Salvage endoscopic therapy is increasingly recommended for localized, superficial failure at the primary site after chemoradiotherapy for esophageal squamous cell carcinoma. This multicenter retrospective study aimed to evaluate the clinical outcomes and prognostic factors associated with overall survival in patients who underwent salvage endoscopic therapy for cT1N0M0 local failure after chemoradiotherapy or radiotherapy for esophageal squamous cell carcinoma.
We retrospectively analyzed patients with cT1N0M0 local failure after chemoradiotherapy or radiotherapy who underwent endoscopic resection or photodynamic therapy using talaporfin sodium at two Japanese institutions between 2012 and 2021. Clinical outcomes and prognostic factors for overall survival were assessed using multivariate analysis.
Complete resection was achieved in 63 of 84 patients (75%) who underwent endoscopic resection, and a local complete response was achieved in 50 of 81 patients (62%) who underwent photodynamic therapy. During a median follow-up of 34 months (range, 2–109 months), 3-year overall survival, disease-specific survival, local recurrence-free survival, and esophagectomy-free survival rates were 79%, 88%, 54%, and 79%, respectively. A high Charlson Comorbidity Index (≥ 3; hazard ratio: 3.3) was significantly associated with poor overall survival (3-year overall survival rate: 64%), although the 3-year disease-specific survival in this group remained high at 94%.
We clarified the clinical outcomes and prognosis of salvage endoscopic therapy for cT1 local failure. The Charlson Comorbidity Index may serve as a useful prognostic factor to aid in clinical decision-making.
Difficult biliary cannulation is a key challenge in endoscopic retrograde cholangiopancreatography and a major risk factor for post-ERCP pancreatitis. When the pancreatic duct is unintentionally accessed, double guidewire (DGW) is the primary rescue strategy, while transpancreatic sphincterotomy (TPS) is an alternative. Previous evidence suggests that TPS may achieve higher cannulation success and lower PEP rates compared to DGW, though direct comparative data remain limited. This review and meta-analysis assess the clinical outcomes of TPS and DGW in the setting of difficult biliary cannulation.
This review involved searching Medline, Embase, Lilacs, Central Cochrane, and Google Scholar. Outcomes assessed included PEP, successful biliary cannulation, mean cannulation time, and other adverse events (bleeding, cholangitis, perforation).
A total of 463 patients from five randomized controlled trials were included. The DGW group showed a higher risk of PEP pancreatitis and other adverse events (p = 0.009; RR = 1.81 [1.16, 2.83]; I2 = 34%) and (p = 0.03; RR = 2.20 [1.10, 4.39]; I2 = 0%), respectively. A significant difference favoring TPS was found for successful cannulation and mild pancreatitis (p = 0.001; RR = 1.79 [1.26, 2.54]; I2 = 40%) and (p = 0.01; RR = 2.26 [1.20, 4.28]; I2 = 35%), respectively. No significant difference was observed for mean cannulation time or moderate to severe PEP (p = 0.18; SMD = −0.37 [−0.91, 0.17]; I2 = 79%) and (p = 0.32; RR = 1.50 [0.67, 3.36]; I2 = 0%), respectively. A restricted analysis excluding two studies affected by external factors inflating the pancreatitis rate did not reveal a significant difference (p = 0.61; RR = 1.16 [0.66, 2.04]; I2 = 0%).
Prior studies comparing TPS and DGW yield different results. This may occur because there are technical variables that are difficult to control. Overall, TPS demonstrated superior cannulation success, may have lower PEP rates, and fewer other complications, although more homogeneous studies are needed to validate these findings.
Percutaneous transhepatic gallbladder drainage (PTGBD) is often the first-line treatment for acute cholecystitis in high-risk patients. However, PTGBD may cause discomfort, leading to self-removal of the drainage tube and severe complications such as biliary peritonitis [1]. As an alternative, endoscopic transpapillary gallbladder drainage (ETGBD) has gained popularity, though it presents challenges like difficult cystic duct cannulation and stent occlusion due to gallstones in narrow-diameter stents [2]. Recently, acute cholecystitis was successfully treated by endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS) [3]. Here, we report a case. A 93-year-old man was transported to our hospital with moderate acute cholecystitis. Initial antibiotic therapy led to temporary improvement, but symptoms recurred upon discontinuation. PTGBD was performed (Figure 1a), but on postoperative day 6, the patient developed an elevated serum CRP level (7.65 mg/dL). The abdominal x-ray revealed spontaneous removal of the drainage tube (Figure 1b). Despite further antibiotic treatment, cholecystitis due to gallstone impaction in the cystic duct recurred after stopping therapy. EUS-GBD was then indicated for sustained drainage. The gallbladder was punctured between the duodenal bulb and the superior duodenal angle under EUS guidance. The distal flange of the LAMS was deployed inside the gallbladder, then pulled back to appose it to the duodenal wall. Under fluoroscopic guidance, deployment of both flanges was confirmed, and drainage of purulent bile was observed (Video S1). The abdominal CT finding 4 days after EUS-GBD showed the stent was patent (Figure 2), so antibiotic administration was discontinued. The patient was discharged 8 days after EUS-GBD. Approximately 2 months have passed as EUS-GBD without removal of the LAMS, and no recurrence of cholecystitis has been observed. In this case, EUS-GBD using LAMS was a safe and effective treatment for a super-elderly patient with a high surgical risk.
