Therapeutic Advances in Gastrointestinal Endoscopy最新文献

Background: Bile leakage following hepatectomy is a challenging issue that poses difficulties for hepatobiliary surgeons. Endoscopic treatment is the primary method for managing this complication, although its effectiveness is still uncertain.

Objectives: The aim of this study was to assess the effectiveness and risk factors of endoscopic treatment for bile leakage after hepatectomy.

Design: A retrospective cohort study.

Methods: A retrospective study was performed on 15 patients who experienced bile leakage following hepatectomy and were successfully treated with endoscopic retrograde cholangiography (ERCP). The primary focus was to examine how factors like the site of bile leakage, the position of biliary drainage, and late-set leakage impact early clinical success (ECS).

Results: Out of the 15 cases, 10 successfully achieved ECS through endoscopic treatment. The highest success rate (80.0%, 4 out of 5) was seen when biliary drainage was performed by bridging, while drainage placed near the leakage site had a success rate of 75.0% (6 out of 8). The best outcomes occurred when bile leakage was located in the tertiary or higher branch bile ducts, with an 83.3% success rate (5 out of 6). Additionally, early-onset leakage had a higher ECS success rate compared to late-onset bile leakage (75.0% (6/8) vs 57.1% (4/7)). Among the 15 cases, 12 involved extensive liver resections of more than two segments, 14 included segments 7 or 8, 11 had received preoperative adjuvant therapy, and 9 had undergone transarterial chemoembolization (TACE). In cases with late-onset bile leakage, 6 out of 7 (85.7%) had undergone TACE. Bile leakage caused by TACE was more likely to be accompanied by bile duct-bronchial fistula, and the healing process took significantly longer.

Conclusion: Endoscopic management of bile leakage following liver resection is both safe and effective, making it a preferred first-line treatment. Improved results can be obtained by placing a stent to bridge and drain near the leakage site. Extensive liver resection, resection involving segments 7 or 8 of the liver, and preoperative adjuvant therapies are significant risk factors for bile leakage, particularly TACE, which may lead to bile duct-bronchial fistulas and extended recovery periods.

Background: The optimal choice between fully covered self-expandable metallic stents (FCSEMSs) and uncovered self-expandable metallic stent (USEMS) for managing inoperable malignant distal biliary obstruction (MDBO) remains debatable. This study aims to compare the efficacy of CSEMS and USEMS in patients with MDBO.

Method: A retrospective analysis was conducted with inoperable MDBO between January 2017 to December 2021 who underwent either USEMS or FCSEMS implantations via endoscopic retrograde cholangiopancreatography (ERCP). Primary outcomes were overall survival and stent patency. Secondary outcomes were stent occlusion rates and postoperative complications.

Results: This study included 310 patients (235 patients received FCSEMS implantations and 75 received USEMS implantations). Median follow-up duration was 5.2 months. No significant difference was observed in overall survival between the FCSEMS and USEMS groups (167 vs 169 days, p = 0.566). The mean stent patency duration was longer in the FCSEMS group compared to the USEMS group (445 vs 348 days, p = 0.020). There were no significant differences in postoperative complications between the two groups. Multivariate analysis indicated that endoscopic sphincterotomy (EST) (HR = 1.259, 95% CI: 1.167-1.358, p < 0.001), USEMS (HR = 2.277, 95% CI: 1.750-2.963, p < 0.001), stent length (HR = 1.804, 95% CI: 1.662-1.959, p < 0.001), preoperative biliary stent (HR = 1.166, 95% CI: 1.070-1.271, p < 0.001) and non-pancreatic cancer (HR = 1.404, 95% CI: 1.299-1.516, p < 0.001) were independent risk factors for stent occlusion, while BMI ⩾ 24 kg/m² (HR = 0.600, 95% CI: 0.548-0.657, p < 0.001) was identified as a protective factor. In the subgroup analysis for pancreatic cancer, patients with FCSEMS (n = 109) had an average survival time of 154.14 ± 93.93 days, while those with USEMS (n = 34) had an average survival time of 130.32 ± 57.31 days (p = 0.21). For non-pancreatic cancer, patients with FCSEMS (n = 115) had an average survival time of 194.10 ± 93.40 days, and patients with USEMS (n = 34) had an average survival time of 204.97 ± 93.40 days (p = 0.67).

