Techniques and Innovations in Gastrointestinal Endoscopy最新文献

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

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.

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.

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

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.