Techniques and Innovations in Gastrointestinal Endoscopy最新文献

Background and Aims

Endoscopic submucosal dissection (ESD) of esophageal lesions is limited by the lengthy procedure time, technique's complexity, and need for specialized training. We propose a standardized esophageal ESD technique that takes advantage of specimen self-retraction to improve visualization and procedure speed by starting the margins’ incision at the anal side, followed by the laterals and the proximal.

Methods

This was a prospective clinical trial of all consecutive patients who underwent a standardized esophageal ESD of esophageal lesions at a single tertiary referral center between December 2016 and January 2021. The primary outcome was the entire procedure speed calculated as centimeters squared per hour. Secondary outcomes included the rates of en bloc resection, R0 resection, and adverse events. Linear regression analysis was conducted to test the association between the entire procedure speed and tumor location, number of knives used, year of procedure, and pathology results.

Results

Thirty-two patients prospectively enrolled in our study. The mean patient age was 65 ± 10.9 years. The mean specimen surface area was 17.9 ± 12.7 cm². The mean entire procedure speed was 11 ± 5.9 cm²/h. The mean total procedure time was 93.5 ± 31 minutes. The entire procedure speed was significantly faster with procedures performed over the last 3 years (+5.86 cm²/h; P = 0.003) or Barrett's esophagus (+7.77 cm²/h; P = 0.001). En-bloc and R0 resection rates were 100% and 68.8%, respectively. There were only 2 early bleeding events (6.3%) and 4 stricture formations (12.5%). All adverse events were successfully managed endoscopically.

Conclusion

Our standardized esophageal ESD technique offered our operator a remarkable entire procedure speed with continuous annual improvement and an acceptable safety profile. Future controlled multicenter studies are warranted to confirm the results’ generalizability and help promote wider adoption of esophageal ESD (ClinicalTrials.gov identifier: NCT04547881).

Conventional endoscopic instruments have intrinsic technical limitations, restraining surgeons’ ability to perform specific colorectal resections with lower complication rates and optimal oncologic results. Robotic transanal surgery has been a recent contribution, considered promising in terms of safety profile, technical learning curve, and oncologic outcomes, an alternative that can ergonomically improve surgeons’ ability to perform more complex procedures. The aim of this study is to report preliminary results regarding the feasibility, safety, and efficacy of ColubrisMX ELS, an endoluminal robotic system for complex polyps and incipient colorectal tumor resection. This was a prospective, single-arm, multicenter study to evaluate the feasibility, safety, and efficacy of an endoluminal robotic system (ColubrisMX ELS) in 8 patients who underwent transanal procedures. All patients were followed up at 7, 30, and 60 days; complication, readmission, and conversion rates, as well as operative time and blood loss, were used to measure safety. Success rates were used to measure efficacy and encompassed the number of procedures performed with a complete tumor resection. Eight patients underwent robotic transanal surgery for local excision of benign or incipient neoplasia over a period of 5.5 months, with a success rate of 100%. Of these, 2 patients (25%) underwent conversions, 1 to manage hemorrhage using endoscopic clips and 1 to complete a polypectomy with the cold snare technique. The mean operative time, from insertion to removal of the transanal flexible tube, was 184 minutes (min 79-max 537), whereas the mean length of hospital stay was 30 hours (min 24-max 144). This approach using a new platform represents a “work in progress” that has the potential to improve not only surgical ergonomics but also surgical outcomes.

Background and Aims

Several criteria have been developed for screening of Barrett's esophagus (BE). Previous studies are limited by analysis in highly selective populations. This study evaluated the performance of 4 criteria in identifying patients with BE from a primary care population.

Methods

This was a post-hoc analysis from a previous retrospective study reporting on BE screening rates of eligible patients in a large health system. Patients were included if they were screened in a primary care population for BE, were at risk for BE per 1 of the accepted criteria, and underwent screening with esophagogastroduodenoscopy. Sensitivity for BE was calculated for 4 screening criteria. These included criteria from the American College of Gastroenterology (ACG), American Society of Gastrointestinal Endoscopy (ASGE), European Society of Gastrointestinal Endoscopy (ESGE), and the Kunzmann model.

Results

In a primary care population, 1077 patients were screened for BE with an esophagogastroduodenoscopy. BE was found in 105 (9.75%) patients. Positive predictive values and negative predictive values of ACG/ESGE, ASGE, and Kunzmann's criteria for BE on pathology were 9.9% and 90.45%, 9.12% and 89.22%, and 10.84% and 92.29%, respectively. The area under the receiver operating characteristic curve for ACG/ESGE, ASGE, and Kunzmann's criteria was 50.49%, 52.23%, and 54.04%, respectively. There was no statistically significant difference in the presence of BE on pathology among patients who did or did not meet ACG/ESGE, ASGE, or Kunzmann's criteria for BE screening.

Conclusion

Current BE screening criteria need optimization in a primary care setting. Use of a combination of criteria might capture the highest number of BE patients.

