Therapeutic Advances in Gastrointestinal Endoscopy最新文献

Background: Digestive endoscopy (DE) is uncomfortable for most patients. Lorazepam is a potent benzodiazepine with anxiolytic and sedative effects.

Objective: This study aims to determine the sedative effect of sublingual lorazepam versus placebo as a premedication in patients who underwent DE.

Design: This is a mono-center, double-blind, and randomized controlled trial.

Methods: A lorazepam sublingual tablet was made by researchers and physical tests were done on it, then the double-blind placebo-controlled trial was done to investigate the efficacy of 2 mg sublingually administered lorazepam as a premedication for endoscopy. Lorazepam or a placebo tablet was administered sublingually 30 min before the endoscopy. The patients, nurses, and physicians were blinded to the patient group. The depth of sedation was evaluated according to the American Society of Anesthesiology.

Results: In all, 116 patients were randomly assigned to take either lorazepam (n = 58) or a placebo (n = 58). The results of physical properties tests were acceptable according to United States Pharmacopeia. There were no statistical differences between groups regarding age and gender. In the lorazepam group, 75.8% of patients showed mild sedation, and 24.2% of patients showed no sedation. All of the patients in the placebo had no sedation (p = 0.001). Time of procedure (p < 0.001), intraoperative O₂ saturation (p < 0.001), intraoperative heart rate (p < 0.001), and intraoperative blood pressure (p < 0.001) were significantly lower in the lorazepam group. No significant or dangerous side effects were observed except a bit of giddiness and dizziness.

Conclusion: The results of this study showed that prescription of sublingual lorazepam 25-30 min before endoscopy provided mild sedation.

Registration: IRCT201611039014N130 (05/11/2016); https://en.irct.ir/trial/9568.

Weight recurrence after one-anastomosis gastric bypass (OAGB), the third most common metabolic and bariatric surgery performed worldwide, is observed in a subset of patients due to the chronic, progressive nature of obesity. Endoscopic revision of the OAGB (ER-OAGB) through full-thickness suturing to reduce the gastrojejunal anastomosis and gastric pouch is a potential alternative to surgical revision. Here, we present a case series of ER-OAGB and long-term nutritional support at two international centers with expertise in bariatric endoscopy. Data were retrospectively evaluated from a prospectively maintained database. The primary outcome was total body weight loss (TBWL) at 12 months. Secondary outcomes included TBWL at 3, 6, and 15 months; excess weight loss (EWL) at 3, 6, 12, and 15 months; frequency of new/worsening symptoms of gastroesophageal reflux disease (GERD); and the frequency of serious adverse events. In this series, 17 adults (70.6% female, mean age 46.8 years, mean BMI 39.1 kg/m²) successfully underwent ER-OAGB an average of 8 years (range 2-21 years) after OAGB for a mean weight recurrence of 43.2% (range 10.9-86.9%). TBWL from ER-OAGB was 9.7 ± 1.8% at 3 months, 13.4 ± 3.5% at 6 months, 18.5 ± 2.1% at 12 months, and 18.1 ± 2.2% at 15 months. EWL from ER-OAGB was 30.5 ± 14.7% at 3 months, 42.6 ± 16.2% at 6 months, 54.2 ± 11.3% at 12 months, and 54.2 ± 11.7% at 15 months. There were no instances of new/worsening GERD symptoms or serious adverse events. In this small series of adults who experienced weight recurrence after OAGB, ER-OAGB facilitated safe and clinically meaningful weight loss, without new or worsening GERD symptoms, when performed by experienced bariatric endoscopists in concert with longitudinal nutritional support.

Introduction: Dynamic changes in liver function tests have been proposed to correctly reclassify the risk of choledocholithiasis; however, information is scarce and insufficient to recommend its use.

Methods: Retrospective cohort of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) due to moderate and high risk of choledocholithiasis according to the 2019 American Society of Gastrointestinal Endoscopy (ASGE) guidelines. We evaluated whether significant changes in liver function tests (bilirubin, transaminases, or alkaline phosphatase), defined as an increase or a reduction ⩾30 or ⩾50% between two measurements taken with a difference of 24-72 h can correctly reclassify the risk of choledocholithiasis beyond the ASGE guidelines. The net reclassification index (NRI) was calculated for patients with and without choledocholithiasis.

Results: Among 1175 patients who underwent ERCP, 170 patients were included in the analysis (59.4% women, median 59.5 years). Among patients without a diagnosis of choledocholithiasis, the number of patients correctly reclassified by transaminases was slightly higher than those incorrectly reclassified (NRI = 0.24 for aspartate amino transaminase and 0.20 for alanine amino transaminase). However, among patients with a diagnosis of choledocholithiasis, it led to incorrect reclassification in a greater number of cases (NRI = -0.21 and -0.14, respectively). The benefits of reclassification were minimal for bilirubin and alkaline phosphatase, or for value changes >50%. A subgroup analysis showed similar findings in patients without a history of cholecystectomy and in those with normal bile duct.

