Digestive Endoscopy最新文献

In their multicenter randomized trial, Ichijima et al.¹ demonstrated that remimazolam achieves significantly better sedation effect during upper gastrointestinal endoscopy than a placebo. However, using a placebo control is questionable, given remimazolam's established efficacy and the typically low placebo effect (<5%). Using widely used sedatives as active comparators would have been more impactful; this limitation of study design reduces the impact of the research findings.

A recent meta-analysis reported propofol's superiority in terms of time to loss of consciousness and sedation success after the first dose, but with no differences in procedural outcomes.² Remimazolam had a better safety profile, showing lower risks of bradycardia, hypoxemia, and injection site pain. A Chinese study of 384 patients undergoing upper gastrointestinal endoscopy reported that the sedation success rate of remimazolam was noninferior to propofol (97.3% vs. 100%), with shorter time to full awakening and fewer circulatory and respiratory issues.³

Considering the potential expansion of remimazolam use over traditional sedatives like midazolam, it is encouraging that studies targeting Asian populations are increasing, as pharmacodynamics and pharmacokinetics of benzodiazepine might vary by ethnicity or genetic polymorphism.⁴ Metabolized by carboxylesterase 1, remimazolam exhibits dose-dependent sedative action and minimal tissue accumulation, largely independent of liver and kidney function. However, recent reports of re-sedation, delayed emergence, and anaphylaxis associated with remimazolam highlight the need for further research on carboxylesterase 1 polymorphism associations.⁵

In conclusion, remimazolam, a new ultra-short-acting benzodiazepine, is notable for its rapid onset, efficacy, and safety, although recent discussions on adverse effects are emerging. Further studies are required to evaluate its efficacy and safety in prolonged sedation for therapeutic endoscopy. Additionally, research on its use in higher risk patients and the benefits of drug combinations with other sedative agents will greatly aid in standardizing its use in endoscopic procedures.

Authors declare no conflict of interest for this article.

There are multiple treatments available for diverticular hemorrhage.¹ Endoscopic identification of stigmata of recent hemorrhage (SRH), especially visible vessels, is important but often difficult.² Exposed vessels are identified by aspirating the diverticulum with a long transparent hood and inverting it. However, some diverticula cannot be visualized inside and are inverted owing to inflammation when the exposed bleeding duct (SRH) is identified. The underwater method improves visibility. Using the opened-it-halfway reopenable clip method³ enables hemostasis without inversion.

The patient, a 77-year-old man, presented with stable vital signs. Computed tomography revealed no obvious sources of bleeding. A colonoscopy (PCF 290TI; Olympus, Tokyo, Japan) with a long hood (MAJ663; Olympus Medical Systems, Tokyo, Japan) (tip protrusion length, 12 mm) was performed using the underwater method to identify the SRH (Fig. 1). Subsequently, we inserted a closed 8 mm SureClip (Micro-Tech, Nanjing, China), opened it halfway, deployed it into the diverticulum (Fig. 2), and performed clipping, successfully achieving hemostasis (Video S1). Other methods do not use a long hood and invert before clipping⁴; however, our method can be used in cases where inversion is impossible. Small diverticula or diverticula that cannot be inverted owing to inflammatory changes can be observed with underwater immersion.⁵ When SRH was identified, a clip was inserted using the opened-it-halfway reopenable clip method, and clip hemostasis was performed. Initial avoidance of underwater procedures was due to potential significant bleeding and fecal masses in patients with diverticular hemorrhage. The use of a long hood offers the advantage of enclosing the diverticulum within the hood without a slit, enabling its observation using the magnification effect and fluid force offered by underwater immersion.

Authors declare no conflict of interest for this article.

In recent years, the usefulness of endoscopic ultrasound (EUS) has been recognized in children. A dedicated pediatric EUS scope has not been developed; in our experience, however, an adult EUS scope can be used. The American Society for Gastrointestinal Endoscopy Technical Committee status assessment report on pediatric endoscopy equipment provides some guidance on the feasibility of EUS according to body size. Careful monitoring is required, keeping in mind potential adverse events such as cervical esophageal perforation and unstable breathing due to tracheal compression. Most devices designed for interventional pancreatobiliary endoscopy are also available for children. Sedation or intubated general anesthesia (GA) is mandatory when performing interventional EUS (I-EUS). I-EUS for children is generally performed using GA in the operating room, but sedation in the endoscopy room is also possible under appropriate monitoring by pediatricians. I-EUS in the operating room is sometimes difficult for endoscopists to perform because of the unsuitable fluoroscopic imaging and the lack of familiar equipment and staff. Compared to GA, sedation in the endoscopy room facilitates easier and quicker repetition of procedures when necessary. Adult pancreatobiliary endoscopists perform most I-EUS procedures in the pediatric population because most pediatric endoscopists have few opportunities to perform EUS-related procedures and thus have difficulty maintaining their skills. To popularize I-EUS techniques for children, it will be necessary to establish a training program for developing pediatric endoscopists.

Postoperative bleeding and perforation are common complications of gastric endoscopic submucosal dissection (ESD),¹ and closure is a topic. However, closures are often complicated.^{2, 3} Nishiyama et al.⁴ described the use of novel thin grasping forceps for over-the-scope clip (OTSC) closure after endoscopic full-thickness resection. The grasping forceps (TechGrasper; Micro-Tech, Nanjing, China) offers two main advantages. The forceps' small diameter does not interfere with suction applied before the OTSC deployment, and the strong grasping power ensures reliable staple application to the muscle layer. Here, we report the first case of successful ulcer closure after gastric ESD using TechGrasper-assisted OTSC.

