Gastrointestinal endoscopy最新文献

Background and aims: Histological diagnosis of autoimmune pancreatitis (AIP) may be difficult to obtain preoperatively. Based on promising results using new-generation "end-cutting" needles, we aimed to assess the utility of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) in enhancing diagnostic levels of International Consensus Diagnostic Criteria (ICDC) in probable AIP patients and in defining the specific AIP subtype.

Methods: Adult patients with suspected AIP were prospectively and competitively enrolled at four Centers. Definitive AIP diagnosis, according to ICDC, or patients recently treated with steroids were excluded. A 22-gauge end-cutting needle was used in all cases. The primary outcome was the rate of enhanced ICDC levels. Secondary outcomes were rates of level 1 or 2, EUS-FNB diagnostic accuracy, rate of malignancy, and safety.

Results: Fifty focal and two diffuse suspected AIP were enrolled (75% male, mean age 57.9±17.3). Final diagnoses were AIP, chronic pancreatitis, and malignancy in 39 (75%), 6 (11.5%), and 7 (13.5%) patients, respectively. EUS-FNB improved the diagnostic level of AIP in 92.3% (74.3% definitive and 17.9% probable). The rate of histology level 1 compatible with a diagnosis of type 1 and type 2 AIP was 73.1% and 50%, respectively. The rate of histology level 2 was 23.1% and 41.7% in type 1 and type 2, respectively. The overall diagnostic accuracy of EUS-FNB was 94.2% [95% CI 84.1-98.8]. Two mild pancreatitis (3.8%) occurred after EUS-FNB.

Conclusions: EUS-FNB using end-cutting needles enhances ICDC criteria in >90% of patients, ruling out malignancy in focal presentations and defining the specific subtype of AIP.

Clinicaltrial: gov number, NCT04397731.

Background and aims: One of the most prevalent and fatal tumors, colorectal cancer (CRC) has a significant impact on the use of healthcare services. Although Hong Kong's CRC screening program has been successful, it does not prioritize preventing early-onset colorectal cancer in people under 50. This study aimed to assess the cost-effectiveness of different starting ages for colorectal cancer (CRC) screening among an Asian population.

Methods: We conducted a simulation study involving 100,000 individuals in Hong Kong who were screened using either fecal immunochemical test (FIT) or colonoscopy as primary screening methods at ages 40, 45, and 50 until age 75. The performance of different strategies was evaluated based on life-years gained, and cost-effectiveness was measured using the incremental cost-effectiveness ratio (ICER).

Results: The ICERs for initiating FIT screening at age 50, screening starting at age 45, and screening starting at age 40 were USD 53,262, USD 67,892, and USD 86,554, respectively. For colonoscopy, the ICERs for initiating screening at ages 50,45 and 40 were USD 267,669, USD 312,848, and USD 372,090, respectively, respectively. Overall, the FIT strategy was found to be less costly. At 70%, 80% and 90% compliance rates, FIT at age 45 gained 2,135, 2,296 and 2,438 life years respectively; colonoscopy at age 45 gained 2,725, 2,798 and 2,855 life-years respectively. With increased compliance rates, FIT could save a similar number of life years as colonoscopy with lower cost.

Conclusions: Initiating CRC screening at age 45 using FIT in Hong Kong was determined to be a well-balanced and cost-effective strategy. This approach demonstrated a cost advantage over starting screening at age 40 and resulted in more lives saved compared to screening at age 50.

Background and aims: High migration rates for fully covered self-expanding metal stents (FC-SEMSs) have been reported in the literature. Endoscopic suture fixation has been explored as a mitigation strategy. We aimed to compare rates of migration and other adverse events after esophageal FC-SEMS placement with and without endoscopic suturing.

Methods: We performed a randomized controlled trial involving adult patients who underwent FC-SEMS placement at our institution for management of esophageal strictures (ClinicalTrials.gov: NCT05082948). Patients were randomly allocated (1:1 stratified randomization based on benign or malignant etiology) to FC-SEMS placement with endoscopic suture fixation or FC-SEMS placement alone. All investigators were blinded to the randomization sequence. Patients and statistical analysts were blinded to intervention assignment. Primary outcome was stent migration, and secondary outcomes were other stent-related adverse events, technical success, procedure duration, time to migration, premature stent removal due to adverse events. Additionally, we performed a cost-effectiveness analysis (CEA) comparing endoscopic suturing with FC-SEMS placement alone.

