Techniques and Innovations in Gastrointestinal Endoscopy最新文献

Background and Aims

Management of fistulas after bariatric surgery has shifted from a surgical to a primarily endoscopic approach. We aimed to determine the efficacy of a novel stent for the closure of fistulas and stent-related adverse events in patients with fistulas after sleeve gastrectomy (SG).

Methods

Fifteen patients who developed fistulas following SG between July 2016 and December 2020 and managed at a tertiary care hospital by a primarily endoscopic approach were retrospectively evaluated. The technical and clinical success of a novel stent for the exclusion and definitive closure of fistulas and the need for endoscopic and surgical reinterventions and adverse events were analyzed.

Results

Fifteen patients with median age of 47 (20-61) years, 11 (73%) females, were included. Fistulas were located at the cardia in 12 (80%) patients, with a median diameter of 4 (2-15) mm. Concomitant stricture of the gastric tube was detected in 8 (53%) patients. A single stent was placed in 13 (87%) patients. Endoscopic reinterventions were required in 5 (33%), and a surgical toilette was needed for 3 (20%) patients. After a median stent implantation duration of 6 (3-21) weeks, fistula closure was documented in all 15 (100%) patients. The concomitant stricture of the gastric tube that occurred in 8 (53%) patients was also successfully managed. Adverse events related to stent placement or removal occurred in 5 (33%) patients and were managed endoscopically. Stent dysfunction occurred in 1 (7%) patient. One patient died due to bleeding from an aortoesophageal fistula 3 cm above the proximal edge of the stent.

Conclusion

The novel stent is effective in closing fistulas after SG. The unique stent design is associated with a low risk of migration, allows for the management of concomitant strictures in the gastric tube, and facilitates stent removal.

Background and Aims

Although obesity affects over 40% of adults in the United States and is a driver of preventable chronic diseases and health care costs, most patients are left untreated.

Methods

This was a randomized, double-blind, sham-controlled trial to investigate the safety and efficacy of a novel, endoscopically placed intragastric device for weight reduction, the TransPyloric Shuttle, implanted for 1 year in 270 patients with Class I and II obesity. An additional 32 treatment patients were enrolled in an Open-Label group. The co-primary efficacy endpoints were percent total body weight loss (%TBWL) in the Treatment group compared with the Sham group and a proportion of treatment patients achieving ≥5% TBWL at 12 months.

Results

The mean %TBWL at 12 months was 9.5% (95% CI, 8.2-10.8) in the Treatment group (n = 181) compared with 2.8% (95% CI, 1.1-4.5) in the Sham group (n = 89). In the Treatment group, 67.0% (95% CI, 59.3-74.4) of patients achieved ≥5% TBWL compared with 29.3% (95% CI, 19.3-39.4) in the Sham group. Patients in the Treatment group achieved lower blood pressure, total cholesterol, and low-density lipoprotein cholesterol compared with the Sham group. Early withdrawals occurred in 22% and 11% patients in the Treatment and Sham groups, respectively. Device- or procedure-related serious adverse events occurred in 6 patients (2.8%), and no deaths occurred.

Conclusion

Treatment with a novel endoscopically placed intragastric device resulted in meaningful weight loss and improvement in cardiometabolic outcomes in patients with Class I and II obesity (ClinicalTrials.gov number NCT02518685).

BACKGROUND AND AIMS

Location-based resect and discard (LBRD) and polyp-based resect and discard (PBRD) are 2 recently proposed strategies to minimize the cost of colonoscopy screening and surveillance. Our study applied these strategies to our colonoscopy database retrospectively to determine the applicability of these strategies in our screening and surveillance colonoscopy population.

METHODS

In total, 6024 elective screening, surveillance, or diagnostic colonoscopies performed at the University of California, Irvine, were analyzed. We compared the LBRD and PBRD recommendations with longer and shorter 2020 United States Multi-Society Task Forces (USMSTF) surveillance interval recommendations. The primary outcome was the achievement of the 90% agreement threshold set by the American Society of Gastrointestinal Endoscopy Preservation and Incorporation of Valuable Endoscopic Innovations.

RESULTS

The LBRD strategy achieved 88.0% and 71.6% concordance with the longer and shorter 2020 USMSTF recommendation guidelines, respectively. The PBRD strategy only applied to 65.4% of procedures, with the remaining procedures still requiring pathologic evaluation. Among the applicable procedures, the PBRD strategy achieved 94.2% and 38.6% concordance with the longer and shorter USMSTF recommendation guidelines, respectively.

CONCLUSION

The PBRD strategy met the 90% preservation and incorporation of valuable endoscopic innovations threshold only when using the longer USMSTF recommendations, but concordance dropped to 38.6% when using the shorter surveillance intervals, which are commonly used in the United States. Although resect and discard may decrease reliance on pathology, these 2 strategies do not achieve the level of concordance required to replace the use of pathology for diminutive polyps in our population.