Conclusion: Compared to USEMS, FCSEMS provides a longer stent patency duration for patients with MDBO. However, no significant differences were found in overall survival and postoperative complications in this retrospective study.

Background: Colorectal cancer (CRC) incidence is rising globally, intensifying pressure on endoscopy services. Colon capsule endoscopy (CCE) offers a non-invasive alternative. Despite several systematic reviews showing reasonable polyp detection rates, clinical scepticism remains.

Objectives: This meta-review and umbrella meta-analysis aim to synthesise evidence on CCE's diagnostic accuracy in polyp and CRC detection, using CT colonography or colonoscopy as the reference standard.

Methods: We conducted a systematic search of EMBASE, MEDLINE and PubMed for systematic reviews evaluating the diagnostic accuracy of CCE in detecting polyps and CRC. A qualitative thematic review and synthesis were conducted following PRISMA guidelines. A bivariate generalised linear mixed model with random effects was used for pooled diagnostic accuracy estimates, and meta-regression was performed using restricted maximum likelihood estimation.

Results: Nine systematic reviews encompassing 28 unique studies (3472 participants) were included. For polyps of any size, the pooled per-patient sensitivity was 0.79 (95% CI: 0.69-0.86), specificity was 0.77 (95% CI: 0.71-0.82), and the area under the curve (AUC) was 0.81. For polyps ⩾6 mm, sensitivity and specificity were 0.80 and 0.87 (AUC 0.81), and for polyps ⩾10 mm, 0.88 and 0.95 (AUC 0.95), respectively. Second-generation CCE (CCE2) improved diagnostic accuracy across all polyp sizes. For polyps of any size, CCE2 achieved a sensitivity of 0.90, specificity of 0.81 and AUC of 0.82. For polyps ⩾ 6 mm and ⩾10 mm, AUCs were 0.92 and 0.94, respectively. CCE2 showed high sensitivity for detecting any polyp size and polyps ⩾6 mm, with low heterogeneity (p > 0.05, I ² < 25%). CRC detection sensitivity was 0.96 (95% CI: 0.73-1.00) after excluding cases where the capsule failed to reach the rectum due to battery exhaustion.

Conclusion: CCE2 has high diagnostic accuracy for polyps and colorectal cancer detection. While technical challenges persist, CCE2 shows promise as a complementary diagnostic tool to help address the increasing demands for endoscopy services.

Background: Patients with inflammatory bowel disease (IBD) have an increased risk of colorectal cancer. Endoscopic surveillance is recommended but is challenging due to the presence of active inflammation, flat dysplasia and inflammatory pseudopolyposis. CAD-EYE, an artificial intelligence (AI) powered endoscopic module by FUJIFILM, optically characterises lesions in real time. The aim of this study was to evaluate the accuracy of CAD-EYE in IBD surveillance.

Methods: Ninety-seven lesions were identified from 38 patients with IBD, undergoing surveillance at a single centre. Non-magnified, still images of lesions identified during the procedure were captured, followed by characterisation by CAD-EYE as neoplastic or hyperplastic (non-neoplastic) prior to resection. Inflammatory pseudopolyps were imaged and only resected based on the physician's discretion. Images of lesions identified were characterised by two expert IBD clinicians. The accuracy of CAD-EYE was assessed for all lesions (composite of histology for resected lesions and expert-verified non-resected pseudopolyps). For the resected lesions, the accuracy of CAD-EYE was compared to expert characterisation.

Results: CAD-EYE correctly characterised 92/97 lesions (94.8%) with a sensitivity of 80.0%, specificity of 97.6%, positive predictive value of 85.7% and negative predictive value of 96.4% for neoplastic lesions. For resected lesions, diagnostic accuracy was similar between CAD-EYE (93.0%) and expert characterisation (88.4%), with no statistically significant differences in sensitivity.

Conclusion: CAD-EYE demonstrated its utility in IBD surveillance with excellent accuracy in the characterisation of lesions, including inflammatory pseudopolyps. Larger studies are required to confirm these findings, particularly for flat dysplasia.

