Gastrointestinal endoscopy最新文献

Background: /Aims: Polypectomy is a procedure associated with a high risk of bleeding. Guidelines recommend uninterrupted aspirin use during polypectomy, whereas cessation of clopidogrel 5-7 days before polypectomy is recommended. The cold snare resection technique, with or without submucosal injection, is considered safer than conventional polypectomy using electrocoagulation for post-polypectomy bleeding. In this study, we aimed to compare the bleeding complications associated with cold snare resection between clopidogrel and aspirin users.

Methods: This multicenter, prospective cohort study was conducted in five academic hospitals in Korea and included clopidogrel and aspirin users who underwent polypectomy. Antiplatelet agents were used without interruption, with ≤ 3 days of interruption defined as continuous use. The primary endpoint was delayed bleeding, which was defined as bleeding occurring several hours after polypectomy, whereas immediate bleeding was defined as bleeding requiring hemostasis 2 min after polypectomy. Risk factors for immediate bleeding were investigated for each polyp.

Results: Among the 263 patients (clopidogrel, n = 129; aspirin, n = 134), 509 underwent polypectomies. The rate of delayed bleeding per patient in the clopidogrel and aspirin groups was 0.8% and 0.7%, respectively, meeting noninferiority (rate difference 0.03% [95% confidence interval: -2.07% to 2.13%]). Hemostasis was achieved in 100 patients who underwent polypectomy (19.8%). Immediate bleeding risk factors included female sex, end-stage renal disease, submucosal injection before resection, and polyp size ≥ 5 mm.

Conclusions: This multicenter prospective study demonstrated the safety of cold snare resection in patients treated with uninterrupted clopidogrel and aspirin (NCT04328987).

Background and aims: Endoscopic ultrasound (EUS) is sensitive in detecting pancreatic neuroendocrine neoplasm (pNEN). However, the endoscopic diagnosis of pNEN is operator-dependent and time-consuming since pNEN mimics normal pancreas and other pancreatic lesions. We intended to develop a convolutional neural network (CNN)-based system named iEUS for identifying pNEN and multiple types of pancreatic lesions via EUS.

Methods: Retrospective data of 12,200 EUS images obtained from pNEN and non-pNEN pancreatic lesions, including pancreatic ductal adenocarcinoma (PDAC), autoimmune pancreatitis (AIP), and pancreatic cystic neoplasm (PCN), were used to develop iEUS. It was composed of a two-category (pNEN/ non-pNEN pancreatic lesion) classification model (CNN1) and a four-category (pNEN/ PDAC/ AIP/ PCN) classification model (CNN2). Videos from consecutive patients were prospectively collected for a human-iEUS contest to evaluate the performance of iEUS.

Results: A total of 573 patients were enrolled in this study. In the human-iEUS contest containing 203 videos, CNN1 and CNN2 showed an accuracy of 84.2% and 88.2% for diagnosing pNEN, respectively, which were significantly higher than that of novices (75.4%) and comparable with intermediate endosonographers (85.5%) and experts (85.5%). In addition, CNN2 showed an accuracy of 86.2%, 97.0%, and 97.0% for diagnosing PDAC, AIP, and PCN, respectively. With the assistance of iEUS, the sensitivity of endosonographers at all three levels in diagnosing pNEN has significantly improved (64.6% vs. 44.8%, 87.5% vs. 71.9%, 74.0% vs. 57.6%, respectively).

Conclusions: The iEUS precisely diagnosed pNEN and other confusing pancreatic lesions, thus could assist endosonographers in achieving more accessible and accurate endoscopic diagnoses via EUS.

Background and aims: Biliary drainage by endoscopic retrograde cholangiography (ERCP) in patients with malignant distal bile duct obstruction (MBO) is frequently associated with complications, such as pancreatitis, hampering patient outcome. EUS-guided choledochoduodenostomy (EUS-CDS) with a lumen-apposing metal stent (LAMS) is a promising alternative in patients with MBO but is associated with a worrisome risk of stent dysfunction. Placement of a fully covered self-expandable metal stent (FCSEMS) through the LAMS, thereby changing the axis of biliary drainage towards the descending duodenum, may decrease the risk of stent dysfunction while maintaining high technical success and low adverse event rates.

