Gastrointestinal endoscopy最新文献

Background and aims: Anesthesia involvement has become commonplace in many procedural settings. The goal of this study is to compare sedation modalities utilized by endoscopists and anesthesiologists in the endoscopy suite, particularly with respect to recovery time and adverse events.

Methods: We conducted a retrospective cohort study including adults (≥18) undergoing outpatient EGD and/or colonoscopy at Mayo Clinic in Jacksonville, Florida between October 1, 2018 through December 31, 2022. Cases were clasified as utilizing Propofol only, Propofol±Adjuvants (including Dexmedetomidine, Ketamine, Fentanyl, Midazolam), General Anesthesia with Endotracheal Tube, or Midazolam/Fentanyl only. The primary outcome was length of stay in the post-anesthesia care unit (PACU LOS), and secondary outcomes included incidence of postoperative nausea and vomiting (PONV), hypoxemia (SpO2

Results: 56,361 cases were included in the analysis. Among patients who received Midazolam/Fentanyl sedation, mean PACU LOS was 52.01, 49.68, and 53.24 minutes for EGD, COL, and Combined procedures, respectively. This was significantly higher than 44.65, 41.41, 41.92 for General Anesthesia, 32.35, 35.75, 33.42 for Propofol + Adjuvants, and 31.63, 32.61, 33.29 for Propofol (p<0.0001). Of the patient receiving Midazolam/Fentanyl, 8.39% experienced bradycardia, 6.12% experienced hypoxia, 0.24% experienced PONV, and 0.05% were hospitalized. These were substantially lower than the rates for other sedation groups, and odds ratios were significantly lower than 1.00 (p<0.05) in 30 out of 36 comparisons across procedural, sedative, and outcome categories.

Conclusions: Sedation achieved with Midazolam/Fentanyl correlated with a lower rate of adverse events but significantly longer PACU LOS compared to Propofol, Propofol + Adjuvants, or General Anesthesia.

Background and aims: Survey based studies show a high prevalence of endoscopy related injury (ERI). This survey aims to provide data regarding the type of design changes to the colonoscope that would be most beneficial for gastroenterologists and facilitate user-centered design changes.

Methods: A 26-item anonymous, electronic, multiple-choice survey was answered by 455 gastroenterologists. Information obtained included demographic data (age, gender), workload parameters (current practice type, years practicing, time spent performing endoscopy), and questions related to colonoscope maneuvers and design (hand size, ease of use of tip angulation controls, impact of shaft parameters, use of right-hand torque, use of dial extenders, future desired design changes). Data analysis was performed using IBM SPSS 29.0.

Results: The survey respondents included a broad distribution of representative groups, with 55.3% in private practice, 31.4% women, and 51.5% having > 10 years in practice. 85.7% favored a pro-ergonomic colonoscope redesign, with customizability for hand size of the control knobs (85%) and decreased force required for "up/down" knob manipulation (78%) being the most desired features. Women were statistically more likely to desire a more ergonomic colonoscope and customizability for hand size (P < 0.001).

Conclusions: This paper reports the results of the first national survey to assess gastroenterologist preferences for ergonomic colonoscope design changes. The colonoscope changes respondents prioritized were those pertaining to customizability for hand size and more easily manipulated control surfaces. Professional societies and industry should work together to design scopes more aligned with best ergonomic principles.

Background and aims: Guidelines recommend endoscopic detorsion in cases of sigmoid volvulus without ischemia or perforation, but the timing in which this should be performed is unclear.

Methods: Admissions for sigmoid volvulus in which endoscopic detorsion was performed between 1/2010-4/2024 were retrospectively reviewed. The timing was calculated as the time between when the confirmatory radiologic exam and endoscopic detorsion were performed. The timing was compared to various patient outcomes.

Results: 118 episodes of sigmoid volvulus from 73 unique adult patients were included (mean age 69.0; 76.3% male). The median time until endoscopic detorsion was 225.5 minutes (IQR 144.5-478.3) with 81 (68.6%) performed in <6 hours. The timing of detorsion was not associated with the presence of ischemia (p=0.289) or a combination of serious outcomes (p=0.777). Those who underwent delayed endoscopic detorsion (>6 hours) were more likely to be younger (62.4 vs 67.4, p=0.034) and have had a rectal tube placed (59.5% vs 21.0%, p<0.001). Delayed cases were associated with a longer length of admission (5.0 vs 3.0 days, p=0.011); however, other outcomes such as the success of endoscopic detorsion, presence of ischemia, readmission rate, and mortality rate showed no difference between the groups. In a multivariate regression analysis, serious outcomes were associated with "on call" status (p=0.045), but not the timing of detorsion (p=0.404).

Conclusions: There does not appear to be a clear correlation between a longer delay until endoscopic detorsion and worse patient outcomes, with only the length of hospitalization affected. This suggests that endoscopic detorsion need not always be performed urgently.

Background & aims: There is conflicting literature describing the durability of complete remission of intestinal metaplasia (CRIM) after endoscopic eradication therapy (EET) for Barrett's esophagus (BE). We aim to assess the timeline, predictors and long-term outcomes of recurrence.

Methods: Data on 365 patients who underwent EET for dysplastic BE were collected prospectively between 2008 and 2022 at a Barrett's referral unit. Kaplan-Meier method and Epanechnikov-kernel density estimate were used to determine the cumulative incidence of recurrence following CRIM and the rate of recurrence over time. A logistic regression analysis was fitted to identify factors associated with recurrence.

