Gastrointestinal endoscopy最新文献

Background and aims: Peroral endoscopic myotomy (POEM) has become a major treatment for esophageal motility disorders. Early routine post-POEM esophagram is frequently performed to assess for adverse events (AEs), although the clinical benefit remains questionable. We conducted a systematic review and meta-analysis to evaluate the clinical impact of a routine esophagram after POEM in asymptomatic patients.

Methods: PubMed was searched from inception to November 2024. The primary outcome was to evaluate the incidence of intramural and extramural esophageal leaks after POEM. Secondary outcomes included radiographic findings on routine esophagram after POEM and the rate in which radiographic findings resulted in a change in management. A random-effects model was used, and outcomes were represented as pooled rates, along with 95% confidence intervals (CIs).

Results: Fourteen studies with 2153 patients were included. Most patients (mean age ranged from 39.4 to 59.3 years) had achalasia (90.6%) with a mean baseline Eckardt score ranging between 3.0 and 12. Patients underwent a routine esophagram within 24 to 72 hours after POEM. The pooled rates of intramural and extramural esophageal leaks were 2.3% (95% CI, 0.8-6.1; I² = 79.4) and 1.4% (95% CI, 0.8-2.5; I² = 81.6), respectively. Pneumoperitoneum and pneumomediastinum were the 2 most common findings on imaging, with pooled rates of 42.0% (95% CI, 26.5-59.2) and 33.7% (95% CI, 12.4-64.6), respectively. Collectively, the frequency in which routine imaging findings resulted in a change in management was 3.4% (95% CI, 1.7-6.8; I² = 81.6).

Conclusions: Esophageal leakage is a very uncommon AE after POEM. Routine esophagram rarely impacted immediate postprocedural care in asymptomatic patients. Selective imaging may result in higher diagnostic yield and improved cost-efficiency, and mitigate the risk of unwarranted additional testing due to incidental radiographic findings.

Esophagogastroduodenoscopy is essential to evaluate symptoms of suspected eosinophilic esophagitis (EoE), assess endoscopic findings, obtain biopsy specimens for histopathologic evaluation, perform esophageal dilation, confirm the diagnosis, and monitor the condition. The American Society for Gastrointestinal Endoscopy (ASGE) previously provided consensus recommendations on the approach to endoscopy in EoE across topics of endoscopic diagnosis, endoscopic grading, and esophageal dilation. Because additional areas of endoscopy still required guidance, we performed an independent modified Delphi process focusing on pediatric considerations, disease assessment, and disease monitoring. A core group of EoE experts reviewed published guidelines and developed a set of patient-centered recommendation statements informed by literature review. A multidisciplinary group of adult and pediatric international EoE experts then voted on the statements over 2 Delphi rounds. All statements with 80% agreement were accepted for inclusion. This process yielded 28 consensus statements. Pediatric-specific statements covered when to suspect EoE and perform endoscopy, how to grade endoscopic severity, and when and how to perform esophageal dilation in children. Statements across all age ranges addressed the role of less-invasive monitoring, performing diagnostic endoscopy off treatment, the need to consider symptoms, endoscopic features, and histologic findings when assessing disease activity, treatment-based monitoring intervals, and the approach to esophageal biopsies during monitoring. Coupled with the original consensus work, we provide a comprehensive endoscopic approach to EoE as well as practical guidance for procedure-related aspects in the field to facilitate high-quality endoscopic care to patients with EoE.

Background and aims: Delayed postpolypectomy bleeding (DPPB) is an established adverse event after EMR of large nonpedunculated colon polyps (LNPCPs). Although clipping is commonly used in clinical settings, particularly for LNPCPs and for patients on antithrombotic agents, the cost-effectiveness of prophylactic clipping is not well studied.

Methods: We conducted an incremental cost-effectiveness analysis comparing prophylactic clipping (PC) versus no clipping (NC) for DPPB over a 1-year time horizon using a Markov decision tree model based on pooled randomized controlled trial data. Costs for hemostatic clips, hospitalization, and EMR were derived from Centers for Medicare & Medicaid Services reimbursement data and published literature. Analysis was performed by using TreeAge Pro Healthcare 2024.

Results: Pooled data from 4557 patients (2288 PC; 2269 NC) were analyzed. For a base case of a 65-year-old patient undergoing EMR of ≥20 mm proximal LNPCP, PC resulted in an incremental cost-effectiveness ratio (ICER) of -$154,706, indicating cost savings. For very large (≥40 mm) LNPCPs, PC was cost-effective compared with NC, with an ICER of $83,894. Among patients with LNPCPs on antithrombotic therapy, PC was cost-saving when up to 2 clips were used, with an ICER of -$120,561. For proximal LNPCPs, PC remains cost-effective when per-clip cost is below $217 or <4 clips are used.

Conclusions: At a willingness-to-pay threshold of $100,000 dollars per quality-adjusted life year, PC is cost-saving for proximal LNPCPs, cost-effective for very large (≥40 mm) LNPCPs, and cost-saving for patients with LNPCPs on antithrombotic agents. Reducing clip costs (≤$217) and optimizing usage (≤4 clips) further improve economic viability of PC.