Techniques and Innovations in Gastrointestinal Endoscopy最新文献

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.

Increases in colorectal cancer screening are linked to the declining incidence of the disease over the past 3 decades. These favorable trends, however, are not observed in marginalized racial and ethnic populations with disproportionately lower rates of screening, higher disease incidence, and increased mortality, despite advances in health technology and policy. This review describes the differences in screening uptake and test selection among racial and ethnic groups, discusses known obstacles and facilitators that impact screening, and highlights existing frameworks developed to achieve health equity in colorectal cancer screening.

Background and Aims

There is considerable variability in adherence to endoscopic quality indicators (QIs) for Barrett's esophagus (BE). The aims of this study were to (1) assess adherence to published Qis for diagnosis and surveillance of BE, (2) compare adherence between BE experts and nonexperts, and (3) identify factors associated with adherence.

Methods

We identified all patients with BE on esophagogastroduodenoscopy between 2010 and 2018. QIs evaluated included inspection using high-definition white light endoscopy, use of the Prague Classification, identification of endoscopic landmarks, use of the Seattle Protocol, and guideline-adherent recommendations for surveillance or endoscopic eradication therapy. BE experts and nonexperts were compared using logistic mixed-effects models.

Results

A total of 467 patients were identified, with BE experts performing fewer overall esophagogastroduodenoscopies (n = 162, 34.7% vs n = 305, 65.3%). Whereas BE experts were more likely to document Prague Classification (52.5% vs 41.3%; P = 0.017) and landmarks (43.2% vs 22.6%; P = 0.036), there was no significant difference between experts and nonexperts in use of high-definition white light endoscopy (8.6% vs 3.3%; P = 0.123), Seattle Protocol (48.1% vs 40.3%; P = 0.313), or guideline-adherent surveillance or treatment recommendations (71.0% vs 67.5%; P = 0.509). Patient enrollment in a BE surveillance program was the only factor associated with improved QI adherence, specifically adherence to Prague Classification documentation (OR 1.85, 95% CI 1.08-3.14; P = 0.025), Seattle Protocol (1.28, 95% CI 1.16-1.50; P < 0.001), and follow-up recommendations (OR 2.64, 95% CI 1.55-4.48; P < 0.001).

Conclusion

Patterns of adherence to published QIs for endoscopy in patients with BE are mostly independent of expertise. Further training initiatives are needed to standardize the performance of endoscopic practice in patients with BE.

Colonoscopic polypectomy, when performed appropriately and completely, reduces subsequent risk of colorectal cancer. However, performance of high-quality polypectomy varies widely among endoscopists based on many factors, from exposure during fellowship to continuing education once in practice. Thus, this review is intended for a wide audience, from gastroenterology trainees to practicing physicians. A review of electrosurgery principles is included to cover effective polypectomy techniques and to prevent and troubleshoot problems.

Similarly, successful colon polypectomy is heavily dependent on both anatomic position and endoscopic clock-face position within the colon. As a result, both equipment choice and hand technique are discussed, and specific tips are offered to maximize the likelihood of success. Additionally, within this review, we highlight several of the latest advances within the field of polypectomy, such as submucosal injection (including choice of fluid), dynamic injection technique, a thorough discussion on hot vs cold snare, site management, and complication management. Lastly, we explore why incomplete polypectomy occurs, the implications of incomplete polypectomy, and methods to reduce this risk.

Background and Aims

Over-the-scope clips (OTSCs) have been increasingly used in the management of bleeding, perforations, fistulae, and anastomotic leaks in the gastrointestinal tract. However, since their Food and Drug Administration (FDA) approval in 2010, data on the adverse events of OTSC systems have been lacking. The aim of our study was to report and analyze adverse events and device failures associated with OTSC systems using the FDA's Manufacturer and User Facility Device Experience (MAUDE) database.

Methods

We analyzed the FDA MAUDE database post-marketing surveillance data from January 2013 through May 2022 on the two OTSC systems available in the United States.

