Techniques and Innovations in Gastrointestinal Endoscopy最新文献

Background and Aims

Gastrointestinal bleeding (GIB) is a common morbidity among continuous-flow left ventricular assist device (CF-LVAD) recipients. The study objectives were to investigate the incidence, recurrence, risk factors, and medical and endoscopic management of GIB among CF-LVAD patients.

Methods

This is a single-center retrospective study analyzing 563 CF-LVAD recipients implanted at a large tertiary referral center from 2007 to 2018 with 619 bleeding events characterized. Patients with device exchanges or history of right ventricular assist devices were excluded. Chart review data pertaining to demographics, LVAD characteristics, endoscopic reports, and medications were collected.

Results

The incidence of GIB was 44%, with a median time to first bleed of 133 days and a recurrence rate of 53%. Approximately 13% of patients had ≥5 GIB events. There is an association of reduced GIB among patients taking angiotensin-converting enzyme inhibitors (ACEis). There was no association with GIB and acid-reducing medications, antiplatelet medications, and history of GIB before device implantation. Arteriovenous malformations were the most common bleeding etiology. CF-LVAD patients that bled more frequently were older, had their CF-LVAD longer, and bled earlier after LVAD implantation.

Conclusion

This is the largest comprehensive single-center GIB study among CF-LVAD recipients. The incidence and recurrence of GIB among CF-LVAD recipients is underreported. Push enteroscopy improves diagnostic yield for upper GIB. Special attention should be given to CF-LVAD patients that bleed within the first 18 days of implantation. There is an associative, dose-dependent benefit of ACEi medications among CF-LVAD recipients. Further studies on this effect are warranted.

Previously, the gold standard surgery for early gastric cancer was gastrectomy. This practice has changed radically with the introduction of advanced endoscopic resection techniques, including endoscopic submucosal dissection (ESD). Compared with traditional gastrectomies, the minimally invasive nature of ESDs allows patients to recover faster and experience less postoperative pain. Nevertheless, procedurists performing gastric ESDs are hampered by the limitations of current endoscopic instruments. The lack of degrees of freedom of existing endoscopic instruments renders it challenging for procedurists to achieve triangulation of instruments, optimal retraction of tissues, and adequate exposure of the operating field. Robotic endoscopic platforms solve these challenges by providing robotic end-effectors with high degrees of freedom. This review analyzes the benefits of robotic endoscopic platforms in reducing the learning curve, procedure times, and complication rates in performing gastric ESD. The review also explores future development of robotic endoscopic platforms that can enhance the efficacy and efficiency of gastric ESD, such as the development of adjunct endoscopic instruments to create and close full-thickness incisions, incorporating haptic feedback into robotic endoscopic platforms, and establishing a structured training program for procedurists.

Background and Aims

Current guidelines recommend that the decision to pursue surveillance colonoscopy in older adults with polyps be individualized, yet how these recommendations are communicated has not been characterized. We aimed to evaluate the effectiveness of endoscopist recommendations after colonoscopy in communicating the need for future surveillance in older adults.

Methods

We performed a single-center, retrospective chart review of adults age ≥ 75 years who underwent colonoscopy for polyp surveillance or screening during which polyps were detected. We performed content analysis of the recommendations from both colonoscopy reports and post-pathology follow-up letters. Recommendations were classified as optimal or less optimal based on whether they were clear, contained a rationale, and maintained consistency between the report and follow-up letter.

Results

Between 2012 and 2019, there were 1428 colonoscopies performed by 17 endoscopists, of which 874 (61%) were optimal and 554 (39%) were less optimal. Among the less optimal recommendations, 76 (14%) lacked a recommendation, 233 (42%) were unclear, and 409 (74%) lacked a rationale. Among the 954 post-pathology follow-up letters, 80 (8%) were inconsistent with the original colonoscopy report recommendation, of which 30 (38%) resulted in a change in management. The frequency of less optimal recommendations ranged from 0% to 50% by endoscopist.

Conclusion

Following colonoscopy in older adults, we found that roughly one-third of the reports were less than optimal, and there was sizable variation in individual endoscopist performance. Discrepancies between colonoscopy reports and patient follow-up letters could be minimized by avoiding providing recommendations on future colonoscopy before pathologic interpretation.

