Therapeutic Advances in Gastrointestinal Endoscopy最新文献

The limited penetration of bariatric surgery and the scarce outcome of pharmacological therapies created a favorable space for primary bariatric endoscopic techniques. Furthermore, bariatric endoscopy is largely used to diagnose and treat surgical complications and weight regain after bariatric surgery. The increasingly essential role of endoscopy in the management of obese patients results in the need for trained professionals. Training methods are evolving, and the apprenticeship method is giving way to the simulation-based method. Existing simulation platforms include mechanical simulators, ex vivo and in vivo models, and virtual reality simulators. This review analyzes current training methods for bariatric endoscopy and available training programs with dedicated bariatric core curricula, giving a glimpse of future perspectives.

Background: Cap-assisted endoscopic sclerotherapy is a new interventional therapy for internal hemorrhoids and rectal prolapse under colonoscopy. The proper length of the endoscopic injection needle is the core for performing cap-assisted endoscopic sclerotherapy well with more benefits and less complications. However, no data are currently available to guide endoscopists to consider the length of injection needle before cap-assisted endoscopic sclerotherapy. This study is designed to evaluate the efficacy and safety of cap-assisted endoscopic sclerotherapy with long or short injection needle in the treatment of internal hemorrhoids.

Methods: This is a nationwide multi-center, prospective, single-blind and randomized controlled trial. Patients with grade I-II internal hemorrhoids who have failed to conservative treatments and grade III internal hemorrhoids who are not suitable for surgery or refuse surgery will be included. Participants will be randomized 1:1 into either long or short injection needle group. The primary outcome is the recurrence rate of internal hemorrhoids 24 weeks after cap-assisted endoscopic sclerotherapy. The secondary outcomes are as follows: (1) symptom severity score, (2) three-level EuroQoL five dimensions health scale scores, (3) occurrence of adverse events and severe adverse events, and (4) patients' attitudes toward cap-assisted endoscopic sclerotherapy. Data collection will be conducted before and during operation, the 1st day, 1st week, 2nd week, and 24th week after cap-assisted endoscopic sclerotherapy.

Discussion: The outcome of this study is expected to provide a practical clinical protocol of cap-assisted endoscopic sclerotherapy for patients with internal hemorrhoids and promote the use of this new endoscopic technique.

Trial registration: ClinicalTrials.gov, NCT03917056. Registered on 12 April 2019.

Obesity is a leading cause of preventable death in developed countries, with a rising incidence over time. Lifestyle modification, pharmacotherapy, and bariatric surgery are the mainstays of bariatric therapy, even though burdened by several limitations in terms of efficacy or safety. Bariatric endoscopy has been developed in the last decades as a minimally invasive alternative, aimed to bridge the gap between conservative and interventional conventional therapies. This review aims to provide an updated overview of the bariatric and metabolic available endoscopic procedures and to drive the choice of the right procedure for the right patient.

Anastomotic leakage with abscess is a rare but severe complication of bariatric surgery. However, there is currently a lack of attention regarding this complication. This study aimed to investigate the risk factors for this complication and relevant treatment strategies to call attention to this severe complication. We retrospectively reviewed the patients who were rehospitalized for anastomotic leakage with abscess after bariatric surgeries in West China Hospital of Sichuan University from November 2017 to November 2018. The clinical profiles analyzed included body mass index, body weight before and after surgery, postoperative hospital stay, diet prescriptions, treatment strategies, and outcomes. A total of six patients (two men and four women) were included. The mean baseline body mass index was 37.52 (29.84-43.37), and the mean weight was 104.95 kg (74.5-127.5). The chief complaints leading to rehospitalization were fever and dull abdominal pain. The average postoperative hospital stay was 3.3 (3-4) days, and the onset time ranged from 7 to 15 days. Finally, revision surgeries were performed in two of the six patients (33%), and they were all cured by percutaneous drainage-based treatments. The postoperative fever and abdominal pain were the signs of leakage and abscess. Similar patients should be followed up once a week for 3 weeks after bariatric surgery to facilitate the early recognition of this complication. A longer hospital stay and sufficient parenteral nutrition plus a later implementation of diet should be helpful to minimize this severe complication. Percutaneous drainage played a significant role in the treatment of these patients.

Background: Patients with Peutz-Jeghers syndrome develop hamartomatous polyps in the small bowel, possibly causing anemia, intussusception, and obstruction. We aimed to evaluate the impact of an enteroscopy-based approach, including both device-assisted and intraoperative enteroscopy, on the reduction of the polyp burden in a cohort of adult Peutz-Jeghers syndrome patients.

Materials and methods: A retrospective study was conducted at Azienda Ospedaliero-Universitaria Città della Salute e della Scienza in Turin, Italy. Consecutive Peutz-Jeghers syndrome patients eligible for device-assisted or intraoperative enteroscopy, between January 2003 and November 2019, were included. Enteroscopy technical issues and complications were recorded. At the time of index enteroscopy, the patients' clinical records were retrospectively reviewed, and clinical data were recorded until November 2019.

