patient age was 59.7 (±7.2) years, and the mean time from LDLT to the occurrence of ABS was 212 (±230) days. Technical and clinical successes were achieved in 92.5% (37/40) and 82.5% (33/40) of patients, respectively. The rates of post-ERCP cholangitis, pancreatitis, and bleeding were 10.0%, 15.0%, and 2.5%, respectively. Intestinal perforation did not occur, and all adverse events were mild in severity. Early stent migration within one month occurred in two (5.4%) patients, and four (10.8%) patients required re-intervention within one month.

Conclusions: This study shows the efficacy and safety of SOC-facilitated management for difficult ABS in LDLT patients after failure of standard ERCP.

Background and aims: We aimed to assess the quality of bowel preparation in a matched cohort of patients actively using and not using GLP-1 RAs in a large health system in the United States.

Methods: We performed a retrospective review of adult patients undergoing colonoscopy in 22 endoscopy units across 18 sites in the US.

Results: Our cohort comprised 6235 patients (3344 cases and 2891 controls). Baseline variables causing suboptimal bowel preparation were setting of procedure (inpatient), sex (male), BMI (higher), T2D, IBD, opioid medications, heart failure, and cirrhosis. Total BBPS was significantly higher in controls even after controlling for the abovementioned variables (p < 0.01). Cases were significantly more likely to meet the definition of inadequate bowel preparation. There was no significant difference between different classes of GLP-1 RAs.

Conclusions: Patients using GLP-1 RAs are more likely to have inadequate bowel preparation during colonoscopy, even accounting for other comorbidities.

Background and aims: Interobserver agreement (IOA) among pancreaticobiliary (PB) pathologists in evaluating high-grade dysplasia and/or invasive carcinoma (HGD-IC) of IPMNs remains understudied. EUS-guided needle-based confocal endomicroscopy (nCLE) can evaluate papillary architecture in branch-duct (BD)-IPMNs. We assessed IOA among PB pathologists in classifying dysplasia in resected IPMNs and compared the performance of the Kyoto guidelines' high-risk stigmata (HRS) and pre-surgical EUS-nCLE against reclassified pathology.

Methods: Subjects in prospective clinical trials (2015-2023) with resected IPMNs were included. Blinded PB-pathologists independently reviewed histopathology, achieving a consensus diagnosis. The accuracy of cyst fluid next-generation sequencing (NGS) analysis, EUS-nCLE, and Kyoto-HRS in predicting HGD-IC was compared with the reclassified pathology.

Results: Among 64 subjects, 25 (39%) exhibited HGD-IC (17 HGD, 8 IC). Disagreements occurred in 14% of cases with substantial IOA (kappa=0.70; 95%CI: 0.53-0.88) between two PB-pathologists for differentiating HGD-IC vs. low-grade dysplasia. To detect HGD-IC, the sensitivity, specificity, and accuracy of Kyoto-HRS and EUS-nCLE were 52%, 95%, 78%, and 68%, 87%, 80%, respectively. Integrating nCLE with Kyoto-HRS improved sensitivity to 80%, with specificity and accuracy at 82% and 81%, respectively. The sensitivity, specificity, and accuracy of NGS (n=47) to detect HGD-IC was 6.3%, 100%, and 68%, respectively. A unique subset of IPMNs were identified in all (n=8, p=0.01) cases where pre-surgical EUS-nCLE underestimated dysplasia revealing a distinct micropapillary architecture on post-surgical histopathology.

Conclusions: Despite substantial IOA among experienced PB-pathologists, a second pathologist's review may be warranted for dysplasia classification in IPMNs under certain circumstances. Incorporating an imaging biomarker such as EUS-nCLE with Kyoto-HRS improves sensitivity for HGD-IC without sacrificing accuracy.

Background and aims: Repeat peroral endoscopic myotomy (Re-POEM) appeared to be a promising salvage option for patients with persistent/recurrent symptoms after initial POEM, but it may be more technical challenging. Here we aim to evaluate the safety and technical difficulty of Re-POEM.