Endoscopic submucosal dissection (ESD) is the current standard treatment for early intramucosal gastrointestinal neoplasia, as ESD achieved a higher rate of en bloc resection and lower rate of local recurrence, especially for neoplastic lesions greater than 20 mm, compared with endoscopic mucosal resection. However, colorectal ESD remains technically challenging, with a significant risk of complications, especially perforation during dissection. The higher risk of perforation is related to the intrinsic operational difficulties of using flexible endoscopy and dissection via the coaxial ESD device, as well as the unfavorable anatomical characteristics, including thin colonic wall and haustrations. The lack of bimanual tissue manipulation, mucosal traction, and poor visualization of dissection plane led to the challenges in colorectal ESD. The development of endoluminal flexible robotic systems aims to overcome these challenges with innovative flexible robotics to refine the endoscope and instrumentations, some of which have already been used in clinical trials. Preclinical studies demonstrated promising outcomes with using flexible robotics in improving the learning curve of colorectal ESD. This review will also explore future development of endoluminal flexible robotics and a training system, which are crucial to ensure an effective, efficient, and safe training program for novice endoscopists to perform robotic colorectal ESD.

Background and Aims

The adenoma detection rate (ADR), is a key quality metric for colonoscopy, but it might fail to measure differences in adenoma detection in different parts of the colon. Because many post-colonoscopy cancers arise in the proximal colon, differences in the ADR of proximal vs distal adenomas could be clinically important. Our aim was to determine the feasibility of measuring ADR for both the proximal and distal colon and to understand differences based on age, sex, and race.

Methods

We queried a large claims database (Health Care Service Corporation) to screen colonoscopies from 2016-2018 to determine the location and pathology of detected polyps. We measured the ADR in both the proximal (P-ADR) and distal (D-ADR) colon to determine differences in the ratio of P-ADR vs D-ADR by age, sex, and race.

Results

The cohort included 93,163 women and 89,132 men. A progressive increase in both P-ADR and D-ADR occurs with advancing age, with the P-ADR/D-ADR ratio rising from 1.2 in patients under 40 years of age to 2.65 in patients age 75 and older, in both men and women. This ratio is affected by the experience of the endoscopist. A higher volume of procedures is directly related to higher polyp detection, specifically the P-ADR.

Conclusion

As age advances, there is an increasing predominance of proximal adenomas relative to distal adenomas in both men and women, in all races. With appropriate coding, it is feasible to measure the ADR for the proximal and distal colon. Measurement of P-ADR could be an important new quality metric.

The incidence of superficial esophageal adenocarcinoma (EAC) is rising and warrants awareness. Invasive surgery with lymph node dissection was long standard treatment for EAC. However, endoscopic resection techniques, such as cap-based endoscopic resection or endoscopic submucosal dissection (ESD), have proven to be safe and effective alternatives for removal of superficial EAC. Therefore, endoscopic resection is now the cornerstone of management for superficial EAC, for both diagnostic and therapeutic purposes. Current guidelines advise use of the cap-based approach for small, flat lesions, whereas ESD is recommended for large and bulky lesions, lesions with suspected submucosal invasion, or lesions in scarred areas. The histopathological assessment after a resection, evaluating histological risk factors for lymph node metastases, plays a key role in the decision about whether additional surgery is indicated. Until recently, all submucosal and/or high-risk EAC had an indication for additional (prophylactic) surgery because of the assumed high risk for lymph node metastases. However, this risk appears lower than initially assumed, and endoscopic management for low-risk submucosal EAC is gaining acceptance. Ongoing prospective trials will help to determine whether a watchful waiting strategy could be an alternative to surgery in patients with submucosal and/or high-risk EAC. In the future, the distinction between patients who can safely be followed with a watchful waiting strategy and patients who might benefit from additional surgery could become more unambiguous, resulting in more optimal patient-tailored management for patients with superficial EAC.

Background and Aims

Endoscopic submucosal dissection (ESD) is an important treatment for gastric neoplasia. Some gastric adenomas with low-grade dysplasia (LGD) and high-grade dysplasia (HGD) on endoscopic forceps biopsy (EFB) are diagnosed as gastric adenocarcinoma (GAC) after ESD. We aimed to identify factors associated with histological diagnosis of gastric lesions and predictors for pathological upstaging following ESD.

Methods

This retrospective study analyzed data from 309 patients who underwent gastric ESD at 25 tertiary care centers in North America. Variables assessed included demographic characteristics, endoscopic lesion characteristics, and histopathological diagnoses. We used logistic regression to identify predictors of GAC following ESD, as well as pathologic upstaging from EFB to ESD.

Results

Four point one percent of all cases with LGD and 12.8% with HGD on EFB were upstaged to GAC after ESD. There were no significant predictors of pathologic upstaging. However, logistic regression revealed that age (odds ratio [OR] = 1.05, P < 0.01), the presence of ulceration (OR = 2.76, P < 0.01), and tumors located in the upper third (OR = 2.35, P = 0.01) or lower third of the stomach (OR = 1.92, P = 0.02) significantly predicted GAC.

Conclusion

In this large North American cohort of patients treated with gastric ESD, we found that tumor location in the upper and lower thirds of the stomach, tumor ulceration, and patient age could predict GAC. Endoscopists should be cognizant of these characteristics as up to 16.9% of lesions may be upstaged to GAC.