Techniques and Innovations in Gastrointestinal Endoscopy最新文献

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.

Background and Aims

Little is known about the outcomes of endoscopic resection (ER) for patients with colorectal adenomas (CRAs) with high-grade dysplasia (HGD) or intramucosal cancer (IMCA). This study aimed to estimate the rate of local/malignant recurrence, identify the predictive factors for local recurrence (LR), and evaluate the treatment outcomes of recurrence after ER for HGD/IMCA.

Methods

A retrospective review was performed to identify patients who underwent ER for HGD/IMCA in 2 academic medical centers. Risk factors for LR were determined by Cox regression analysis.

Results

Overall, 188 lesions with HGD/IMCA were included; 61 lesions were removed by en-bloc ER (e-ER), whereas 127 lesions were removed in a piecemeal ER (p-ER). The mean lesion size was 20.3 mm. Of the 125 patients who underwent follow-up, local adenoma recurrence occurred in 31 (23%), and malignant recurrence occurred in 2 (1.6%) patients at a median follow-up of 16 months. HGD/IMCA ≥ 4 cm removed by p-ER have the greatest hazard ratio (HR = 21.5; 95% CI 2.5-180.5; P = 0.005) for LR, compared with the HGD/IMCA < 4 cm removed by e-ER. Surgery was performed in 3.2% of patients after a complete ER, all after p-ER. Of all patients who had LR, 22.6% (7/31 patients) had recurrent adenomas despite repeat ER attempts after a mean of 1.9 ± 0.79 procedures from the index ER.

Conclusion

Our study demonstrates a high rate of LR (23%) after ER of CRAs with HGD/IMCA with a rate of malignant recurrence of 1.6%, especially after p-ER. Thus, e-ER should be preferred for these lesions whenever technically feasible.

Background and Aims

There is a need for a real-time objective tool to assess the mucosal health of the gastrointestinal (GI) tract during endoscopy. Our aim was to develop, design, and validate a low-cost mucosal impedance (MI) device and determine its role in differentiating diseased mucosa from normal mucosa.

Methods

A biocompatible catheter was designed and developed after multiple iterations. It was validated with a commercially available catheter and histopathological analysis in a blinded manner. Patients undergoing resection of the GI tract were recruited after consent, and the resected specimens were analyzed ex vivo for MI within 10 minutes of resection. An average of 3 MI readings of the visually diseased segment and adjacent normal segment were analyzed. MI values of diseased and non-diseased mucosa were compared.

Results

The in-house catheter was validated with a commercially available impedance measuring device. It showed a high degree of positive correlation (rho = 0.616; P < 0.001). Two hundred and thirty-two patients (age 46 ± 15 years; 68% females) (180 inflammatory and 52 malignant pathology) who were undergoing abdominal surgery were enrolled. The median impedance value of diseased segments was significantly lower than that of the adjacent normal segments of gut in 130 paired samples [1832(727)Ω vs 2604(1295)Ω; P < 0.001]. The MI value of segments containing malignant tissue (n = 50) and inflamed tissue (n = 80) was significantly lower than the MI value of adjacent normal segments of the GI tract [1880(977)Ω vs 2583(1431)Ω; P < 0.001 and 1787(557)Ω vs 2515(1244)Ω; P < 0.001, respectively]. There was a 24% reduction in visually diseased segments [median reduction 712(661)Ω] from adjacent normal segments. A biocompatible endoscopic catheter (3-mm diameter) has been developed and tested in 3 patients and was found to differentiate diseased from normal mucosa.

Conclusion

Impedance spectroscopy is an effective real-time, simple, objective tool to differentiate diseased gut mucosa from healthy mucosa.

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.