Results

Forty medical device reporting claims were found from January 2013 through May 2022. Adverse events were classified as device-related problems and patient-related adverse events. Forty device-related problems were reported, along with 20 device-related adverse events. Most device-related problems were reported in the Padlock defect closure system (n = 23), followed by the Padlock pro clip system (n = 8) and Ovesco OTSC system (n = 9). The most common device-related problem was related to the failure of OTSC deployment (n = 13), followed by material protrusion or extrusion (n = 7). The most common patient adverse events were perforation (n = 4), esophageal laceration (n = 4), bleeding (n = 3), and luminal stenosis (n = 3). All 4 patients required surgical management of the perforation. No deaths related to the use of OTSCs were reported.

Conclusion

Failure of OTSC deployment and perforation were the most common device-related problem and patient-related adverse event, respectively. As the use of OTSC systems continues to increase, it is important for endoscopists to be mindful of both the common and rare adverse events associated with OTSC use.

Background and Aims

Despite technological and procedural improvements, esophageal stents (ESs) have high rates of adverse events (AEs), including stent migration, recurrent stenosis, and chest pain. We sought to evaluate predictors and causes for early readmission following ES placement in hospitalized patients.

Methods

The National Readmission Database 2016-2018 was queried to identify hospitalized patients with an ICD-10-CM code for endoscopic ES placement. Primary outcome was early (≤ 30-day) readmission rate. Univariate and multivariable logistic regression models were used to evaluate predictors of early readmission.

Results

A total of 949 patients underwent index ES placement, and most (67%, n = 634) patients had benign indications. Overall, the most common indication was benign esophageal leak/fistula (n = 359), followed by malignant dysphagia from esophageal neoplasm (n = 252). The 30-day readmission rate was 26% (n = 251), with higher rates for benign (29%) compared with malignant (22%) indications (P = 0.09). An analysis of primary diagnosis for early readmissions revealed that stent-related AEs were higher in the benign than in the malignant group (42% vs 23%, respectively; P = 0.008). Multivariable analysis revealed that ES placement for esophageal leak/fistulas (OR = 1.98; 95% CI, 1.20-3.24; P = 0.022) was the only significant variable associated with early readmission.

Conclusion

In recent years, inpatient ESs have been placed predominantly in patients with benign conditions, with esophageal leak/fistula being the most common indication. Stent-related AEs account for a significant burden of readmissions, particularly when placed for benign conditions. There is a need for focused research to refine indications, optimize techniques, and improve stent technology.

Background and Aims

Endoscopic resection (ER) can be a curative treatment for early esophageal adenocarcinoma (EAC). Poor tumor differentiation is a histologic feature of noncurative ER and, when seen on preoperative biopsies, may lead to avoidance of endoscopic treatment. However, the accuracy of tumor grade on preoperative endoscopic biopsies remains unclear. The aim of this study was to determine the accuracy of tumor differentiation on endoscopic forceps biopsy compared with endoscopically or surgically resected tissue.

Methods

This retrospective cohort study from 2 tertiary referral centers compared tumor differentiation from preoperative biopsies with endoscopically or surgically resected EAC samples. Accuracy (%) of preoperative biopsy and agreement analyses (Gwet's AC2) were performed.

Results

In total, 346 EAC lesions (225 esophagectomies, 121 ERs) were included. The overall accuracy and reliability of EAC grade on preoperative biopsies compared with postoperative tissue from ER or esophagectomy was 74% (114/154), with a substantial agreement coefficient (Gwet's AC2 0.78 [0.72-0.85]; P < 0.001). The accuracy of ER was only 56%, with moderate agreement (Gwet's AC2 0.60 [0.46-0.73]; P < 0.001). Poorly differentiated tumors were downgraded to moderately differentiated in 19.6% (20/102) of tumors, and conversely, moderately differentiated tumors were upgraded to poorly differentiated in 22.7% (37/163) of tumors. For patients with T1a tumors, poorly differentiated tumors on preoperative biopsies were downgraded to moderately differentiated tumors in 40% (4/10) of cases after resection.

Conclusions

The accuracy of tumor grade of EAC on preprocedural biopsies is suboptimal and should not be depended upon solely to make decisions regarding endoscopic treatment.