Methods: Between July 2012 and October 2023, 158 achalasia patients underwent Re-POEM were retrospectively enrolled. Another 2978 patients without prior myotomy were selected for naïve POEM. After propensity score matching (PSM), procedure-related parameters were compared between the two groups. Univariable and multivariable analyses were performed to reveal risk factors for difficult Re-POEM (defined as procedure time ≥ 90 min).

Results: With similar baseline characteristics between two groups after PSM, the procedure time was comparable between Re-POEM and naïve POEM groups (61.4±27.0 vs. 59.3±29.9, p=0.496). The Re-POEM group showed shorter esophageal myotomy length (7.0±2.1 vs. 8.2±1.1, p<0.001) and longer gastric myotomy length (2.3±0.6 vs. 2.1±0.4, p=0.017), compared with the naïve POEM group. Mucosal injury in Re-POEM group was slightly higher, which was not statistically significant (20.3% vs. 13.9%, p=0.135). No differences were found in the incidence of gas-related adverse events (AEs), major AEs, and technical difficulty. Multivariate analysis determined mucosal edema (OR=4.942, 95% CI, 1.554-15.714, p=0.007) and submucosal fibrosis (OR=3.817, 95% CI, 1.333-10.931, p=0.013) to be independent risk factors for difficult Re-POEM.

Conclusions: Re-POEM appears safe and feasible as a salvage option after initial POEM failure, with comparable procedure duration, incidence of AEs and technical difficulty to naïve POEM. Mucosal edema and submucosal fibrosis were associated with difficult Re-POEM.

Background and aims: In the colorectum, intramucosal carcinoma (IMC), like high-grade dysplasia (HGD), should be resected endoscopically. We were interested to understand how real-world treatment of IMC cases compares to management of HGD and T1 colorectal cancer (CRC).

Methods: A multicenter cohort study was conducted. Through pathology databases, all patients diagnosed between 2010-2019 with HGD, IMC or T1 CRC polyps at three hospitals in a regional Canadian center were identified. The primary outcome was the proportion of surgical management of IMC compared to HGD after complete endoscopic resection. Secondary outcomes were the proportion of synchronous advanced neoplasia (SAN) and the adjusted hazard ratios (aHR) for metachronous advanced neoplasia (MAN) in the three groups among patients eligible for follow-up.

Results: We identified 753 patients with IMC or HGD on a first pathology diagnosis, including 601 after complete endoscopic resection. Patients with IMC were more likely to undergo surgery after complete endoscopic resection compared to patients with HGD (10.5% [6/57] vs 0% [0/544], p<0.001). 455 patients had follow-up endoscopy and pathology (mean age 67.1y, 42.2% female, median follow-up 3.4y): 269 with HGD, 60 with IMC, 126 with T1 CRC. Proportions of SAN were 24.2%, 26.7% and 25.4% (p=0.908). Compared to HGD, patients with IMC and T1 CRC had similar MAN risks (aHR 0.82 [0.43-1.59] and aHR 1.16 [0.66-2.05], respectively). No lymph nodes were positive (0/363) and no metastasis occurred among patients with IMC.

Conclusions: Patients diagnosed with colorectal IMC were more likely to undergo surgery after complete endoscopic resection than when HGD was diagnosed, although they were not at increased risk of SAN or MAN in this study and the known risk of nodal metastasis with colorectal IMC is small (0-2%). Unless a patient diagnosed with IMC is particularly concerned with this small risk, complete endoscopic resection should be considered definitive treatment for IMC and should not be followed by surgery.

Background and aims: Insufficient bowel preparation accounts for up to 42% of missed adenomas in colonoscopy. However, major analysis programs found no correlation between adenoma detection rate and the human-rated Boston Bowel Preparation Scale (BBPS), indicating limitations of the scale. We therefore aimed to develop an open-source automatic bowel preparation scale (OSABPS) based on artificial intelligence that is correlated to the polyp detection rate (PDR).

