Techniques and Innovations in Gastrointestinal Endoscopy最新文献

This comprehensive review addresses the critical role of colonoscopy in colorectal cancer (CRC) prevention. With CRC as one of the most common cancer types in men and women, high-quality colonoscopy is vital to reduce CRC incidence and mortality. Persistent gaps in quality, evidenced by interval CRCs and large variations in both provider adenoma detection rate (ADR) and resection methods, highlight the need to prioritize colonoscopy quality improvement through feedback and training.

This review delves into key factors influencing colonoscopy quality with lesion detection and removal. Excellent bowel preparation is necessary for effective colonoscopy, impacting lesion detection, ADR, procedure time, and complication risk. Optimal inspection techniques, encompassing provider maneuvers and utilization of technological devices such as distal attachment devices and artificial intelligence, hold promise in enhancing inspection quality. For optimal lesion resection, we explore cold snare polypectomy as a safe, cost-effective, and efficacious technique, particularly for diminutive and small polyps, and endoscopic mucosal resection for large (≥20 mm) polyps.

We outline the importance and critical need for quality assurance programs and to implement education science principles into endoscopy training. Innovative simulation-based mastery learning training, which includes various educational strategies to engage endoscopists in deliberate practice with assessment and feedback, holds great potential to efficiently scale the practice of high-quality colonoscopy to improve ADR and resection methods.

Background and Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure that has evolved from being primarily diagnostic to predominantly therapeutic, leading to an increased potential for ERCP-related adverse events. Frailty is an independent predictor of adverse outcomes, and its impact on ERCP-related outcomes requires investigation. This study evaluated the impact of frailty on ERCP-related adverse events.

Methods

The National Inpatient Sample from 2016 to 2019 was used to identify adult patients who underwent ERCP. Frailty was defined using the Frailty Risk Score. Outcomes were categorized into procedure-related adverse events, sedation-related adverse events, and hospitalization outcomes. Multivariate linear or logistic regression was used as appropriate. Stata, version 14.2, was used to perform analyses considering a 2-sided P < 0.05 to be statistically significant.

Results

Among a total of 693,730 ERCPs performed, 870,30 (12.54%) were frail. Frail patients had higher odds of procedure-related adverse events, including hemorrhage (9.1/1000 vs 4.9/1000) and duodenal perforation, but not post-ERCP pancreatitis, bile duct perforation, cholecystitis, and cholangitis. Frailty imparted a higher risk of sedation-related respiratory failure, aspiration pneumonia, and the requirement of intubation and mechanical ventilation. Inpatient mortality was higher among frail patients (4.54% vs 1.03%), and they had prolonged hospital stays and higher hospitalization costs.

Conclusion

Frailty is associated with worse outcomes in patients undergoing ERCP, with higher risks of hemorrhage and sedation-related adverse events, in addition to increased resource utilization. Therefore, the findings of this study suggest strict adherence to guidelines governing anticoagulant management during the peri-endoscopic period, and sedative administration should be carefully monitored. Preprocedural optimization measures and diligent monitoring can minimize resource utilization and decrease periprocedural morbidity.

Background and Aims

The advantages of esophageal hydraulic balloon dilation include the ability to dilate up to 30 mm without fluoroscopic guidance and real-time display of the esophagogastric junction diameter during dilation. We aimed to explore the safety and efficacy of esophageal hydraulic balloon dilation in patients with and without previous foregut surgery, as well as to evaluate for predictors of clinical success.

Methods

We reviewed our database for patients who had esophageal hydraulic balloon dilation, and patients were divided into those with and without previous foregut surgery. Clinical success was determined by improvement in Eckardt/Brief Esophageal Dysphagia Questionnaire scores or, if not available, by physician assessment documented in the medical records. Technical success was defined as the ability to successfully perform esophageal hydraulic balloon dilation with visualization of the waist and stabilization of the balloon. Univariate analysis and logistic regression were used to evaluate predictors of clinical success after dilation.

Results

Among 80 patients who had esophageal hydraulic balloon dilation (36 without and 44 with previous foregut surgery), clinical success was achieved in 48% of patients without previous foregut surgery (43% in achalasia and 73% in esophagogastric junction outflow obstruction) and 83% of patients with previous foregut surgery (87% in surgically treated achalasia and 80% in patients without achalasia with previous fundoplication). Technical success was achieved in 86% of patients without previous foregut surgery and 98% in patients with previous foregut surgery. There was 1 esophageal perforation (1.3%). Opiate use was a negative predictor of clinical success.

Conclusion

Clinical success rates after esophageal hydraulic balloon dilation differ depending on the patient's foregut surgery history. Opiate users appear to have a lower clinical success rate compared with nonusers.

The need for endoscopic service has been well established within gastroenterology globally, and it is equally critical in areas with limited resources. We highlight the educational situation in underserved areas, pertinent goals to aim for, current initiatives and programs, as well as limitations and potential for improvement. Gastroenterology training for medical and surgical endoscopists includes variable components of basic and advanced endoscopies. Various models for training have been used, including traditional 1- to 3-year fellowships, short courses for upskilling, exchange programs, bolus or apprenticeship training, and training camps. There is a steadily increasing demand for endoscopic procedures in the region. We highlight the successes and challenges of current models, which are at various levels, including trainee, institutional, and even geopolitical. In addition, we explore the role that national and international societies as well as industry partners and other stakeholders play in influencing and implementing training. Given the diversity in access to resources as well as endoscopic capacity, we also highlight some of the innovative ways that have been used to provide and continue endoscopy training. Successful training also involves curriculum development, adoption of guidelines, and discussions on assessment of competency as well as having a glimpse into the future of endoscopy training in resource-limited settings. Ultimately, the goal is to ensure harmonized and quality training efforts across the various settings.