Results: 216 patients achieved CRIM and were then followed for a median (IQR) 5.8 years (2.9, 7.2). Intestinal metaplasia (IM) recurred in 57 patients (26.4%) and dysplasia in 18 patients (8.3%). The time to recurrence peaked at 1.8 years. The cumulative recurrence risk within 2 years was 23.1% with an additional 29.2% risk over the next 10 years. Increased risks of any BE recurrence (Odds ratio (OR) 3.0; p=0.009), dysplastic (Relative risk ratio (RRR) 5.53; p=0.001) and late (≥2 years) recurrences (RRR 3.24; p=0.01) were associated with radio-frequency ablation (RFA) monotherapy, whereas combination endoscopic mucosal resection (EMR) and RFA was associated with a decreased risk of dysplastic recurrence (RRR 0.27; p=0.02).

Conclusion: The risk of recurrence is highest within the first 2 years post-CRIM, but remains significant long term. The risk of IM, dysplasia and late recurrence is higher when RFA was the sole modality used to achieve CRIM, raising the possibility that RFA provides a less durable response. These findings may impact treatment and surveillance decisions.

Background and aims: Malignant gastric outlet obstruction (MGOO) is an unfortunate complication of advanced upper gastrointestinal malignancies. Historically, surgical gastrojejunostomy has been the procedure of choice to achieve enteral bypass. Recently, endoscopic techniques have gained popularity in the management of MGOO. We aimed to compare peri-procedural outcomes between surgical and endoscopic gastrojejunostomy in patients with MGOO.

Methods: The National Inpatient Sample (NIS) was queried for 2016 through 2020. The International Classification of Diseases, Tenth Revision (ICD-10) codes were used to identify adult admissions with a principal diagnosis of gastric, pancreatic, or duodenal cancer undergoing endoscopic gastrojejunostomy (EGJ) or surgical gastrojejunostomy (SGJ). The two cohorts were compared for peri-procedural adverse events.

Results: Twenty thousand nine hundred thirty (20,930) hospitalizations undergoing gastrojejunostomy (16,585 SGJ and 4,345 EGJ) for MGOO were identified. The SGJ cohort had a higher proportion of patients with pancreatic cancer (36.16% vs 19.56%) and a lower proportion of patients with gastric cancer (55.16% vs 71.99%). A higher percentage of endoscopic GJs were performed in the Northeast (20.33% vs 27.66%, P<0.001), while a smaller percentage of endoscopic GJs were performed in the South (30.56% vs. 39.52%, P <0.001). Between the two groups, the difference in mortality rates was not significantly different [0.62, 95% CI 0.35-1.10, P =0.106), but the EGJ group had lower odds of respiratory failure [4.7% vs. 7.4%, aOR (adjusted odds ratio) 0.68, 95% CI (confidence interval) 0.48 - 0.96, P =0.032], blood transfusion [9.25% vs. 13.74%, aOR 0.63, 95% CI 0.48 - 0.82, P =0.001], and peritonitis [2.19% vs 4.5%, aOR 0.55, 95% CI 0.33-0.91, P =0.022]. The EGJ group had lesser hospitalization charges [mean $164,794 vs. $183,519, adjusted difference on regression $16,495, 95% CI $29,204 - $3,786, P =0.011], and shorter hospital stays [mean 9.88 vs. 12.56 days, adjusted difference 2.24 days, 95% CI 1.53 - 2.96 days, P <0.001]. The use of EGJ increased over five years [16.86% in 2016 to 24.14% in 2020, P-value for trend=0.002], while the use of SGJ decreased [83.13% in 2016 to 75.85% in 2020, Trend P=0.002].

Conclusions: Compared to surgical GJ, endoscopic GJ is associated with lower rates of peri-procedural adverse events, hospitalization charges, and length of stay. For these reasons, endoscopic GJ should be strongly considered in managing malignant gastric outlet obstruction.

Background and aims: Factors predicting the need for step-up procedures after EUS-guided drainage (EUS-FCD) of peripancreatic fluid collections (PFCs) were explored in retrospective studies restricted to Walled-Off Necrosis (WON) and Lumen Apposing Metal Stents (LAMS).

Methods: All consecutive candidates for EUS-FCD between 2020-2024 were included in a Prospective Registry of Therapeutic EUS (PROTECT, NCT04813055), with prospective monthly follow-up evaluating clinical success, adverse events and recurrences. Prospectively assessed baseline clinical and morphological factors, including the Quadrant-Necrosis-Infection (QNI) classification, were included in a stepwise logistic regression model to predict the need for step-up. The agreement between EUS and Radiology in assessing the extent of necrosis was compared with Cohen's kappa.

Results: Seventy patients (29 post-surgical collections, 21 pseudocysts, and 20 WONs) were treated with double-pigtail plastic stents (DPPS) in 59% of cases and LAMS in 41%. Clinical success was 92.9%, with a need for step-up (mostly endoscopic necrosectomy) in 35.7% of cases. Necrosis ≥60% (OR=7.7, 95%CI 1.4-43) and being in the high-risk QNI group (OR=4.6, 95%CI 1.4-15) were the only independent predictors of any step-up. The same factors predicted the endoscopist's decision to allocate PFCs to LAMS vs. DPPS. The high-risk QNI group was associated with a significantly longer hospital stay (12 days vs. 4 days, p=0.004). EUS tended to upscale the necrotic content compared to preprocedural Radiology (κ=0.31) CONCLUSIONS: The extent of necrosis and the QNI classification strongly correlated with the need for step-up and allocation to LAMS vs. DPPS drainage, proposing a central role in treatment personalization.