Colorectal cancer is the third most common cancer in the United States and the second leading cause of cancer-related death. Colonoscopy with polypectomy reduces the incidence and mortality of colorectal cancer, and with the growing number of advanced endoscopic resection techniques, select malignant polyps can now be managed endoscopically. Optimal management of malignant colorectal polyps involves careful assessment of the polyp based on morphologic and surface features to determine the risk of submucosal invasion. Lesions with features of deep submucosal invasion typically require surgical resection, although in the absence of these features, superficially invasive lesions are often amenable to endoscopic resection with techniques such as endoscopic mucosal resection, endoscopic submucosal dissection, and, more recently, endoscopic full-thickness resection. These resection techniques should be performed by endoscopists trained in advanced resection modalities.

Background and Aims

Estimation of the solid component in walled-off pancreatic necrosis (WOPN) during endoscopic ultrasound (EUS) is an important parameter to guide the selection of stent for drainage but is often not objectively quantified.

Methods

We aimed to study the interobserver agreement (IOA) among endosonographers assessing debris in the pancreatic fluid collection and their choice of stent. EUS videos of 15 patients having pancreatic fluid collection with concurrent magnetic resonance imaging (MRI) assessment of debris were independently reviewed by 40 endosonographers for the percentage of debris (10% increments) and their choice of stent (plastic or metal). The Fleiss kappa (κ) coefficient was used to assess IOA. Post-hoc analysis was done using wider debris intervals (20% or greater increments).

Results

Poor agreement was observed for the percentage of debris (κ = 0.188), which did not improve (κ = 0.196) even after including only expert endosonographers with more than 10 years of experience (n = 33). There was fair agreement (κ = 0.266) with reference MRI on the percentage of debris. On post-hoc analysis, the IOA (κ = 0.56, substantial agreement) and agreement with MRI (κ = 0.59, substantial agreement) improved as the debris intervals widened (<10%, 10%-50%, >50%). The agreement for stent selection (plastic vs metal) was poor (κ = 0.174) and did not improve with case volume (κ = 0.153 among respondents with >25 EUS-guided drainage/year; n = 21) or years of experience (κ = 0.195 for >10-year experience; n = 33).

Conclusion

IOA between endosonographers regarding estimation of debris in WOPN and subsequent stent choice for drainage is poor. The experience of endosonographers did not improve IOA. Studies to standardize the EUS criteria for debris assessment in WOPN and subsequent therapeutic approaches are warranted.

Colonoscopy remains one of the most common procedures performed by gastroenterologists and is critical for early detection and management of precursors to colorectal cancer (CRC). Although CRC remains one of the deadliest malignancies, earlier detection of precancerous polyps is directly associated with increased patient survival. As such, quality metrics for colonoscopy, such as polyp detection and mucosal visualization, are key parameters that are directly tied to patient outcomes. Over the past 2 decades, artificial intelligence and machine learning (AI/ML) tools have been tested and developed to augment colonoscopy performance and in 2021 resulted in the first-ever FDA-approved computer-aided detection (CADe) tool. This narrative review begins by reviewing the evidence behind the use of CADe that led to FDA approval. Next, the review discusses the current evidence and technological approaches for computer-aided diagnosis for optical in situ histopathological differentiation of colorectal polyps, including narrow-band imaging, blue light imaging, and endocytoscopy. Studies are ongoing to develop systems to predict the depth of submucosal invasion and to assess endoscopic disease activity among patients with inflammatory bowel disease. The applications of AI/ML to quality improvement are explored, including real-time assessment of bowel preparation, detection of cecal intubation, and automated polyp reporting and surveillance recommendations using natural language processing. Despite initial cost concerns, models have suggested that CADe systems could result in long-term cost savings and are generally accepted by patients and gastroenterologists. There is some reservation in adopting computer-aided diagnosis systems among gastroenterologists due to medico-legal concerns. Future directions for AI/ML in colonoscopy include health system improvements, such as automating note writing, optimizing procedural scheduling, and predicting sedation needs.

Background and Aims

Pancreatic fluid collections (PFCs) are common complications of acute pancreatitis and can cause pain, difficulty feeding, and infection. Endoscopic ultrasound-guided drainage has become the standard of care, with lumen-apposing metal stents (LAMSs) replacing double pigtail plastic stents (DPPSs) as the preferred device. Coaxial placement of DPPSs through LAMSs is hypothesized to lower the risks of adverse events related to LAMSs. We conducted a retrospective study to evaluate the safety and efficacy of this strategy.

Methods

We conducted a retrospective study of consecutive patients with PFCs undergoing endoscopic cystgastrostomy with LAMSs and DPPSs or LAMSs alone at two U.S. academic tertiary care centers from January 2016 until November 2022. Propensity scoring and an adjusted logistic regression model were used for analysis.