Conclusion: Dynamic changes in liver function tests do not improve choledocholithiasis risk classification beyond the 2019 ASGE criteria. New criteria should continue to be sought to optimize risk stratification.

Background: Endoscopic approaches in the treatment of transmural esophageal defects, either after esophageal resection or due to perforation, have demonstrated convincing feasibility. Surgical options are limited and associated with high morbidity and mortality rates. Currently, internal endoscopic drainage with pigtail stents, self-expanding metal stent (SEMS), or endoscopic vacuum therapy (EVT) are options for first-line treatment. Here, we report the outcome of the recently developed combination of SEMS and EVT using the endoscopic Microtech^®-VAC-Stent (EVS).

Methods: Between June and July 2022, three consecutive patients (one female and two males) with esophageal transmural defects were treated with the Microtech^®-VAC-Stent. Two patients suffered from an anastomotic leak after oncologic gastroesophageal surgery, and one patient presented with esophageal perforation due to Boerhaave syndrome.

Results: Three consecutive patients were successfully treated with EVS. In one patient, one EVS treatment was sufficient, whereas the other two patients needed two and six EVS exchanges. Exchanges were scheduled every 7 days and no procedural adverse events were observed.

Conclusion: In line with the former case series, EVS therapy is a promising new approach for the treatment of esophageal leaks. Exchange of the EVS seems feasible every 7 days reducing interventions for the individual patient. Prospective studies comparing EVS with other endoscopic therapies are needed to define the best therapeutic approach.

Symptomatic colon lipoma is a rare occurrence in clinical practice, and its association with sigmoid volvulus is even rarer. We present a case of a man in his 70s who presented to our emergency department with suspected intestinal obstruction. Upon examination, sigmoid volvulus was diagnosed and successfully treated endoscopically through decompression and detorsion. However, the patient experienced a recurrence, leading to the decision to perform sigmoid resection as a Hartmann's procedure. Subsequently, a prolapsed tumor was observed through the stoma, which was endoscopically resected, revealing a pedunculated submucous colonic lipoma. This case report highlights the potential association between sigmoid volvulus and the presence of a large colon lipoma. Thus, giant colonic lipoma should be considered as a differential diagnosis among the causes of colonic volvulus.

Background: Dysphagia is the most frequent symptom in patients diagnosed with esophageal cancer. Self-expanding metal stents (SEMS) are the current palliative treatment of choice for dysphagia in patients with non-curable esophageal cancer. This study aimed to evaluate the efficacy and adverse events (AEs) of different types of SEMS for palliation of dysphagia.

Methods: We performed a retrospective cohort study of patients with advanced esophageal cancer and SEMS placement for dysphagia palliation in a tertiary care center. The primary outcome was the clinical success defined as an improvement in dysphagia (reduction of at least 2 points in the Mellow-Pinkas scoring system for dysphagia) after SEMS placement.

Results: Between January 1999 and May 2020, 295 patients with esophageal cancer were identified. Among them, 75 had a SEMS placement for dysphagia palliation. The mean age of the patients was 61.3 years (standard deviation: 13.4), 69 patients (92%) were men, and the mean Mellow-Pinkas scoring for dysphagia pre- and post-SEMS placement were 3.1 and 1.4 (change from baseline -1.7), respectively. Technical success and clinical success were achieved in 98.6% and 58.9%, respectively. AEs were identified in 35/75 patients (46.7%), and SEMS migration was the most frequent AE in 22/75 patients (29.3%). There were no significant differences in improvement in dysphagia (p = 0.054), weight changes (p = 0.78), and AE (p = 0.73) among fully covered SEMS (fc-SEMS) and partially covered SEMS (pc-SEMS). The median follow-up was 89 days (interquartile range: 29-221).

Conclusion: SEMS placement was associated with a rapid improvement in dysphagia, high technical success, and a modest improvement in dysphagia with no major AE among fc-SEMS and pc-SEMS.

Background: Reports suggest that the rate of adverse events (AEs) post-endoscopic sphincterotomy (ES) to be as high as 10%, with gastrointestinal bleeding being most common after post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

Objective: The aim of this study was to characterize the incidence of bleeding in patients with thrombocytopenia following ES.

Design: Retrospective observational cohort study.

Methods: Patients with thrombocytopenia (defined as <150,000 platelets/μL) who underwent ES between May 2017 and December 2020 were identified at a tertiary care medical center. The incidence of immediate (intraprocedural oozing >5 min or requiring intervention) or delayed (clinical bleeding with associated hemoglobin drop within 14 days) post-ES bleeding was determined via manual chart review.