Background and Aims

Inadequate bowel preparation during colonoscopy is associated with decreased adenoma detection, increased costs, and patient procedural risks. The aim of this study was to develop a prediction model for identifying patients at high risk of inadequate bowel preparation for potential clinical integration into the electronic medical record (EMR).

Methods

A retrospective study was conducted using outpatient screening/surveillance colonoscopies at the University of North Carolina from 2017 to 2022. Data were extracted from the EMRs of Epic and ProVation, including demographic, socioeconomic, and clinical variables. Logistic regression, LASSO regression, and gradient boosting machine models were evaluated and validated in a held-out testing set.

Results

The dataset included 23,456 colonoscopies, of which 6.25% had inadequate bowel preparation. The reduced LASSO regression model demonstrated an area under the curve of 0.65 (95% CI 0.63-0.67) in the held-out testing set. The relative risk of inadequate bowel prep in the high-risk group determined by the model was 2.42 (95% CI 2.07-2.82) compared with patients identified as low risk. The model calibration in the testing set revealed that among patients categorized as having 0%-11%, 11%-22%, and 22%-33% predicted risk of inadequate prep, the respective proportions of patients with inadequate prep were 5.5%, 19.3%, and 33.3%. Using the reduced LASSO model, a rudimentary code for a potential Epic FHIR application called PrepPredict was developed.

Conclusion

This study developed a prediction model for inadequate bowel preparation with the potential to integrate into the EMR for clinical use and optimize bowel preparation to improve patient care.

Background and Aims

Stent migration is a consequential complication associated with esophageal stent placement. We aimed to compare endoscopic suturing vs clips vs no intervention to determine the optimal strategy.

Methods

A literature search was performed using the MEDLINE, Embase, Cochrane, Web of Science, and Global Index Medicus databases. Direct head-to-head comparator analysis and network meta-analysis of all available groups were performed using the random-effects model. A P value less than 0.05 was considered statistically significant.

Results

Ten studies with 1019 participants were included in the final analysis. The direct meta-analysis revealed comparable stent migration rates between endoscopic suturing and clips, with an odds ratio (OR) of 1.07 (95% CI 0.07-14.8, P = 0.96), signifying no significant difference in their efficacy. When compared with the no intervention group, endoscopic suturing demonstrated a lower stent migration rate, with an OR of 0.33 (95% CI 0.17-0.62, P < 0.001). Conversely, endoscopic clips did not exhibit a statistically significant advantage over the no intervention group, displaying an OR of 0.29 (95% CI 0.06-1.48, P = 0.14). The results were consistent in the network meta-analysis. The rankings of interventions, as reflected by the P scores, underscored the superior effectiveness of endoscopic suturing with a score of 0.78, followed closely by endoscopic clips at 0.70, whereas the no intervention approach lagged behind with a score of only 0.03.

Conclusion

Our findings indicate that stent fixation with sutures significantly prevents stent migration, with no clear advantage of one modality over another. However, it is essential to acknowledge that the feasibility of implementing endoscopic suture fixation in every case is constrained by cost, time, and technical expertise.

Background and Aims

Although esophageal widening is a normal consequence of growth in pediatric individuals, esophageal remodeling plays a major role in the morbidity of pediatric and adult eosinophilic esophagitis (EoE). However, the disease is defined by esophageal dysfunction and mucosal eosinophilia. One potential explanation is the difficulty in quantitating remodeling.

Methods

This prospective, IRB-approved longitudinal study evaluated endoscopic ultrasound (EUS) in 78 children, adolescents, and young adults referred to a single academic medical center for esophageal indications. Patients with proven EoE had serial EUS exams that measured total wall thickness (TWT) and esophageal wall sublayers during routine endoscopies to manage their disease. Student t tests and mixed linear models were employed to compare groups.

Results

TWTs from the distal (2.3 ± 0.5 vs 1.7 ± 0.3, P < 0.01) and mid esophagus (2.1 ± 0.5 vs 1.6 ± 0.3, P < 0.05) were increased in active EoE patients > 10 years of age compared with similarly aged controls. After achieving clinical and histologic remission, their TWTs were significantly decreased (distal: 1.9 ± 0.4 vs 2.3 ± 0.5, P < 0.05; mid: 1.7 ± 0.4 vs 2.1 ± 0.5, P < 0.05). Mixed linear models further demonstrated that during active EoE, TWTs, esophageal muscle layers, and the mucosa and submucosa were thickened in older adolescents at both sites (P < 0.05 for each). In remission, TWTs returned to control values.

Conclusion

This pilot study demonstrates that EUS, a unique application of point-of-care ultrasound, can identify the esophageal remodeling that occurs in older adolescents with active EoE. Furthermore, EUS has defined this remodeling as a transmural phenomenon that occurs in the mid and distal esophagus and can completely reverse with adequate treatment.

