Techniques and Innovations in Gastrointestinal Endoscopy最新文献

Background and Aims

Esophagogastroduodenoscopy (EGD) is routinely performed in patients who undergo conversion from adjustable gastric banding to another bariatric procedure (eg, gastric bypass) of band removal. Band erosion is the main concern in these patients. The objective of this study was to analyze the yield of EGD in these patients.

Methods

All patients between 2008 and 2020 who underwent bariatric surgery with an adjustable gastric band in place were included. Results of EGD were analyzed retrospectively and categorized according to clinical consequences.

Results

Overall, 514 patients (62 male, 452 female; mean age 46 years; mean BMI 40) underwent surgery with an adjustable gastric band in situ. In total, 488 patients (95%) underwent preoperative EGD. No abnormalities were found in 205 patients (42%), 112 patients (23%) had abnormalities without treatment consequences, 156 patients (32%) had findings that required pharmaceutical (ie, proton pump inhibitors and/or antibiotics) intervention, and 15 patients (3.1%) had severe findings altering management (group D). In 5 of these patients (1.0%), surgery was postponed due to Barrett's esophagus, and 10 of these patients (2.0%) had gastric band erosion. No subgroup of patients could be identified to increase the yield of the EGD.

Conclusion

Routine preoperative assessment by EGD in patients before bariatric surgery with an adjustable gastric band in situ still detects some severe abnormalities significantly altering management.

Barrett's esophagus (BE) is a premalignant precursor to esophageal adenocarcinoma (EAC), a cancer whose incidence has increased sixfold in the Western world over the past 3 decades. The prognosis associated with EAC remains poor, with the 5-year survival estimated to be < 20%. Epidemiological and clinical study evidence has suggested that early detection and treatment of BE-related neoplasia is associated with improved survival, suggesting that screening for this condition could impact EAC survival. Over the past few decades, there have been accelerated advances in the field of BE and EAC, particularly in the emergence of non-endoscopic cell-collection devices that could be used for screening. In this review, we critically discuss the concept of screening BE and EAC, as well as identifying the target population who should be screened. We then review the evidence for various cell-collection devices that could be used for screening in the office-based setting, such as screenig using prediction models, transnasal endoscopy (TNE), Cytosponge and biomarker Trefoil-factor 3 (TFF3), EsophaCap and methylated DNA markers (MDMs), and the balloon-based EsoCheck and MDMs. We also discuss other novel technologies, such as volatile organic compound detection using the electric nose and technologies using optical coherence tomography. These promising technologies have paved the way for the potential introduction of a screening program for BE and EAC, with the hope that this could lead to improved outcomes among patients who suffer from this unfortunate disease.

Colorectal cancer (CRC) incidence continues to steadily rise in various parts of the world, and there remains an urgent need for effective interventions to tackle this. Effective and timely implementation of CRC screening interventions and adherence to post polypectomy surveillance recommendations remain paramount. Colonoscopy is the gold standard for timely diagnosis and removal of precursor lesions or polyps to CRC; however, patient uptake and cost effectiveness, especially in the era of noninvasive testing strategies, require closer evaluation. Furthermore, the risk of progression to CRC varies with the morphology, size, and histology of colorectal polyps. Several colonoscopy-based resection techniques have been reported in literature to effectively and safely remove these precursor lesions. In this review, we summarize the current guidelines (US and Europe) and evidence for the effectiveness of post-polypectomy surveillance, resection, and surveillance for sessile serrated lesions. We also appraise the current literature regarding non-colonoscopy options for post colonoscopy surveillance, as well as interventions to boost adherence to surveillance.

Background and Aims

The standard of care for treatment of patients with acute cholecystitis is cholecystectomy. However, many patients are unfit for surgery due to substantial medical comorbidities, or surgery is technically challenging due to anatomic considerations. Options for patients who are not surgical candidates include percutaneous cholecystostomy tube placement by interventional radiology, endoscopic gallbladder drainage (EGBD), or conservative management. Over the last decade, techniques of EGBD have been employed for temporary or definitive gallbladder drainage in patients with acute cholecystitis who are not surgical candidates. Despite growing interest and clinical use of EGBD, little is known about practice patterns of EGBD. Our aim was to survey endoscopists to evaluate the practice patterns and technical considerations regarding EGBD.

Methods

An 18-item survey was distributed to all members of the American Society of Gastrointestinal Endoscopy. Each response was included in the final analysis. Descriptive statistics were calculated using frequencies and percentages.