Methods: Prospective single center pilot study in patients with a pathology confirmed MBO without gastric-outlet obstruction. Primary outcome was stent dysfunction, defined as recurrent jaundice after initial clinical success, ongoing jaundice in combination with persistent bile duct dilatation, or cholangitis. The study was registered in clinicaltrials.gov (registry number NCT05595122).

Results: Overall, 27 consecutive patients eligible for EUS-CDS were enrolled. The placement of a LAMS was successful in 24/27 patients (89%), and placement of FCSEMS through the LAMS was successful in 20/24 (83%), in the remaining 4 patients a coaxial double-pigtail plastic stent was placed. In 2 of these 20 patients there was persistent jaundice requiring stent revision (10%), leading to a clinical success rate of 90%. No patients developed stent dysfunction after initial clinical success.

Conclusions: This study showed a stent dysfunction rate of 10% following technically successful EUS-CDS with placement of a FCSEMS through the LAMS. Improving the design of LAMS may further reduce the rate of stent dysfunction.

Background and aims: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are known to cause delayed gastric emptying, however the effect on clinical outcomes during upper endoscopy/colonoscopy remains unclear. We conducted a meta-analysis to reconcile the data.

Methods: Online databases were searched for studies evaluating GLP-1RAs vs control group (no GLP-1RAs) in patients undergoing endoscopy. The outcomes of interest were rate of retained gastric contents (RGC), aborted procedures, aspiration events and subjective bowel preparation quality. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a random-effects model.

Results: A total of 23 studies with 77,271 patients (4,449 in the GLP-1 RA arm and 72,703 in the control arm) were included. The mean age ranged from 47.6 to 72 years and 58.4% were females. As compared to the control group, the GLP-1 RA group had higher odds of RGC (OR 15.39, 95% CI 4.65-50.99, p < 0.01) and aborted procedures (OR 13.86, 95% CI 4.42-43.43, p < 0.01). No significant differences were observed between the two groups in terms of aspiration events (OR 21.06, 95% CI 0.13-3379.01, p=0.24) and subjective bowel preparation quality (OR 0.94, 95% CI 0.67-1.31, p=0.83).

Conclusion: While statistical significance was reached in terms of visible RGC and early termination of endoscopies in patients on GLP-1RAs, these events were overall rare. GLP-1RAs do not appear to pose significant risk, as the odds of developing aspiration were comparable in the two groups.

Background and aims: Audit and feedback (A&F) for endoscopic retrograde cholangiopancreatography (ERCP) is relatively understudied despite the demonstrated effectiveness of A&F for endoscopic procedures such as colonoscopy. Endoscopist 'report cards' are one A&F tool. We aimed to develop an ERCP report card and assess its appropriateness, acceptability and feasibility through usability testing.

Methods: A prototype report card was designed using a combination of published quality indicators and established predictors of adverse events (AE). Exploratory analyses from a prospective multi-center registry were performed to further identify novel and/or understudied parameters for possible inclusion. Semi-structured interviews with ERCP endoscopists were conducted and framework analysis performed. Validated post-interview usability instruments were administered. Feedback was incorporated to create a final report card.

Results: The report card included domains of technical parameters, AE rates/prevention, and patient-reported experience measures (PREMs). Qualitative feedback was positive, with respondents agreeing with inclusion of relevant content in most domains. Post-interview instruments revealed adequate appropriateness and acceptability. PREMs were felt by respondents to be poorly actionable and were replaced with appropriateness of indication and fluoroscopy usage parameters in the final report card. Concerns were raised regarding the feasibility of implementation due to reliance on difficult-to-obtain granular intraprocedural data.

Conclusions: We designed and tested an ERCP report card that has potential to be an effective A&F intervention for endoscopists in clinical practice. Though feasibility of data capture and implementation are currently limitations, advances in video recording and artificial intelligence technologies could accelerate widespread adoption of such a tool.