Results: Between July 2021 and December 2022, 46 patients were enrolled - 24 in the fixation group and 22 in the non-fixation group. In intention-to-treat analysis, stent migration rate was significantly lower in the fixation group compared to the non-fixation group (Risk ratio, 0.28, 95% CI, 0.11-0.74, p = 0.008). All secondary outcomes were similar in both groups, except procedure duration, which was longer in the fixation group (p = 0.001). Endoscopic suturing was cost-effective for preventing stent migration compared to stent placement alone. The trial was terminated early after interim analysis clearly showed inferior primary outcomes in the non-fixation group.

Conclusions: These findings support the efficacy, safety, and cost-effectiveness of endoscopic suture fixation for preventing esophageal FC-SEMS migration. Further studies comparing endoscopic suturing and other stent fixation strategies are warranted.

Background and aims: Zenker's peroral endoscopic myotomy (Z-POEM) has demonstrated excellent technical and clinical success. However, the remnant mucosal flap can result in symptom recurrence. In addition, mucosal closure can be technically challenging. This study introduces Open Z-POEM (OZ-POEM), a modified approach that allows additional mucosotomy by eliminating mucosal closure.

Methods: This is a retrospective observational study, in which patients with Zenker's diverticulum who underwent OZ-POEM were included from December 2022 to May 2024. The primary outcome was clinical success (Kothari-Haber Score <3). The secondary outcomes included technical success, recurrence, and adverse events.

Results: A total of 53 patients (mean age 74±10 years, 69.8% males) underwent OZ-POEM in two centers (USA and India), with a mean diverticulum size of 26±14 mm. OZ-POEM was technically successful in all patients, with a mean procedure time of 19±6 minutes. There was a significant decrease in the median (IQR) Kothari-Haber score from 7 (5-8) to 1 (0-1) (p < 0.01) after a median follow-up of 23.5 weeks. Two patients (3.8%) experienced symptomatic recurrence after a median of 28.5 weeks, requiring re-intervention. One patient (1.9%) had a late ulcer resolved with medical therapy, and another (1.9%) an early leak treated with vacuum therapy, with all asymptomatic at follow-up.

Conclusions: OZ-POEM is a novel, feasible, and safe procedure with a short procedure time, eliminating the need for incision site closure. The incorporation of extensive mucosotomy is the likely reason behind the very low recurrence rate (3.8%); however, prospective comparative studies are necessary to support these findings.

Background and aims: Human-computer interaction, particularly the graphical user interface (GUI) for displaying detection results, is an important but underexplored aspect of CADe systems in endoscopy. The aim of this study was to study if the use of a bounding box GUI or a heatmap GUI results in different performance of endoscopists when using CADe for Barrett's neoplasia.

Methods: Thirty-seven endoscopists from six countries with varying expertise assessed 70 Barrett's esophagus videos. All videos were evaluated by our previously developed CADe system and comprised, at some point, a CADe detection, irrespective if the video contained neoplasia or not. The study had two phases: initially, videos were shown with either a bounding box or heatmap; after a two-week wash-out, the same videos were reordered and displayed with the alternate GUI. Endoscopists marked perceived neoplastic lesions and biopsy sites, also noting their subjective GUI preference. Primary endpoints were objective classification and localization performance. Secondary endpoint was the subjective preference.

Results: There was no statistically significant difference in classification performance when endoscopists were provided with the bounding box or the heatmap visualization (sensitivity 83% vs. 83%, p = 0.29; specificity 86% vs 86%, p =0.09). Also, the comparison of localization accuracy between the bounding box and heatmap methods showed no significant differences, with both methods yielding a median score of 97%. Subjectively, 23 endoscopists preferred the heatmap and 14 the bounding box (p=0.04).

Conclusions: Although endoscopists expressed a preference for the heatmap GUI, this was not associated with a statistical difference in performance outcomes.