Therapeutic Advances in Gastrointestinal Endoscopy最新文献

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.

Background: Endoscopic management of abdominal collections includes endoscopic ultrasound (EUS)-guided transmural drainage, transpapillar via endoscopic retrograde cholangiopancreatography (ERCP), and EUS-guided simple puncture-aspiration (SPA). The latter is little reported, and there are some doubts about its real usefulness.

Objectives: The aim of this study was to assess the effectiveness of EUS-guided SPA as a first-line approach for treatment in selected abdominal collections.

Design: Retrospective observational study performed in two tertiary centers (Barcelona area).

Methods: Inclusion of all consecutive patients with abdominal collections that underwent EUS-guided SPA from July 2007 to July 2021. The decision was based on endoscopist criteria and collection characteristics. Clinical success was defined as avoidance of an additional interventional approach (endoscopic stenting, percutaneous drainage, surgery).

Results: Of 241 patients with abdominal collections treated endoscopically, 55 were included for analysis (mean age, 56 ± 12 years). Collection features: mean size 63.3 ± 24.8 mm; positive culture in 22 (40%) and pancreatic nature in 45 (81.8%). EUS-SPA was performed successfully in all cases, and clinical success was achieved in 76.3% (95% confidence interval (CI), 65.5-87.3) of cases (n-42/55). The most frequently used needle size was 19 Ga (85%). A nonsignificant trend for success was detected for noninfected collections (84.8 vs 63.6; p = 0.07) and lower size (mean ± SD; 60.2 ± 22.9 vs 73.8 ± 29 mm; p = 0.09). Two related adverse events were detected: one bleeding and one abdominal pain. Recurrence was detected in five pseudocysts after clinical success. Median follow-up was 629 days (IQR 389-877).

Conclusion: EUS-SPA of selected abdominal collections seems to be a safe and effective technique, avoiding a more aggressive strategy such as transmural stenting. EUS-SPA may be a viable alternative in collections with limited size and preferably noninfected.

Graphical abstract:

Colonoscopy is a commonly performed procedure in the United Kingdom and the gold standard for diagnosis and therapy in the gastrointestinal tract. Increased levels of pain during colonoscopy have been associated with reduced completion rates and difficulties in maintaining attendance for repeat procedures. Multiple factors play a role in causing discomfort intra-procedurally: patient factors, such as gender, anatomy and pre-procedure anxiety; operator factors, such as patient position and level of experience and other factors, such as bowel preparation and total procedure time. A literature search was performed to identify papers that explained how patient, operator and endoscopy factors influenced pain and discomfort in endoscopy. A further search then also identified papers describing solutions to pain and discomfort that have been explored. After review of the literature, key methods are selected and discussed in this paper. Solutions and aids that can resolve and improve pain and discomfort include endoscopic methods such as variable stiffness and ultrathin scopes. Operator improvements in techniques and ergonomics alongside the use of newer technologies such as propelled endoscopy, computer-assisted endoscopy and task distraction. To improve patient experience and outcomes, the investigation and research into improving techniques to reduce pain is crucial. This review aims to identify the modifiable and non-modifiable factors associated with intra-procedural discomfort during colonoscopy. We discuss established methods of improving pain during colonoscopy, in addition to newer technologies to mitigate associated discomfort.

Numerous factors can contribute to a difficult colonoscopy, potentially leading to an incomplete procedure and overlooked lesions. Alternative strategies for handling difficult and incomplete colonoscopies should be considered. We present the case of an 85-year-old male who underwent a difficult colonoscopy, during which two expert endoscopists spent 1.5 h attempting various techniques but failed to intubate the cecum. Subsequently, colonic transendoscopic enteral tubing (TET) was performed. Abdominal plain film revealed tortuosity of the TET tube in the left abdomen corresponding to the distribution of the descending colon. Retrograde colon imaging was conducted by injecting a mixture of contrast medium and air into the colon via the TET tube. X-ray demonstrated well-developed visualization of the entire colon and terminal ileum. And evident elongation and tortuosity of the descending colon resembled an N-type folding pattern. The final diagnosis was determined as descending colon redundancy. Colonic TET combined with retrograde colon imaging through the TET tube may serve as an effective supplementary approach for identifying causes of difficult colonoscopy and improving diagnostic accuracy for bowel diseases when complete visualization is not achieved.

Background: In patient with a complete or near-complete clinical response after neoadjuvant treatment for locally advanced rectal cancer, the organ-sparing approach [watch & wait (W&W) or local excision (LE)] is a possible alternative to major rectal resection. Although, in case of local recurrence or regrowth, after these treatments, a total mesorectal excision (TME) can be operated.

Method: In this retrospective study, we selected 120 patients with locally advanced rectal cancer (LARC) who had a complete or near-complete clinical response after neoadjuvant treatment, from June 2011 to June 2021. Among them, 41 patients were managed by W&W approach, whereas 79 patients were managed by LE. Twenty-three patients underwent salvage TME for an unfavorable histology after LE (11 patients) or a local recurrence/regrowth (seven patients in LE group - five patients in W&W group), with a median follow-up of 42 months.

Results: Following salvage TME, no patients died within 30 days; serious adverse events occurred in four patients; 8 (34.8%) patients had a definitive stoma; 8 (34.8%) patients undergone to major surgery for unfavorable histology after LE - a complete response was confirmed.

Conclusion: Notably active surveillance after rectal sparing allows prompt identifying signs of regrowth or relapse leading to a radical TME. Rectal sparing is a possible strategy for LARC patients although an active surveillance is necessary.