Results

Responses were received from 217 endoscopists. Of these, 178 perform endoscopic ultrasound-guided gallbladder draining and 178 perform endoscopic transpapillary gallbladder drainage. The preferred approach for EGBD was endoscopic ultrasound-guided gallbladder drainage in 58.8%, endoscopic retrograde cholangiopancreatography (ERCP)-guided transpapillary gallbladder stent placement in 30.2%, and no preference in 11%.

Conclusion

Despite growing interest in EGBD, significant heterogeneity in practice patterns exists. Further study is needed to better understand these differences and provide data for future guidelines.

Background and Aims

Advanced adenomas (AAs) with high-grade dysplasia (HGD) represent risk factors for metachronous neoplasia, for which guidelines recommend short-interval endoscopic surveillance. Although worse survival of proximal colon cancers has been established, the prognostic impact of laterality for AAs with HGD remains unknown. We hypothesized that proximal HGD would have a worse prognosis than distal lesions.

Methods

In this retrospective cohort study, adults with HGD managed with endoscopic polypectomy were identified in the National Cancer Database from 2004-2017. Survival probabilities were estimated and plotted using the Kaplan-Meier method. Cox regression models were used to assess the effect of adenoma laterality on overall survival (OS) while adjusting for patient and disease characteristics. One sample log-rank test was employed to compare the survival of patients with that of the US population.

Results

Of 3953 patients identified in the database, 29% had proximal lesions, which were more common in elderly, Black, publicly insured, and comorbid patients. Unadjusted 5- and 10-year OS was 81% and 67% for proximal vs 89% and 78% for distal HGD (P < 0.01). In multivariable analysis, proximal location did not demonstrate significantly worse OS (hazard ratio 1.09, 95% confidence interval [CI] 0.92-1.29). When compared with the age- and sex-matched US population, patients with HGD had significantly increased mortality (standardized mortality ratio 1.54, 95% CI 1.42-1.68), which was more pronounced for right-sided AAs.

Conclusion

Patients with HGD, particularly those with proximal lesions, had lower OS than the US population. Although proximal location was not independently associated with worse survival, OS may not represent the optimal endpoint for AAs given the low cancer incidence and effective treatment for early-stage tumors. Future research should focus on the risk of metachronous neoplasia to determine adequate surveillance protocols.

Mitigating colorectal cancer (CRC) risk is a pillar in caring for patients with inflammatory bowel disease (IBD). Over the last decade, there have been significant advances in understanding the natural history of colitis-associated dysplasia (CAD) and its management. The identification of patient- and disease-specific risk factors has enabled a tailored approach to initiating colonoscopy screening and surveillance programs. Improved video endoscopy systems and the development of advanced endoscopic resection techniques have evolved the role of endoscopy in CAD. Modern-era endoscopic instruments can better detect and effectively intervene with CAD, reducing CRC risk. As a result, the last decade has brought forth substantial changes to how endoscopic technologies are applied to IBD surveillance. This review will go over the latest updates in the stratification and management of CAD and CRC risk for patients with IBD, as well as discuss the exciting future in this topic area.

Artificial intelligence (AI) can aid endoscopic and surgical procedures in various ways, such as detecting and diagnosing gastrointestinal lesions, assisting in procedures, recognizing dissection planes, and predicting adverse events. 3D imaging has also improved the visual and technical aspects of endoscopic and surgical procedures by improving depth recognition. Robotic endoscopy involves aspects of both endoscopy and surgery. It is based on a flexible endoscopic technology; however, it allows for bimanual control of devices for better triangulation. Thus, AI and 3D imaging technologies should be incorporated into robotic endoscopy to improve learning curves and enable more precise operation of robotic instruments. The utilization of robotics will expand the spectrum of current therapeutic endoscopy. Natural orifice transluminal endoscopic surgery (NOTES) is associated with shorter operative time, faster patient recovery, and less postoperative pain. However, current efforts to promote NOTES have been hampered by suboptimal NOTES surgical instruments, which have limited maneuverability and degrees of freedom. These challenges are overcome by the robotic endoscope, which has end-effectors with high degrees of freedom. Surgeons performing NOTES using the robotic endoscope can perform triangulation and 360-degree rotation of the robotic wrists. As a 3-armed procedurist, the surgeon can now retract tissues effectively for optimal exposure of the operating field.