Results: A total of 221 patients with a mean platelet count of 108,000 ± 13,000 platelets/μL underwent ERCP with ES. Immediate bleeding occurred in 11 (5%) patients with no significant drop in hemoglobin or transfusion requirement. Two patients (0.9%), both of whom were noted to have immediate bleeding, also developed delayed bleeding. Presence of malignancy was associated with an increased risk of bleeding (36.4% versus 11.4%, p = 0.037) while platelet count was not.

Conclusion: In a cohort of patients with thrombocytopenia, rates of immediate and delayed bleeding are similar to previously reported AE rates of ES in the general patient population. Careful attention should be given to patients with a history of active malignancy as well as those who develop immediate bleeding as they appear to be at increased risk for bleeding complications.

Background: Lumen apposing metal stents (LAMSs) have a higher clinical success rate for managing pancreatic fluid collections. But they are associated with adverse events (AEs) like bleeding, migration, buried stent, occlusion, and infection. It has been hypothesized that placing a double pigtail stent (DPS) within LAMS may mitigate these AEs. The present systematic review and meta-analysis were conducted to compare the outcome and AEs associated with LAMS with or without a coaxial DPS (LAMS-DPS).

Methods: A comprehensive literature search of three databases from January 2010 to August 2022 was conducted for studies comparing the outcome and AEs of LAMS alone and LAMS-DPS. Pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated for all the dichotomous outcomes.

Results: Overall, eight studies (n = 460) were included in the final analysis. The clinical success rate (RR 1.00, 95% CI: 0.87-1.14) and the risk of overall AEs (RR 1.60, 95% CI: 0.95-2.68) remained comparable between both groups. There was no difference in the risk of bleeding between LAMS alone and LAMS-DPS (RR 1.80, 95% CI: 0.83-3.88). Individual analysis of other AEs, including infection, stent migration, occlusion, and reintervention, showed no difference in the risk between both procedures.

Conclusion: The present meta-analysis shows that coaxial DPS within LAMS may not reduce AE rates or improve clinical outcomes. Further larger studies, including patients with walled-off necrosis, are required to demonstrate the benefit of coaxial DPS within LAMS.

Background and aims: Acute calculous cholecystitis (ACC) represents about one-third of all surgical emergencies. The gold standard management of ACC is laparoscopic cholecystectomy. Although cholecystectomy is a safe procedure, it may be dangerous and contraindicated in patients with complex comorbidities. Endoscopic transpapillary gallbladder stenting (ETGBS) and drainage had been widely used to manage patients suffering from ACC with comorbidities.

Methods: We searched PubMed, SCOPUS, Web of Science, and Cochrane Library for relevant studies assessing the use of ETGBS in patients suffering from ACC with various comorbidities. Risk of bias assessment was performed using the National Institues of Health (NIH) tool. We included the following outcomes: clinical success, technical success, late complications, and pancreatitis.

Results: We included seven studies that met our inclusion criteria. We found that the pooled proportion of clinical success, technical success, late complications, and pancreatitis was [91.3%, 95% confidence interval (CI) (86.8%, 95.9%)], [92.8%, 95% CI (89%, 96.5%)], [5.4%, 95% CI (2.9%, 7.9%)], and [3.5%, 95% CI (1.2%, 5.8%)], respectively.

Conclusion: We found that an ETGBS was an effective and well-tolerated method for the treatment of cholecystitis, especially in high-risk individuals.

Introduction: The gold-standard procedure to address malignant gastric outlet obstruction (MGOO) is surgical gastrojejunostomy (SGJJ). Two endoscopic alternatives have also been proposed: the endoscopic stenting (ES) and the endoscopic ultrasound-guided gastroenterostomy (EUS-G). This study aimed to perform a thorough and strict meta-analysis to compare EUS-G with the SGJJ and ES in treating patients with MGOO.

Materials and methods: Studies comparing EUS-G to endoscopic stenting or SGJJ for patients with MGOO were considered eligible. We conducted online searches in primary databases (MEDLINE, EMBASE, Lilacs, and Central Cochrane) from inception through October 2021. The outcomes were technical and clinical success rates, serious adverse events (SAEs), reintervention due to obstruction, length of hospital stay (LOS), and time to oral intake.

Results: We found similar technical success rates between ES and EUS-G but clinical success rates favored the latter. The comparison between EUS-G and SGJJ demonstrated better technical success rates in favor of the surgical approach but similar clinical success rates. EUS-G shortens the LOS by 2.8 days compared with ES and 5.8 days compared with SGJJ. Concerning reintervention due to obstruction, we found similar rates for EUS-G and SGJJ but considerably higher rates for ES compared with EUS-G. As to AEs, we demonstrated equivalent rates comparing EUS-G and SGJJ but significantly higher ones compared with ES.

Conclusion: Despite being novel and still under refinement, the EUS-G has good safety and efficacy profiles compared with SGJJ and ES.