Techniques and Innovations in Gastrointestinal Endoscopy最新文献

Background and Aims

Endoscopic submucosal dissection (ESD) is a technically challenging and time-consuming procedure. A major limitation of ESD is the lack of a “second hand” to provide traction. We have developed a novel retraction device, a traction wire (TW), for ESD. This study was conducted to assess the efficacy, safety, and efficiency of TW-ESD.

Methods

We initially evaluated TW-ESD in a randomized live pig study. After the device was approved for clinical use, we used it in patients undergoing ESD at 8 academic centers in the United States and Japan. Data on demographics, procedural performance, histopathology, and clinical follow-up were collected and analyzed retrospectively.

Results

Porcine study: In total, 12 ESDs were performed in random order in 3 live pigs. ESDs performed with TW had significantly shorter submucosal dissection time (7.0 ± 1.9 minutes vs 18.3 ± 3.4 minutes; P < 0.001) and shorter total ESD time (21.5 ± 4.1 minutes vs 29.5 ± 7.7 minutes; P= 0.049). TW was successfully deployed in all 103 study patients. The median device deployment time was 2 minutes (2, 3.0), and the median procedure time was 100.5 (65.50, 175.75) minutes. En-bloc and R0 resection rates were 98.1% (101/103) and 90.29% (93/103), respectively. The median ease of deployment and retrieval of the device on a 100-mm visual analog scale was 100 (80, 100). The median degree to which the device improved ease of procedure was 90 (77.5, 100). No adverse events related to the TW were seen.

Conclusion

The TW device was safe and efficient to use in ESD.

The incidence of early onset colorectal cancer (EoCRC), defined as colorectal cancer (CRC) in patients under age 50, has been increasing in the United States. This is due to a birth cohort effect in which the younger generation has experienced an accelerating rise in EoCRC for reasons currently unknown, although epidemiologic research points to several traditional and emerging generation-specific risk factors. There are several racial/ethnic and geographic differences in the presentation of EoCRC with disparate outcomes. A subset of EoCRC patients have a familial or hereditary cause of EoCRC, although the etiology for most EoCRC remains to be discovered. Our current approach to prevention and early detection includes early screening for familial CRC, germline genetic testing for all cases of EoCRC, triage of alarm symptoms with prompt evaluation of red flag signs and symptoms (such as hematochezia, iron deficiency anemia, and unexplained weight loss), offering a menu of average-risk screening options to those age 45 and older, and performing outreach/navigation to improve opportunistic screening uptake. Unfortunately, full actualization of these approaches remains suboptimal, and the increasing burden of EoCRC demands immediate action. Opportunities to improve prevention and early detection of EoCRC include initiating organized screening approaches through leveraging the electronic health record, centralization of care in medical homes, outreach using blockchain or social media technology, and biotechnological innovations in diagnosis and risk stratification.

The incidence of Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) continues to increase in Western countries, and EAC continues to have an overall 5-year survival rate of less than 20%. This is predominantly due to most EAC cases being diagnosed at advanced stages, after the onset of alarm symptoms. The rationale behind endoscopic surveillance of BE follows the paradigm that metaplasia (BE) progresses to EAC via the development of low- (LGD) and then high-grade dysplasia (HGD). Hence, endoscopic surveillance is recommended to enable early detection of dysplasia and EAC. Numerous endoscopic eradication therapy (EET) modalities, such as radiofrequency ablation (RFA), cryotherapy, and endoscopic resection, enable effective treatment of dysplasia and early-stage EAC. Indeed, randomized trials have conclusively shown that endoscopic treatment of BE-HGD and BE-LGD with RFA reduces progression to EAC. Additionally, EET effectively treats early-stage EAC.

Background and Aims

Endoscopic submucosal dissection (ESD) is a therapeutic technique for en-bloc resection of both large (>20 mm) and smaller, complex gastrointestinal neoplasms. ESD has a higher success rate of en-bloc resection and a lower rate of local recurrence compared with endoscopic mucosal resection. Removal of lesions via ESD can leave large mucosal defects, raising unique challenges leading to adverse events. We aimed to determine clinical outcomes, including delayed bleeding, perforation, and hospitalization, in patients undergoing endoscopic suturing after ESD.

Methods

This was a single-center retrospective study of a prospectively collected database of consecutive adult patients who underwent ESD with mucosal defect closure using endoscopic suturing. Primary outcomes were adverse events, specifically delayed bleeding or perforation. Secondary outcomes included need for hospitalization and suturing complications.