The past four decades have seen an increase in the incidence of early-onset gastrointestinal cancer. Because early-stage cancer detection is vital to reduce mortality rate, mass screening colonoscopy provides the most effective prevention strategy. However, conventional endoscopy is a painful and technically challenging procedure that requires sedation and experienced endoscopists to be performed. To overcome the current limitations, technological innovation is needed in colonoscopy. In recent years, researchers worldwide have worked to enhance the diagnostic and therapeutic capabilities of endoscopes. The new frontier of endoscopic interventions is represented by robotic flexible endoscopy. Among all options, self-propelling soft endoscopes are particularly promising thanks to their dexterity and adaptability to the curvilinear gastrointestinal anatomy. For these devices to replace the standard endoscopes, integration with embedded sensors and advanced surgical navigation technologies must be investigated. In this review, the progress in robotic endoscopy was divided into the fundamental areas of design, sensing, and imaging. The article offers an overview of the most promising advancements on these three topics since 2018. Continuum endoscopes, capsule endoscopes, and add-on endoscopic devices were included, with a focus on fluid-driven, tendon-driven, and magnetic actuation. Sensing methods employed for the shape and force estimation of flexible endoscopes were classified into model- and sensor-based approaches. Finally, some key contributions in molecular imaging technologies, artificial neural networks, and software algorithms are described. Open challenges are discussed to outline a path toward clinical practice for the next generation of endoscopic devices.

Background and Aims

Cold snare polypectomy can only be used for en-bloc resection of small lesions. We describe a new technique, cold snare avulsion, where a cold snare is closed tightly, and traction, at times with substantial force, is applied to resect the ensnared tissue. We aimed to determine the feasibility and safety for lesions up to 15 mm.

Methods

A randomized study in ex-vivo porcine colons comparing en-bloc resection (successful mucosal entrapment and resection in one piece) and perforation rate for cold snare cut vs cold snare avulsion for lesions (1) 10 mm without submucosal injection, (2) 10 mm with submucosal injection, and (3) 15 mm with submucosal injection. Mucosal defects were endoscopically examined, and full-thickness punch biopsies were performed to determine histological depth and completeness of resection.

Results

For 10-mm lesions without submucosal injection, en-bloc resection occurred in 1 of 15 (6.7%) with cold snare cut vs 10 of 15 (66.7%; P = 0.002) with cold snare avulsion. For 10-mm lesions with submucosal injection, en-bloc resection occurred in 9 of 15 (60%) with cold snare cut vs 14 of 15 (93.3%; P = 0.08) with cold snare avulsion. For 15-mm lesions with submucosal injection, en-bloc resection occurred in 1 of 15 (6.7%) with cold snare cut vs 12 of 14 (85.7%; P < 0.001) with cold snare avulsion. No perforations occurred. Resection to the level of the submucosa was confirmed by histologic analysis of the mucosal defect in all but one case.

Conclusion

In an ex-vivo animal model, cold snare avulsion was superior to cold snare cut for complete en-bloc resection of lesions up to 15 mm, with no adverse outcomes reported.

Background and Aims

Severe acute pancreatitis is one of the most catabolic illnesses. Meta-analyses have shown that enteral nutrition is safer and more effective than parenteral nutrition in suppressing these losses. However, there is intense debate about how the enteral nutrition should be delivered.

Methods

The design was a randomized controlled trial of early nasogastric (NG) vs distal jejunal (DJ) tube feeding with a semi-elemental diet during the first 4 weeks of severe acute pancreatitis. The setting involved multiple national tertiary care centers. Two hundred and twenty-eight patients were screened, and 26 met the inclusion criteria for new onset severe acute pancreatitis based on an APACHE II score >8, computed tomography evidence of >30% necrosis or computed tomography score >8, and/or a Marshall score >2. The intervention was a randomized allocation to either feeding tube bedside placement by NG or transnasal endoscopy for DJ. The primary endpoint was “feeding failure” to tolerate a rate of >10% of the goal for a 48-hour period.

Results

Twenty-six eligible patients were randomized, 12 to NG and 14 to DJ, 20 of 26 from the Pittsburgh center. Most were obese (BMI 31.5 kg/m²). Feeding failure occurred in 0 of 14 in the DJ group and in 6 of 11 (55%) in the NG group (P = 0.0026). NG failures were crossed over to DJ feeding with good tolerance and eventual recovery. As a result, the quantity of feed delivered was significantly higher in the DJ group (P < 0.05). Serious adverse events (cardiorespiratory arrests, unrelated to endoscopy) occurred in 2 of the DJ and none of the NG group; 3 patients from the DJ group died of progressive organ failure, 2 with associated compartment syndrome.

Conclusion

This randomized controlled trial indicates that in patients with acute pancreatitis of this level of severity, NG feeding will be ineffective. Although this is a common indication for parenteral nutrition, a safer alternative would be endoscopic-assisted DJ feeding tube placement to bypass the usually dysfunctional or obstructed upper gastrointestinal tract.