Background: Delayed gastrointestinal transit time (TT), frequently observed in diabetes mellitus (DM), may hinder bowel preparation quality and visualization in video capsule endoscopy (VCE).

Objectives: The study aim was to compare VCE preparation adequacy and completion rates between patients with and without DM.

Design: Retrospective analysis of a prospectively maintained database, including all consecutive VCEs performed in patients aged ⩾35 years.

Methods: Patients were divided into two groups based on a DM diagnosis reported at admission and confirmed by medication records. Clinico-demographic characteristics, bowel preparation quality, TTs, and completion rates were compared between the groups. Logistic regression analysis was performed to identify independent risk factors for inadequate bowel preparation.

Results: Out of 672 included VCEs, 189 (28.1%) patients had DM and 483 (71.9%) were controls. Completion rates were comparable (DM-98.4% vs controls-99.0%, p = 0.553). Gastric TT was similar (DM-37.5 ± 45.5 vs controls-34.3± 48.6 min, p = 0.420), while small bowel TT was longer (DM-261.8 ± 95.6 vs controls-244.9 ± 98.4 min, p = 0.040). DM patients had higher inadequate preparation rates (31.2% vs controls-23.4%, p = 0.040). In a multivariate analysis adjusted for age and gender, DM was not independently associated with inadequate preparation. However, DM treated with insulin (26.5% of patients with DM) was significantly associated with inadequate bowel preparation (Odds ratio (OR) 2.355, p = 0.006). Glucagon-like peptide-1 receptor agonist usage (11.8% of patients with DM patients) compared to no-DM controls achieved borderline significance as a risk factor for preparation inadequacy (OR 2.148, 95% CI 0.887-5.201, p = 0.090).

Conclusion: VCE appears to be feasible in patients with DM, with similar completion rates and gastric TTs despite slightly prolonged small bowel TTs. However, DM treated with insulin is a significant risk factor for inadequate bowel preparation, suggesting the need for a more intensive preparation protocol within this patient group.

Celiac disease (CeD) is a widely diffused chronic autoimmune disorder triggered by the ingestion of gluten, in genetically predisposed individuals. Small bowel capsule endoscopy (SBCE) plays a pivotal role as a noninvasive tool for diagnosing and monitoring CeD. This review aims to summarize the current and potential future role of SBCE in the field of CeD. SBCE offers the advantage of visualizing the entire small bowel, allowing the extent of disease involvement to be described. According to international guidelines, SBCE has a defined role in cases of inconclusive histopathology or when clinical suspicion persists despite negative duodenal biopsies. To date, more and more interest is shown toward its role in monitoring CeD, specifically in terms of mucosal healing, early detection of complications such as ulcerative jejunitis, or performing differential diagnosis among other small bowel diseases that mimic CeD. With the rise of artificial intelligence systems being applied in this field, the future role of SBCE in CeD is expected to improve diagnostic accuracy and streamline the evaluation process, allowing its use as a routine tool for monitoring and early diagnosis of CeD-related complications. The environmental impact of SBCE is still under debate, but increasing evidence is suggesting ways to apply circular economy to the capsule lifecycle, turning it into a more sustainable device. In conclusion, SBCE is increasingly recognized as a critical tool in the diagnosis and monitoring of CeD.

Background: Colonoscopic polypectomy significantly reduces the incidence of colorectal cancer, but it carries potential risks, with colonic perforation being the most common and associated with significant morbidity.

Objectives: This study evaluated the clinical outcomes and risk factors of microperforation during colonoscopic polypectomy.

Design: A retrospective cohort study.

Methods: We retrospectively reviewed the patients' records who underwent colonoscopic polypectomy and subsequent plain radiographic examination to monitor perforation. Patients with pneumoperitoneum detected on plain radiography were enrolled. Patients who underwent adverse event-free colonoscopic polypectomies within 1 week of each case and were matched 2:1 by age and sex to the cases were selected as controls.