A 78-year-old man with lung adenocarcinoma underwent esophagogastroduodenoscopy for preoperative screening, which revealed a 30 mm gastric cancer. Although the patient was a candidate for ESD, lung resection was prioritized because of advanced-stage lung cancer (pT2aN2M0, pStage IIIA). Postoperative adjuvant chemotherapy including regimens associated with increased risk of perforation and thrombocytopenia was recommended. Therefore, before chemotherapy initiation, the patient underwent TechGrasper-assisted OTSC closure of the post-ESD ulcer, which measured 50 × 34 mm in diameter (Fig. 1a,b).⁵ Briefly, immediately after ESD, an OTSC (Ovesco Endoscopy GmbH, Tuebingen, Germany) was attached to the tip of a two channel endoscope (GIF-2TQ260M; Olympus Co., Tokyo, Japan). After grasping the edge of the post-ESD ulcer, the TechGraspers were pulled into the cap of the OTSC, which was then released with sufficient suction (Fig. 1c,d). The endoscopist pulled and adjusted one pair of forceps, and the assistant pulled the other pair of forceps. Four OTSCs were successfully applied to the post-ESD ulcer (Fig. 2a and Video S1). The patient underwent adjuvant chemotherapy 4 weeks after ESD, without subsequent adverse events (Fig. 2b–d). The present case illustrates the utility of TechGrasper-assisted OTSC as a simple technique to promote effective wound healing following gastric ESD.

Authors declare no conflict of interest for this article.

A 62-year-old man who had undergone Roux-en-Y hepaticojejunostomy because of choledochal cyst presented with jaundice. Magnetic resonance cholangiopancreatography revealed obstructive stones in left intrahepatic duct (Fig. 1).

Double-ballon enteroscope-assisted endoscopic retrograde cholangiopancreatography was initially attempted but failed to reach anastomosis. Endoscopic ultrasound-guided hepaticogastrostomy (HGS) was alternatively performed (Fig. 2a). Cholangiography confirmed multiple intrahepatic bile duct stones and a 2 cm length anastomotic stricture. After dilatation of the stomach wall and anastomotic stricture, a 10 × 80 mm fully covered self-expanding metal stent (FCSEMS) was deployed.

One week later when the FCSEMS was assumed to be fully expanded (Fig. 2b), transluminal stone removal was attempted. With the concern of stent migration during stone removal, a clip and dental floss was used for FCSEMS traction and fixation (Fig. 2c). SpyGlass-guided laser lithotripsy and stone extraction was performed through the endoscopic ultrasound-guided HGS route (Fig. 2d). A coaxial double-pigtail plastic stent was inserted through the FCSEMS to function as an anchor. No postoperative adverse event was observed. Jaundice was rapidly relieved (Video S1).

Removal of left intrahepatic duct stones via the HGS route has been described in sporadic cases.¹ Three highlights of this case are specifically introduced as follows. First, given that the stone's size exceeded the width of intrahepatic bile duct and the diameter of metal stent when it was not fully expanded, adequate stone removal cannot be accomplished in a single session. An HGS route must first be established. Lithotripsy was then carried out. Second, to decrease the risk of stent migration during accessory devices pass-by, we borrowed the method of dental floss traction applied in endoscopic submucosal dissection.² Last, anastomotic stenosis is difficult to alleviate from a single dilation. With the help of the HGS route, double-ballon enteroscope-assisted endoscopic retrograde cholangiopancreatography can be easily performed by rendezvous technique in the subsequent session and the transgastric stent can be removed thereby.

Authors declare no conflict of interest for this article.

This study was supported by the National Natural Science Foundation of China (Grant No. 82070663 [J.Y.M.]) and Specific Research Fund of The Innovation Platform for Academicians of Hainan Province (Grant No. YSPTZX202029 [K.X.W.]).

Successful ileus tube (I-tube) insertion requires passing the I-tube into the pylorus,^{1, 2} which may be achieved using an endoscope, and then advancing the I-tube through the duodenum. The latter can be difficult because the force pushing the I-tube may not be effectively transmitted to the tip.^{3, 4} Because the duodenum runs through the retroperitoneum like a tunnel and does not stretch, the I-tube can pass smoothly through the duodenum if directly pushed from inside the stomach, ensuring that the tip does not get trapped into the duodenal folds.

Here, we propose a new I-tube insertion method that involves attaching grasping points by tying silk threads on the I-tube and pushing the I-tube from inside the stomach with an endoscope (Fig. 1). Specifically, we used a 16F closed-end I-tube with a soft atraumatic tip that was designed to avoid getting trapped into the folds. Silk threads were tied on the I-tube at 5 cm intervals to cover 60 cm from the tip. After the I-tube entered the duodenum, it was pushed by using an endoscope (Fig. 2; Video S1).

A 60-year-old man underwent surgery for an abdominal aortic aneurysm. The patient presented with abdominal distention and was suspected to have a combination of paralytic ileus and adhesive intestinal obstruction. Endoscopic I-tube insertion was performed on the sixth operative day. Insertion to a depth of 60 cm into the pylorus was smoothly completed within 6 min, with the balloon successfully entering the jejunum. The patient was discharged on the 27th postoperative day.

The body of the designed I-tube showed sufficient stiffness to not require the use of a guidewire, and the I-tube did not retract during endoscope removal. Insertion was performed in 14 cases and was successful in all cases. The proposed use of an I-tube with endoscope grasping points is a promising method for rapid and simple ileus tube insertion.^{2, 5}

Author Y.B. holds a United States Patent on the naso-jejunal medical tubes (Patent No. US10,524,988 B2). The other authors declare no conflict of interest for this article.