Methods: OSABPS was trained on 50,000 frames from 20 colonoscopies from three hospitals. It involved quantifying the presence of fecal matter within the colonoscopy frames, using an approach termed the fecal ratio - the proportion of pixels identified as feces (F) relative to those identified as mucosal tissue (M) (OSABPS = F/M) - thereby making 0 the optimal score indicating a perfect cleansing. Youden's J was used to set the threshold, as it determines the optimal balance between sensitivity and specificity. The algorithm was then tested on 1,405 colonoscopies from three hospitals (internal validation), and 5,525 frames from a public colonoscopy database (Nerthus, external validation).

Results: Internal validation: OSABPS correlated significantly with BBPS (Pearson's r = -.42, P<.001). A threshold of .09 OSABPS was determined using Youden's J. PDR was higher for colonoscopies below the threshold of Youden's J (Two proportion z-test, P<.001). External validation: OSABPS correlated significantly with BBPS (Pearson's r = -.70, P<.001).

Conclusions: OSABPS can automatically, instantly and without human bias assess bowel preparation quality. Colonoscopies with an OSABPS > .09 should be considered for reexamination. OSABPS' open-source nature allows free implementation.

Background and aims: We sought to validate the British Society of Gastroenterology (BSG) guidelines for acute lower gastrointestinal bleeding (ALGIB).

Methods: We analyzed 8,956 patients with ALGIB in CODE BLUE-J study and categorized them into four groups based on BSG guidelines. Outcomes included 30-day rebleeding, 30-day mortality, blood transfusion, therapeutic intervention, and severe bleeding.

Results: The severe bleeding rates significantly decreased from Group I to IV: 92.1%, 70.1%, 58.7%, and 38.4%. The rate of the need for blood transfusion and 30-day mortality also decreased from I to IV. Although outpatient follow-up was recommended in Group IV, it had high rates of severe bleeding (38%) and 30-day rebleeding (11%). Notably, for colonic diverticular bleeding, the rate of 30-day rebleeding was 25.5%, even with an Oakland score ≤ 8. We identified abdominal pain, diarrhea, and a high white blood cell count as independent factors that differentiate between non-severe and severe bleeding cases in Group IV. Using these factors, the 30-day rebleeding rate in the non-severe group was 3.6%, suggesting the feasibility of outpatient follow-up in this group. Furthermore, a novel, Group X, which deviated from the existing four groups, had a high severe bleeding rate (70.9%) comparable to that of Group II.

Conclusions: The BSG guidelines suggest a management approach that can clearly differentiate severity. However, caution is advised when using the Oakland score to triage patients for outpatient follow-up. Additionally, prompt intervention may be necessary for groups not covered by the guidelines.

Background and aims: Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for early gastric cancer. However, post-ESD bleeding presents significant risks. Closing mucosal defects following ESD may reduce the incidence of post-ESD bleeding. Currently, no optimal closure method exists. Therefore, we invented clip-line closure using the reopenable-clip over the line method (ROLM) and evaluated its efficacy in preventing post-ESD bleeding.

Methods: We retrospectively reviewed data from patients who underwent gastric ESD between January 2012-March 2024. Patients were categorized into two groups: the non-closure group (mucosal defect remained unclosed) and the ROLM group (defect was closed using ROLM). Baseline characteristics of patients, distribution of bleeding risk factors, and incidence and timing of post-ESD bleeding were compared between the groups. Propensity score matching was employed to minimize potential bias.

Results: Following propensity score-matching, 162 ESDs were performed for 168 lesions in the non-closure group, whereas 160 ESDs were performed for 168 lesions in the ROLM group. The mean long diameter of the mucosal defects, procedure time for ROLM, and number of clips required for ROLM were 45.9 mm, 35.6 min, and 33.2, respectively. All mucosal defects resulting from the ESD were fully closed using ROLM. The post-ESD bleeding rate in the ROLM group was significantly lower (1.8%, 3/168 lesions) than in the non-closure group (7.7%, 13/168 lesions, p = 0.02).

Conclusions: ROLM is feasible for mucosal defect closure following gastric ESD and effectively prevents post-ESD bleeding in high-risk patients, addressing a significant gap in existing methods.