Diverticular peroral endoscopic myotomy (D-POEM) has emerged as a minimally invasive, safe, and effective option for Zenker's diverticula (ZDs) and several other types of esophageal diverticula. D-POEM involves submucosal dissection to create tunnels on the luminal and diverticular aspects of the diverticular septum, allowing for precise visualization of the septum. The operator then performs a myotomy, releasing the diverticula and reconnecting the diverticular and esophageal lumens. Approaches for D-POEM vary on the basis of the location of the initial incision for the submucosal dissection; in the long D-POEM approach, operators begin submucosal dissection 1-2 cm above the septum, whereas in the ultra-short D-POEM approach, operators begin submucosal dissection directly on the septum. Observational studies and systematic reviews demonstrate consistent technical success (93.4%-100%), high clinical success (87.1%-94.1%), few adverse events (4.6%-16.9%), and low recurrence rates (0.9%-4.4%). Meta-analyses of observational studies comparing D-POEM with surgical approaches (flexible endoscopic septotomy and rigid endoscopic septotomy) have found that D-POEM may have higher rates of clinical success (RR 1.13, CI 1.05-1.22 and RR 1.11, CI 1.03-1.18) with comparable technical success, adverse event, and recurrence rates. However, further rigorous prospective and randomized trials are warranted. Early comparisons of the ultra-short and long approaches to D-POEM have not found significant differences in efficacy. Outside of ZD, D-POEM should be further investigated for Killian-Jamieson, epiphrenic, and Rokitansky diverticula

BACKGROUND AND AIMS

Quality indicators (QIs) are essential for evaluating the safety and effectiveness of endoscopy but are difficult to measure accurately for endoscopic retrograde cholangiopancreatography (ERCP). We developed a fully automated, real-time endoscopy analytics tool using Health Level-7 standards that collects ERCP QIs from an endoscopy reporting system to generate an ERCP quality report card in a third-party analytics suite.

METHODS

ERCP report data were collected between June 2021 and December 2022 from 4 referral centers. Discrete data elements from endoscopy reports generated in the EndoPro reporting platform were imported into the Qlik analytics suite, and QI data were aggregated into a report card. The collected data were manually validated to confirm accuracy.

RESULTS

Pooled data were successfully used to generate a comprehensive institutional ERCP quality report card comprising a total of 2146 ERCPs performed by 12 endoscopists. Manual review confirmed high accuracy (96.5%-100%) of automatic extraction of ERCP QIs from endoscopy reports. Multiple procedural data elements were successfully extracted, including cannulation difficulty, success rate, and administration of post-ERCP pancreatitis prophylaxis for procedures with biliary and pancreatic indication. Generation of the report card required minimal additional work on the part of the performing endoscopist and was updated in real time.

CONCLUSION

We developed an automated ERCP analytics tool that accurately and automatically extracts QI data into a succinct ERCP quality report card without the need for manual data extraction or natural language processing. The use of the Health Level-7 standard provides a framework for the creation of similar tools in other electronic health records. This tool allows for accurate ERCP quality and performance data evaluation at individual and institutional levels.

Background and Aims

There are several limitations to the application of conventional endoscopic therapy for refractory esophageal stenosis and even atresia, and the secondary option of surgery involving reanastomosis also has drawbacks. Magnetic compression anastomosis (MCA) is a novel technique that relies on magnetic attraction for recanalization and the repair of esophageal obstruction. We evaluate and discuss the clinical value and implementation strategies of the MCA technique as a promising countermeasure for esophageal obstruction.

Methods

In this study, we retrospectively enrolled 7 patients with esophageal stenosis or atresia who underwent MCA from December 2015 to June 2023. Gastroscopic combined with laparoscopic-assisted gastroesophageal MCA and jejunostomy were performed for patient 1; laparotomy and gastroscopic-assisted MCA and jejunostomy were performed for patient 2; laparoscopic gastrostomy combined with endoscopic-assisted MCA was performed for patients 3 and 4; thoracotomy combined with MCA and gastrostomy were performed for patient 5; and endoscopic-assisted MCA was performed for patients 6 and 7.

Results

Anastomosis and recanalization were successfully performed for all patients. A total of 42.86% (3/7) of the patients underwent subsequent conventional endoscopic treatment, including balloon dilatation and stent implantation. The incidences of postoperative pulmonary infection and anastomotic leakage were both 14.29% (1/7), and no other adverse events occurred. The magnetic complexes were removed at a median of postoperative day 18. All patients resumed oral feeding.

Conclusion

MCA appears to be a safe and effective therapy for the management of severe esophageal stenosis, refractory stenosis, and atresia of different etiologies, locations, lengths, and patterns, with the advantages of less trauma, high safety, and effectiveness. When making the operative proposal, diverse and individualized magnetic compression devices and methods should be flexibly adopted according to the patient's individual characteristics, history, obstruction distance, and obstruction patterns.