Background and Aims

Although obesity affects over 40% of adults in the United States and is a driver of preventable chronic diseases and health care costs, most patients are left untreated.

Methods

This was a randomized, double-blind, sham-controlled trial to investigate the safety and efficacy of a novel, endoscopically placed intragastric device for weight reduction, the TransPyloric Shuttle, implanted for 1 year in 270 patients with Class I and II obesity. An additional 32 treatment patients were enrolled in an Open-Label group. The co-primary efficacy endpoints were percent total body weight loss (%TBWL) in the Treatment group compared with the Sham group and a proportion of treatment patients achieving ≥5% TBWL at 12 months.

Results

The mean %TBWL at 12 months was 9.5% (95% CI, 8.2-10.8) in the Treatment group (n = 181) compared with 2.8% (95% CI, 1.1-4.5) in the Sham group (n = 89). In the Treatment group, 67.0% (95% CI, 59.3-74.4) of patients achieved ≥5% TBWL compared with 29.3% (95% CI, 19.3-39.4) in the Sham group. Patients in the Treatment group achieved lower blood pressure, total cholesterol, and low-density lipoprotein cholesterol compared with the Sham group. Early withdrawals occurred in 22% and 11% patients in the Treatment and Sham groups, respectively. Device- or procedure-related serious adverse events occurred in 6 patients (2.8%), and no deaths occurred.

Conclusion

Treatment with a novel endoscopically placed intragastric device resulted in meaningful weight loss and improvement in cardiometabolic outcomes in patients with Class I and II obesity (ClinicalTrials.gov number NCT02518685).

Background and Aims

Although esophageal widening is a normal consequence of growth in pediatric individuals, esophageal remodeling plays a major role in the morbidity of pediatric and adult eosinophilic esophagitis (EoE). However, the disease is defined by esophageal dysfunction and mucosal eosinophilia. One potential explanation is the difficulty in quantitating remodeling.

Methods

This prospective, IRB-approved longitudinal study evaluated endoscopic ultrasound (EUS) in 78 children, adolescents, and young adults referred to a single academic medical center for esophageal indications. Patients with proven EoE had serial EUS exams that measured total wall thickness (TWT) and esophageal wall sublayers during routine endoscopies to manage their disease. Student t tests and mixed linear models were employed to compare groups.

Results

TWTs from the distal (2.3 ± 0.5 vs 1.7 ± 0.3, P < 0.01) and mid esophagus (2.1 ± 0.5 vs 1.6 ± 0.3, P < 0.05) were increased in active EoE patients > 10 years of age compared with similarly aged controls. After achieving clinical and histologic remission, their TWTs were significantly decreased (distal: 1.9 ± 0.4 vs 2.3 ± 0.5, P < 0.05; mid: 1.7 ± 0.4 vs 2.1 ± 0.5, P < 0.05). Mixed linear models further demonstrated that during active EoE, TWTs, esophageal muscle layers, and the mucosa and submucosa were thickened in older adolescents at both sites (P < 0.05 for each). In remission, TWTs returned to control values.

Conclusion

This pilot study demonstrates that EUS, a unique application of point-of-care ultrasound, can identify the esophageal remodeling that occurs in older adolescents with active EoE. Furthermore, EUS has defined this remodeling as a transmural phenomenon that occurs in the mid and distal esophagus and can completely reverse with adequate treatment.

Background and Aims

Stent migration is a consequential complication associated with esophageal stent placement. We aimed to compare endoscopic suturing vs clips vs no intervention to determine the optimal strategy.

Methods

A literature search was performed using the MEDLINE, Embase, Cochrane, Web of Science, and Global Index Medicus databases. Direct head-to-head comparator analysis and network meta-analysis of all available groups were performed using the random-effects model. A P value less than 0.05 was considered statistically significant.

Results

Ten studies with 1019 participants were included in the final analysis. The direct meta-analysis revealed comparable stent migration rates between endoscopic suturing and clips, with an odds ratio (OR) of 1.07 (95% CI 0.07-14.8, P = 0.96), signifying no significant difference in their efficacy. When compared with the no intervention group, endoscopic suturing demonstrated a lower stent migration rate, with an OR of 0.33 (95% CI 0.17-0.62, P < 0.001). Conversely, endoscopic clips did not exhibit a statistically significant advantage over the no intervention group, displaying an OR of 0.29 (95% CI 0.06-1.48, P = 0.14). The results were consistent in the network meta-analysis. The rankings of interventions, as reflected by the P scores, underscored the superior effectiveness of endoscopic suturing with a score of 0.78, followed closely by endoscopic clips at 0.70, whereas the no intervention approach lagged behind with a score of only 0.03.

Conclusion

Our findings indicate that stent fixation with sutures significantly prevents stent migration, with no clear advantage of one modality over another. However, it is essential to acknowledge that the feasibility of implementing endoscopic suture fixation in every case is constrained by cost, time, and technical expertise.