Techniques and Innovations in Gastrointestinal Endoscopy最新文献

Background and Aims

The absence of contrast passage to the duodenum is frequently encountered during an intraoperative cholangiogram (IOC), and patients with this finding are suspected of having choledocholithiasis. This study was conducted to determine the positive predictive value (PPV) of the absence of contrast passage during IOC and identify predictors, if any, that increase the pretest probability of choledocholithiasis in these patients.

Methods

All laparoscopic cholecystectomies with IOCs between September 1, 2019, and September 1, 2021, at a tertiary medical center were reviewed to identify those with abnormal cholangiograms due to only the lack of contrast passage to the duodenum. Patient demographic information, pre- and postoperative laboratory results, and radiographic studies were recorded. Postprocedural clinical outcomes including endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) findings were tabulated to determine the presence of choledocholithiasis. Patient factors and outcomes were compared between a cohort that was found to have choledocholithiasis vs those who were not. Finally, multiple logistic regression was performed to identify predictors of choledocholithiasis.

Results

Of 320 IOCs, 31(9.7% of all abnormal IOCs) showed the lack of contrast passage in the duodenum as the only abnormality. The PPV of an IOC with the lack of contrast in the duodenum was 29%. Preoperative bilirubin levels, postoperative aspartate aminotransferase levels, and postoperative alanine transaminase levels were significant predictors of choledocholithiasis in this group of patients.

Conclusions

The lack of contrast passage to the duodenum as the sole finding of an abnormal IOC has poor PPV for choledocholithiasis. Thus, it is reasonable to consider using less invasive modalities such as EUS and/or magnetic resonance cholangiopancreatography before ERCP in these patients.

Background and Aims

Hybrid endoscopic resection with an endo-knife and snare (HYB-ER) has been used to overcome the difficulties of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). This study clarified the role of HYB-ER in colorectal neoplasm treatment.

Methods

We searched PubMed, Web of Science, and the Cochrane Library up to May 2021. Pooled data of patients with non-pedunculated colorectal tumors treated with HYB-ER, EMR, and ESD were analyzed. The outcomes of en bloc resection rate, procedure time, and adverse events (perforation, bleeding, and recurrence) were compared across HYB-ER, EMR, and ESD groups.

Results

Twenty-four studies were included in this meta-analysis. The mean tumor sizes were 24.4, 19.9, and 30.3 mm in the HYB-ER, EMR, and ESD groups, respectively. The proportion of en bloc resections following HYB-ER in 1626 colorectal lesions was 82%, with perforation and postprocedural bleeding in 4% and 3% of the cases, respectively. HYB-ER was superior to EMR because of its higher proportion of en bloc resections (57% in EMR) and lower recurrence rates (2% with HYB-ER vs 12% with EMR), but the procedure time for HYB-ER (30.85 minutes) was longer than that for EMR (9.97 minutes) and significantly shorter than for ESD (56.6 minutes). According to meta-regression analysis of tumor size and location, there was no significant difference in the en bloc resection rate between HYB-ER and ESD.

Conclusion

HYB-ER significantly contributed to improve en bloc resection, with fewer recurrence events than EMR and faster procedure times than ESD, with similar en bloc resection and adverse events. Favorable indications for HYB-ER include colorectal lesions of 20-30 mm in size that are difficult to treat with EMR.

Systematic review registration: PROSPERO CRD42020209097.

Background and Aims

Endoscopic mucosal resection (EMR) has become the standard for removing large colon polyps but has a 10%-30% recurrence rate using standard techniques. Data shows improved recurrence rates with focal therapy of the edge of the resection base using cautery. We examine a novel technique, hybrid APC assisted EMR, which treats both the edge and the base with cautery to assess its effect on local recurrence.

Methods

We reviewed all EMRs of polyps >2 cm by a single endoscopist with 6-month follow-up from May 2018 to November 2019 using both standard EMR as well as hybrid APC assisted EMR to assess local recurrence as well adverse events.

Results

Forty-eight patients with 59 polyps removed by EMR had full 6 month follow up with a mean age of 66.1 years of age, 45% were female. Thirty polyps were removed by hybrid APC assisted EMR and 29 removed with standard EMR. Overall, 0 (0%) polyps in the h-APC arm had local recurrence while 6 (20.7%) in the standard group had histological proven local recurrence (P = 0.01). Postresection bleeding occurred in 6 patients, 2 in the hAPC arm and 4 in the standard arm (P = 0.41).

Conclusion

In this retrospective pilot study, hybrid APC assisted EMR was superior to conventional EMR for local recurrence after removal of large colon polyps and trended towards a less post-EMR bleeds.

Portal hypertension (PH), resulting from increased resistance of hepatic sinusoids to blood flow, is a severe complication of liver cirrhosis. The pathogenesis involves alteration of the liver vasculature due to fibrosis as well as increased production of vasoconstrictive mediators relative to endogenous vasodilators. Complications of PH include esophageal varices, gastric varices, portal hypertensive gastropathy, ascites, and hepatorenal syndrome. On endoscopy, the signs of portal hypertension include the presence of portal hypertensive gastropathy and/or esophageal/gastric varices. On Endoscopic Ultrasound (EUS), the liver parenchyma can be qualitatively and quantitatively assessed by imaging, “palpation,” as well as shear wave elastography. In addition, EUS can detect the presence of ascites, as well as intra and extra-mural dilated vessels that can be caused by PH. However, the most significant breakthrough for endoscopists is the ability to directly measure hepatic and portal vein pressures by means of EUS-guided portal pressure gradient (PPG) measurements. The endoscopic diagnosis of PH can be useful in determining the stage, progression, and prognosis of cirrhosis in individual patients.