Conception and design of the study: R.R., K.K., T.I. Drafting and revision of the manuscript: R.R., K.K., T.I. Approval of the final version of the manuscript: R.R., K.K., T.I.
The authors have nothing to report.
Informed consent was obtained from the patient regarding the procedure.
The authors declare no conflicts of interest.
For the management of walled-off necrosis (WON), applying direct endoscopic necrosectomy (DEN) to endoscopic ultrasound (EUS)-guided drainage reportedly accelerates disease resolution [1, 2]. However, conventional removal using grasping forceps can lead to prolonged procedures due to adhesive necrotic tissue, thereby reducing efficiency. The novel over-the-scope grasper (OTSG Xcavator; Ovesco Endoscopy AG, Tübingen, Germany) has been introduced recently [3]. Here, we describe a case in which the over-the-scope grasper (OTSG) was effectively used, outlining the key procedural steps along with practical tips that facilitated effective removal of necrotic tissue.
A 54-year-old man developed WON after severe acute pancreatitis (Figure 1). Despite multiple DEN sessions via the transgastric lumen-apposing metal stent (LAMS), necrotic tissue remained. During the fourth session, the OTSG was introduced. This involved applying an overtube to facilitate repeated extracorporeal removal of necrotic tissue. The procedure consisted of a three-step routine: (1) access via the LAMS into the WON, (2) grasping necrotic tissue using the OTSG, and (3) withdrawing the scope for extracorporeal release. A frequent complication was impaired vision from lens contamination by oil-rich tissues, which was managed with an anti-fog solution and olive oil coating between sessions (Video S1). A substantial volume of necrotic tissue was successfully removed during a single 60-min procedure without adverse events (Figure 2a–g). The patient underwent several additional conventional DEN sessions and was discharged 1 month after admission with near-complete resolution of the WON (Figure 2h).
One published study has demonstrated the safety and efficacy of the OTSG [3]. However, opening or closing the OTSG in confined spaces may injure vessels beneath debris. A key drawback of the OTSG is its larger tip diameter, which limits maneuverability. Therefore, it remains effective for a large single cavity WON. The OTSG facilitated effective DEN; however, further studies are required to validate its efficacy and safety.
Akira Shirohata conceived the study, acquired images, and drafted the manuscript. Arata Sakai and Atsuhiro Masuda contributed to the data interpretation, literature review, and critical revision of the manuscript.
The authors declare no conflicts of interest.
Accurate diagnosis of biliary strictures remains challenging. This study aimed to develop an artificial intelligence (AI) system for peroral cholangioscopy (POCS) using a Vision Transformer (ViT) architecture and to evaluate its performance compared to different vendor devices, conventional convolutional neural networks (CNNs), and endoscopists.
We retrospectively analyzed 125 patients with indeterminate biliary strictures who underwent POCS between 2012 and 2024. AI models including the ViT architecture and two established CNN architectures were developed using images from CHF-B260 or B290 (CHF group; Olympus Medical) and SpyScope DS or DS II (Spy group; Boston Scientific) systems via a patient-level, 3-fold cross-validation. For a direct comparison against endoscopists, a balanced 440-image test set, containing an equal number of images from each vendor, was used for a blinded evaluation.
The 3-fold cross-validation on the entire 2062-image dataset yielded a robust accuracy of 83.9% (95% confidence interval (CI), 80.9–86.7) for the ViT model. The model's accuracy was consistent between CHF (82.7%) and Spy (86.8%, p = 0.198) groups, and its performance was comparable to the evaluated conventional CNNs. On the 440-image test set, the ViT's accuracy of 78.4% (95% CI, 72.5–83.8) was comparable to that of expert endoscopists (82.0%, p = 0.148) and non-experts (73.0%, p = 0.066), with no statistically significant differences observed.
The novel ViT-based AI model demonstrated high vendor-agnostic diagnostic accuracy across multiple POCS systems, achieving performance comparable to conventional CNNs and endoscopists evaluated in this study.
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：