Results: Overall, 24 patients were included. Before inclusion, 16/24 patients (66.7%) underwent small bowel surgery for polyp-related complications, 13 of which (81.2%) in an emergent setting. Two patients had a history of small bowel neoplasms. During the timeframe, 47 device-assisted enteroscopies and 9 intraoperative enteroscopies were performed, and 247 small bowel polyps were endoscopically removed. The overall complication rate was 12.8% (8.5% for device-assisted enteroscopy, 22.2% for intraoperative enteroscopy). The median observation time was 108 months: in this timeframe, two patients developed small bowel polyp-related complications requiring emergent surgery. No patients developed small bowel cancer, but nine extra-gastrointestinal neoplasms were recorded.

Conclusion: An enteroscopy-based approach appears to be well tolerated and effective in decreasing polyp-related complications in Peutz-Jeghers syndrome patients, thus reducing the need for emergent surgery. Although the prevention of small bowel polyp-related complications remains the main goal in these patients, the high incidence of extra-gastrointestinal neoplasms appears to be a rising issue.

Ampullary tumors are rare neoplasms but increasingly encountered due to an increase in diagnostic procedures, mainly upper gastrointestinal endoscopy. Diagnosis, staging, and treatment of these tumors are described and recommendations given based on the most recent literature.

Upper gastrointestinal perforations, leaks and fistulae are relatively common occurrences with a growing number of these complications occuring as a result of therapeutic advancement and adoption of newer and bolder endoscopic therapies. Historically, these were predominantly managed surgically; however, owing to high morbidity and mortality associated with surgical repair, endoscopic options are preferable. Over the past decade, vast expansion in the endoscopic armamentarium for the management of perforations, leaks and fistulae has led to endoscopic management now being the first-line treatment. Here, we will review the endoscopic modalities including through-the-scope clips, over-the-scope clips, stents, vacuum therapy, endoscopic sutures and sealants. In addition, we will discuss nonendoscopic approach to management including early recognition of perforations, ways to reduce septic complications and format algorithms to guide therapy for different scenarios. However, it is important to stress that there is a lack of high-quality randomised studies to clearly guide management of such complications, resulting in a wide variation of approaches in management by specialists. Each case requires some degree of individualisation due to the potential array of problems encountered and patient-specific co-morbidities. In the future, more robust studies are clearly required to better guide specialist management.

Background and aim: Endoscopic ultrasound-guided biliary drainage is an alternative to failed endoscopic retrograde cholangiopancreatography. Unfortunately, this procedure remains relatively less explored in Egypt due to its high cost, lack of adequate training, and the perception of increased risk. This study is the first multicenter Egyptian experience of an endoscopic ultrasound-guided biliary drainage in patients with malignant biliary obstruction.

Patients and methods: We retrospectively reviewed 15 patients (10 men and five women) with malignant biliary obstruction who from October 2013 to May 2019, following a failed or inaccessible endoscopic retrograde cholangiopancreatography, underwent an endoscopic ultrasound-guided choledochoduodenostomy, endoscopic ultrasound-guided hepaticogastrostomy, or endoscopic ultrasound-guided rendezvous. Their mean age was 57.4 years and mean bilirubin was 18.2 mg/dL. The outcome parameters included technical and clinical success. Technical success was defined as the successful placement of a stent in the biliary system, while clinical success was defined as a greater than 50% decrease in the bilirubin levels 2 weeks after the procedure. Patients were monitored for complications during and after the procedure.

Results: In total, 15 patients underwent endoscopic ultrasound-guided biliary drainage (eight underwent endoscopic ultrasound-guided choledochoduodenostomy, five underwent endoscopic ultrasound-guided hepaticogastrostomy, and two underwent endoscopic ultrasound-guided rendezvous). The technical and clinical success rates were 100% (15/15 patients) and 93.3% (14/15 patients), respectively. The complication rate was 26.6% (4/15 patients). All complications were mild and self-limited, and included fever, mild biliary peritonitis, pneumoperitoneum, and a slight migration of one plastic stent during insertion.

Conclusion: Although slowly gaining acceptance in Egypt, endoscopic ultrasound-guided biliary drainage is an effective and safe procedure in patients with a malignant biliary obstruction after a failed or inaccessible endoscopic retrograde cholangiopancreatography.

Refractory benign oesophageal strictures are an infrequent presentation but a cause of significant morbidity and mortality. The treatment of these strictures has changed little in recent years, yet new evidence is emerging for the optimal timing and application of different therapies. In this article, we have carefully reviewed the current literature on the evaluation and management of refractory strictures and provided practical advice as to their management. A number of areas require attention in future research, including carefully designed randomised trials of endoscopic and medical therapies, and a focus on risk factors at a patient and molecular level to facilitate development of medical therapies that can reduce recurrent fibrosis in these patients.