Results

Fifty-five patients (mean age: 67 years) were included, with a mean lesion size of 27.4 ± 15 mm. Defect closure occurred in the esophagus (6), gastroesophageal junction (2), stomach (30), cecum (2), sigmoid colon (2), and rectum (13). A mean of 1.8 ± 1.0 sutures were required for defect closure. The hospital admission rates was 14% (8/55), with an average length of stay 2 days (range 1-3 days). Intraprocedural perforation occurred in 2 patients, and both were successfully treated with endoscopic suturing. There was one case of delayed bleeding and no cases of delayed perforation or suturing complications.

Conclusion

The use of endoscopic suturing following ESD is a safe and clinically reliable method to close mucosal defects. This approach is associated with minimal adverse events and need for hospitalization. Larger studies are needed to further validate these findings.

Barrett's esophagus (BE) is characterized by the metaplastic transformation of the normal squamous epithelium of the distal esophagus to columnar-lined mucosa with intestinal metaplasia. BE is the only known precursor to esophageal adenocarcinoma (EAC). Given the rising incidence of EAC in recent decades, early detection, enrollment in surveillance programs, and effective treatment are critical. BE-related neoplasia and select early esophageal cancers should be treated with endoscopic eradication therapy (EET). The toolbox for BE endotherapy has grown tremendously alongside evolving techniques in resection and new ablative devices. The success of EET hinges on thoughtful patient selection, appropriate choice of therapeutic modality, and adherence to surveillance intervals including ongoing surveillance after BE eradication. We emphasize the importance of reflux optimization and the role of patient education and counseling throughout the process.

Background and Aims

Reliable tools to diagnose and prognosticate acute cholangitis are needed to improve patient outcomes. We assessed the accuracy of 2 clinical criteria, Tokyo and BILE criteria, for the diagnosis and severity of acute cholangitis.

Methods

We identified all patients from 2020-2021 seen at our institution with suspected cholangitis, defined as having abdominal pain or fever, and abnormal liver enzymes or biliary abnormality on imaging studies. Patient medical records were reviewed, and demographics, laboratory results, imaging findings, and procedure results were collected. To ascertain clinical outcomes, patients were followed until hospital discharge or for 30 days after presentation.

Results

During the study period, 175 patients with suspected acute cholangitis were prospectively identified. The average patient age was 69.6 years, 50.3% were women, and 115 met criteria standard for diagnosis of acute cholangitis. Intensive care admissions in 14.3%, mortality in 5.7%, and 30-day readmissions in 7.4% were observed. Tokyo diagnostic criteria for definite cholangitis had higher accuracy (64%), sensitivity (69.6%), and specificity (53.3%) when compared with BILE criteria, with an accuracy of 48.6% (P = 0.005), sensitivity of 42.61%, and specificity of 60%. Both criteria performed better in patients with choledocholithiasis (80% and 51% accuracy) than in patients with preexisting biliary stents (56% and 41% accuracy). The Tokyo severity grading criteria for severe cholangitis had an accuracy of 67.83% and was highly predictive of in-hospital mortality and ICU admission, but not 30-day readmission.

Conclusion

Tokyo criteria were more accurate than BILE criteria for acute cholangitis; however, neither criteria achieved high diagnostic accuracy, especially in patients with preexisting biliary stents.

Background and Aims

Submucosal fibrosis is a commonly encountered problem associated with complex polyps referred for endoscopic mucosal resection (EMR). Previous biopsies, submucosal tattoo injection, and previous unsuccessful attempts at polyp resection have all been shown to induce submucosal fibrosis, which makes subsequent EMR more difficult and increases the risk of recurrence.

Methods

We conducted a multicenter, international, retrospective study of 61 distal cap-assisted endoscopic mucosal resection (EMR-DC) cases done for the indication of a non-lifting colorectal lesion occurring after a previous biopsy, tattoo, or attempted resection at 3 tertiary referral centers.

Results

EMR-DC was preceded by attempted polypectomy or EMR in 88.5% of cases, submucosal tattoo injection in 2%, previous biopsy in 5%, and both biopsy and tattoo in 5%. Complete macroscopic resection was achieved in 100% of EMR-DC procedures in an average procedure time of 49.5 minutes. The adenoma recurrence rate for these adherent lesions at surveillance (average 6.6 months) was only 9.8%. Two serious adverse events occurred (3.3%) within 30 days of the procedure: one instance of postprocedural bleeding and one episode of post-polypectomy syndrome.

Conclusion

This large, multicenter series demonstrates EMR-DC to be a safe, effective, and efficient approach to a difficult and common clinical problem: adherent and non-lifting polyps. It may offer several advantages over more expensive or invasive endoscopic techniques used for this indication. The use of EMR-DC for larger adherent polyps with adjuvant techniques such as hot avulsion or cold forceps avulsion with adjuvant snare tip soft coagulation for smaller adherent sections may represent an ideal approach.