Results: Microperforations occurred in 12 patients (8 males; age: median 64.5 years). Polyps with microperforations were more frequent in the right colon (83.3% vs 33.3%). Endoscopic mucosal resection with precutting (EMR-P; 16.7% vs 0.0%) or hot-snare polypectomy (8.3% vs 0.0%) was more frequently performed in the microperforation group. Muscle fibers at the polypectomy site were more frequently visible in the microperforation group (58.3% vs 8.3%). By multivariate analysis, right colon location and visible muscle fibers were independent risk factors for microperforation. All patients with microperforation received intravenous antibiotics and were advised to fast. Patients responded well to these conservative treatments and were discharged after a median of 3 (2-6.75) days of hospital stay.

Conclusion: Our data suggest that conservative treatment is feasible and could be the primary management option for selected patients with microperforations postcolonoscopic polypectomy. Right-sided colonic polyps and visible muscle fibers predispose to microperforations.

The utilization of artificial intelligence (AI) in gastrointestinal (GI) endoscopy has witnessed significant progress and promising results in recent years worldwide. From 2019 to 2023, the European Society of Gastrointestinal Endoscopy has released multiple guidelines/consensus with recommendations on integrating AI for detecting and classifying lesions in practical endoscopy. In Vietnam, since 2019, several preliminary studies have been conducted to develop AI algorithms for GI endoscopy, focusing on lesion detection. These studies have yielded high accuracy results ranging from 86% to 92%. For upper GI endoscopy, ongoing research directions comprise image quality assessment, detection of anatomical landmarks, simulating image-enhanced endoscopy, and semi-automated tools supporting the delineation of GI lesions on endoscopic images. For lower GI endoscopy, most studies focus on developing AI algorithms for colorectal polyps' detection and classification based on the risk of malignancy. In conclusion, the application of AI in this field represents a promising research direction, presenting challenges and opportunities for real-world implementation within the Vietnamese healthcare context.

Background: The faecal immunochemical test (FIT) is an immunoassay used to detect human blood in the stool. The role of FIT as a screening tool for small bowel pathology remains unclear.

Objectives: This study aimed to investigate the role of FIT in predicting small bowel pathology in patients with iron deficiency anaemia (IDA).

Design: This was a single tertiary centre prospective study. The inclusion criterion was adults (⩾18 years and <80 years) with IDA who were referred to secondary care for endoscopic investigations.

Methods: All patients had a FIT test done in primary care. Eligible patients were invited to have a small bowel capsule endoscopy (SBCE) prior to endoscopy. Patients with subsequent upper or lower gastrointestinal tract malignancy were excluded from the study. IDA was defined as a Hb < 131 g/L for men and <110 g/L for women with ferritin <30 µg/L and/or iron levels <11 µmol/L. A further 100 patients with recurrent/refractory IDA who did not have a FIT test done and had an SBCE were used as the control group.

Results: In total 179 patients were included in the final analysis with a median age of 64.5 years (interquartile range (IQR 51-75)); haemoglobin 101 (IQR 90-111) and ferritin 11(7-20). In the prospective FIT group of 79 patients, there were 35 (44%) patients with significant findings on SBCE which was classed as contributing to IDA. These findings included angioectasia in n = 21 (26.6%) patients which was the most common finding. The other findings included erosions and ulcers = 5 (7.6%); inflammatory strictures = 3 (3.8%); active Crohn's n = 1 (1.3%); visible blood with no clear source n = 3 (3.8%) and bleeding angioectasia n = 1 (1.3%). A positive FIT (>10) had a sensitivity, specificity, positive predictive value and negative predictive value of 34.29%, 54.55%, 37.5% and 51.08%, respectively. In the control group (n = 100), 37% of the patients had significant pathology on SBCE. On logistic regression, age (OR 1.06; 95% CI: 1.03-1.11) was the only factor related to the probability of having a positive finding on SBCE.

Conclusion: Over a third of the patients with IDA have significant findings on SBCE. However, in this study, we did not find that FIT conferred any additional benefit in the detection of small bowel pathology.

Endoscopic ultrasound-guided drainage of loculated malignancy-related ascites has been reported in limited case series with success in achieving symptomatic relief. In this case report, we detail the successful drainage of a loculated paragastric ascites with insertion of a lumen-apposing metal stent (LAMS) in a patient diagnosed with metastatic ovarian cancer.