Results

We included 68 patients with an average follow-up of 189 days. The most common etiology of pancreatitis was gallstones (35.3%), most PFCs were walled-off necrosis (61.8%), and the mean size was 14.7 cm (SD ± 5.9 cm). Overall clinical success was 88.2%, without significant differences between LAMSs and DPPSs vs LAMSs alone (95.7% vs 84.4%; P = 0.18; aOR = 4.6; 95% CI, 0.5-41.4). We found no statistically significant differences in rates of LAMS occlusion (aOR = 0.47; 95% CI, 0.09-2.5), infection (aOR = 1.03; 95% CI, 0.17-6.2), bleeding (aOR = 0.4; 95% CI, 0.03-5), or stent migration (aOR = 0.42; 95% CI, 0.04-4.1) between the 2 groups.

Conclusion

This retrospective cohort study found no statistically significant differences in the safety or efficacy of cystgastrostomy with LAMSs and DPPSs vs LAMSs alone. Larger, prospective trials comparing these strategies are needed.

Background and Aims

Gastrointestinal bleeding (GIB) is a common morbidity among continuous-flow left ventricular assist device (CF-LVAD) recipients. The study objectives were to investigate the incidence, recurrence, risk factors, and medical and endoscopic management of GIB among CF-LVAD patients.

Methods

This is a single-center retrospective study analyzing 563 CF-LVAD recipients implanted at a large tertiary referral center from 2007 to 2018 with 619 bleeding events characterized. Patients with device exchanges or history of right ventricular assist devices were excluded. Chart review data pertaining to demographics, LVAD characteristics, endoscopic reports, and medications were collected.

Results

The incidence of GIB was 44%, with a median time to first bleed of 133 days and a recurrence rate of 53%. Approximately 13% of patients had ≥5 GIB events. There is an association of reduced GIB among patients taking angiotensin-converting enzyme inhibitors (ACEis). There was no association with GIB and acid-reducing medications, antiplatelet medications, and history of GIB before device implantation. Arteriovenous malformations were the most common bleeding etiology. CF-LVAD patients that bled more frequently were older, had their CF-LVAD longer, and bled earlier after LVAD implantation.

Conclusion

This is the largest comprehensive single-center GIB study among CF-LVAD recipients. The incidence and recurrence of GIB among CF-LVAD recipients is underreported. Push enteroscopy improves diagnostic yield for upper GIB. Special attention should be given to CF-LVAD patients that bleed within the first 18 days of implantation. There is an associative, dose-dependent benefit of ACEi medications among CF-LVAD recipients. Further studies on this effect are warranted.

Previously, the gold standard surgery for early gastric cancer was gastrectomy. This practice has changed radically with the introduction of advanced endoscopic resection techniques, including endoscopic submucosal dissection (ESD). Compared with traditional gastrectomies, the minimally invasive nature of ESDs allows patients to recover faster and experience less postoperative pain. Nevertheless, procedurists performing gastric ESDs are hampered by the limitations of current endoscopic instruments. The lack of degrees of freedom of existing endoscopic instruments renders it challenging for procedurists to achieve triangulation of instruments, optimal retraction of tissues, and adequate exposure of the operating field. Robotic endoscopic platforms solve these challenges by providing robotic end-effectors with high degrees of freedom. This review analyzes the benefits of robotic endoscopic platforms in reducing the learning curve, procedure times, and complication rates in performing gastric ESD. The review also explores future development of robotic endoscopic platforms that can enhance the efficacy and efficiency of gastric ESD, such as the development of adjunct endoscopic instruments to create and close full-thickness incisions, incorporating haptic feedback into robotic endoscopic platforms, and establishing a structured training program for procedurists.

The incidence of superficial esophageal adenocarcinoma (EAC) is rising and warrants awareness. Invasive surgery with lymph node dissection was long standard treatment for EAC. However, endoscopic resection techniques, such as cap-based endoscopic resection or endoscopic submucosal dissection (ESD), have proven to be safe and effective alternatives for removal of superficial EAC. Therefore, endoscopic resection is now the cornerstone of management for superficial EAC, for both diagnostic and therapeutic purposes. Current guidelines advise use of the cap-based approach for small, flat lesions, whereas ESD is recommended for large and bulky lesions, lesions with suspected submucosal invasion, or lesions in scarred areas. The histopathological assessment after a resection, evaluating histological risk factors for lymph node metastases, plays a key role in the decision about whether additional surgery is indicated. Until recently, all submucosal and/or high-risk EAC had an indication for additional (prophylactic) surgery because of the assumed high risk for lymph node metastases. However, this risk appears lower than initially assumed, and endoscopic management for low-risk submucosal EAC is gaining acceptance. Ongoing prospective trials will help to determine whether a watchful waiting strategy could be an alternative to surgery in patients with submucosal and/or high-risk EAC. In the future, the distinction between patients who can safely be followed with a watchful waiting strategy and patients who might benefit from additional surgery could become more unambiguous, resulting in more optimal patient-tailored management for patients with superficial EAC.