Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society最新文献

Background and aims: To compare the incidence of hypoxia and other sedation-related adverse events (AEs) in overweight patients undergoing gastrointestinal (GI) endoscopy who were sedated using ciprofol or propofol.

Methods: A randomized, controlled trial was conducted in five hospitals in China between September 2022 and August 2023. Patients were randomized into either ciprofol or propofol sedation. The primary outcome was the total incidence of hypoxia and severe hypoxia. The secondary outcomes were hypoxia incidence, severe hypoxia incidence, subclinical respiratory depression incidence, endoscopy success rate, injection pain incidence, and corrective hypoxic measures proportion.

Results: A total of 1018 patients were randomized into either ciprofol group (n = 506) or propofol group (n = 512). The mean BMI was 26.23 kg/m² in the ciprofol group and 26.17 kg/m² in the propofol group. Compared with propofol, ciprofol showed lower incidences of total hypoxia and severe hypoxia in both the full analysis set (FAS) and per-protocol analysis set (PPS). The lower incidence was particularly significant for severe hypoxia (4.35% vs. 7.62%, p = 0.028 in FAS). The injection pain incidence was significantly lower in the ciprofol group than in the propofol group (2.57% vs. 13.28%, p < 0.001 in FAS). Moreover, fewer patients in the ciprofol group required oxygen-correction therapy (20.40% vs. 25.70%, p = 0.047 in PPS), and ciprofol had a lower incidence of AEs associated with sedation.

Conclusions: During GI endoscopy, overweight patients are significantly less prone to hypoxia when sedated with ciprofol than with propofol, offering a safer alternative.

Trial registration: ClinicalTrials.gov (NCT05518929).

The growing number of bariatric and oncologic gastrointestinal and hepatopancreatobiliary surgeries has fueled the increased need for biliary interventions in patients with surgically altered anatomy (SAA), where standard endoscopic retrograde cholangiopancreatography (ERCP) is often unfeasible. Traditional alternative methods, such as enteroscopy- or laparoscopy-assisted ERCP, are associated with technical and logistical limitations. Endoscopic ultrasound (EUS)-directed ERCP uses lumen-apposing metal stents (LAMS) to create temporary anastomoses between adjacent lumens, thus restoring access for standard ERCP. These procedures include EUS-directed transgastric (EDGE), transenteric (EDEE), transduodenal (EDDE), and transcholedochal/transcystic (EDCE) ERCP. This review provides an evidence-based analysis of the available techniques and comparative outcomes, with a particular focus on technical and strategic aspects including: (1) how to create an EUS-guided anastomosis across different surgical scenarios; (2) how to perform a through-the-LAMS ERCP, including endoscope and accessory selection, ERCP timing and LAMS fixation; and (3) how to manage the fistula after completion of therapy, including timing of LAMS removal and fistula closure. An algorithm is proposed to guide the endoscopist through the complex decision-making inherent to pancreatobiliary interventions in SAA.

Endoscopic submucosal dissection (ESD) is technically demanding with the main limitation on the lack of effective countertraction. Existing countertraction methods such as clip-related techniques only provide unidirectional static traction force that may restrict their utility in complicated colorectal ESD. The magnetic countertraction system provides dynamic force by manipulating an external magnetic source. We designed a novel magnetic countertraction system with an internal magnet retractor introducible via the endoscopy channel and the external magnetic effector mounted on a robotic arm that could be easily manipulated. We evaluated the performance and safety of the system in an ex vivo randomized crossover study. ESD was performed on ex vivo porcine colon models with standardized 3 cm target lesions marked at gravity-dependent locations. Endoscopists performed the ESD in pairs, randomized to magnetic countertraction (MAG-ESD) or conventional ESD (C-ESD) first to minimize bias from the learning effect. During MAG-ESD, a flexible internal magnetic retractor was deployed via the endoscopic channel and anchored to the lesion margin. A robotic arm-mounted external permanent magnet (EPM) was positioned above the colon model to engage the retractor and provide dynamic countertraction. Seventy-two ESD (36 MAG-ESD and 36 C-ESD) were performed by 18 endoscopists. MAG-ESD significantly reduced procedure time by 20.4% (p = 0.0002) and workload (NASA-TLX mean difference: -19.81, 95% CI: -25.42 to -14.19). All procedures achieved en bloc resection. MAG-ESD had significantly fewer complications (OR = 0.782, 95% CI: 0.644-0.949), including lower rates of perforation and muscle injury. The novel magnetic countertraction system significantly improved procedural efficiency, reduced operator workload, and enhanced safety in ex vivo colonic ESD.