Background and Aims

The goal of this systematic review and meta-analysis was to assess the probe-based confocal laser endomicroscopy (pCLE) benefit as an adjunct to random four-quadrant biopsies in the surveillance of patients with Barrett's esophagus for dysplasia and early esophageal cancer (EAC) detection.

Methods

The MEDLINE and EMBASE databases were systematically searched for studies reporting pCLE detection rates and diagnostic accuracy for esophageal dysplasia and EAC. Three meta-analyses were performed to estimate pooled sensitivities (SEs), specificities (SPs), negative predictive values (NPVs), and per-patient pooled absolute and relative detection rate of neoplasia with 95% confidence intervals (CIs) to compare pCLE detection rate with that of random four-quadrant biopsies.

Results

A total of 9 studies were included (688 patients and 1299 lesions). Per-patient pCLE pooled SEs, SPs, and NPVs were 96% (95% CI 65%-100%), 93% (95% CI 71%-99%), and 98% (95% CI 93%-100%), respectively. Per-lesion pCLE pooled SEs, SPs, and NPVs were 82% (95% CI 63%-92%), 90% (95% CI 84%-94%), and 95% (95% CI 94%-97%), respectively. Compared with random biopsies, the per-patient pooled absolute and relative detection rate increases of neoplasia with pCLE were significant and equal to 5% (95% CI 1%-9%) and 243% (95% CI 122%-482%), respectively.

Conclusion

The addition of pCLE-guided biopsies provides a significantly higher diagnostic yield for dysplasia and cancer and reduces sampling error compared with random four-quadrant biopsies alone. Therefore, pCLE should be considered an important adjunct to Seattle protocol biopsies in patients undergoing screening or surveillance for Barrett's esophagus.

Background and Aims

The depth of tumor invasion in colorectal cancer (CRC), especially T1b or T2, is crucial in treatment decision-making. However, their differences are not well-characterized. Thus, this study aimed to investigate the predictive endoscopic findings in tumor invasion of CRC.

Methods

Data from patients with T1b or T2 CRCs resected endoscopically or surgically were reviewed retrospectively. The patients were divided into 2 groups: T1b (n = 298) and T2 (n = 267) tumor invasion. A scoring system was established based on the endoscopic findings in each group, and the accuracy of the system was assessed using a receiver-operating-characteristic (ROC) curve analysis.

Results

T2 invasion was predicted by tumor size, irregular bottom of depression, existence of depression, expansion appearance, convergency of folds, and erosion or white coat. The risk scoring system was developed using the regression coefficient values of the above variables. The area under the ROC curve was 0.894 (95% confidence interval, 0.868-0921). Cases with a score ≥4 had a high risk of T2 (sensitivity, 84.5%; specificity, 78.9%).

Conclusion

Our scoring system was useful for the diagnosis of T1b and T2, and a score ≥4 could predict T2 invasion. Additional studies are warranted to confirm these results before our scoring system can be applied clinically.

Anastomotic leakage is the most important postoperative complication following colorectal anastomoses. Endoscopic techniques are newly implemented and are somewhat in between options that can be considered for the treatment of AL in selected cases. Aim of this literature review is to present, analyze, and synthesize material from diverse sources to provide a comprehensive summary of the endoscopic procedures available for the treatment of fistula following LAR for rectal cancer. A bibliographic search was carried out on Pubmed for articles published until 31th January 2021. Two hundred thirteen articles were screened and after a proper assessment thirty-four articles were left for the scopes of this narrative review. The most commonly applied endoscopic solutions are the transrectal vacuum-assisted closure (VAC), the Over-The-Scope clipping system (OTSC) and the OverStitch suturing system. They all seem to offer integrate solutions in the management of colorectal anastomotic leaks. Early detection of anastomotic leak might increase the success rate of endoscopic techniques, reducing overall healing time and length of hospital stay. Endoscopic evaluation could be added as an adjunctive screening test to all those patients who are suspected of an early postoperative colorectal leak, in order to confirm the suspicion and to promptly start the endoscopic treatment.

Acute cholecystitis is a common condition affecting 500,000 Americans per year. Although the gold standard treatment is cholecystectomy, some patients are poor surgical candidates requiring alternative treatment. Alternative treatment usually involves gallbladder drainage through a percutaneous or endoscopic approach. One common endoscopic approach is the transpapillary approach which involves cannulating the common bile duct and cystic duct sequentially and inserting a stent into the gallbladder. This technique can be technically challenging as the cystic duct can be difficult to cannulate and has a risk of postprocedure pancreatitis. However, this technique can be advantageous as it preserves a patient's anatomy for possible surgery in the future. The other common endoscopic approach is the transmural approach. This involves using an echoendoscope to determine an appropriate place to puncture the gallbladder and then using a needle and guidewire to create an opening to place a stent connecting the gallbladder and GI lumen. Use of a needle and guidewire can be obviated if an electrocautery method is used. This technique has an exceptionally high technical and clinical success rate but there is concern for stent occlusion and tissue overgrowth in long term stent placement. Technical and clinical success rates are similar between the percutaneous and transmural approaches which are higher than those in the transpapillary approach. Taken together, the endoscopic approaches are associated with shorter hospital stays and readmissions. Mortality rates are similar in all the approaches.