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

Objectives: Lymph node metastasis (LNM) is crucial in determining treatment strategies for gastric neuroendocrine tumors (gNETs). While type 3 is considered more aggressive than types 1 and 2 within the clinical subtype of gNETs, the supporting data were insufficient, due to their rarity. We aimed to study the prevalence and risk factors associated with LNM in gNETs.

Methods: We searched electronic databases from 1990 to 2023 to identify case-control and cohort studies regarding gNETs resected either endoscopically or surgically. The primary outcome measured was the pooled prevalence of LNM in gNETs. Secondary outcomes included categorizing the prevalence of LNM by clinical subtypes and identifying pathological risk factors associated with LNM in gNETs.

Results: We included 28 studies, involving 1742 patients, among whom 240 had LNM (pooled prevalence rate, 11.8%; 95% confidence interval 7.6-17.9%). The pooled prevalence rates of LNM for type 1, type 2, and type 3 gNETs were 6.0%, 38.5%, and 23.2%, respectively. Type 2 (odds ratio [95% confidence interval] 11.53 [3.46-38.49]) and type 3 (6.88 [3.79-12.49]) gNETs exhibited a higher risk for LNM compared to type 1. Pathological risk factors for LNM included tumor size >10 mm (4.18 [1.91-9.17]), tumor invasion into the muscularis propria or deeper (11.21 [3.50-35.92]), grade 2/grade 3 (5.96 [2.65-13.40]), and lymphovascular invasion (34.50 [6.70-177.51]).

Conclusion: We demonstrated that type 2 gNETs, as well as type 3, had a high risk of LNM. Additionally, four pathological risk factors associated with LNM were identified.

Objectives: Achalasia is an esophageal motility disorder that impairs quality of life and is often missed (20-50%) on endoscopy. A newly developed computer-aided detection (CAD) software has shown high accuracy for achalasia diagnosis in preclinical settings. However, its benefit in a clinical setting remains unclear.

Methods: Between February and August 2023, 83 endoscopists from 27 centers assessed 50 randomized endoscopic videos (25 achalasia, 25 nonachalasia) without and with CAD. Endoscopists assessed videos without CAD, then with CAD after 2 months. The primary end-point was improvement in sensitivity for nonexperienced endoscopists (no endoscopic experience of achalasia). Sensitivity, specificity, and accuracy with and without CAD were compared using the McNemar test.

Results: Sensitivity for diagnosing achalasia increased significantly with CAD, rising from 74.2% (95% confidence interval [CI] 72.2-76.0%) to 91.2% (95% CI 89.9-92.4%) for all readers, showing a difference of 17.1% (95% CI 15.1-19.0%). Specifically, sensitivity improved from 66.9% (95% CI 63.6-70.0%) to 91.9% (95% CI 89.9-93.6%) among nonexperienced endoscopists, resulting in a difference of 25.0% (95% CI 21.7-28.4%), and from 79.5% (95% CI 77.1-81.8%) to 90.8% (95% CI 89.0-92.3%) among experienced endoscopists (endoscopic experience of at least one achalasia case), with a difference of 11.3% (95% CI 8.9-13.6%). Accuracy and specificity improved significantly with CAD assistance, regardless of reader's experience.

Conclusion: CAD improves achalasia detection by 17%, confirming preclinical results. The benefit was higher for nonexperienced endoscopists. CAD assistance may lead to prompt and effective treatment, minimizing the risk of false-negative diagnosis in clinical practice.

Trial registration: This study was registered in the University Hospital Medical Information Network Clinical Trial Registry (https://www.umin.ac.jp/ctr/) number: UMIN000053047.

Objectives: Reusable colonoscopes pose a risk of iatrogenic infections due to improper disinfection and maintenance, prompting the development of disposable colonoscopes. However, direct comparisons between disposable and reusable colonoscopes remain limited. This pilot study aimed to evaluate the technical performance of disposable colonoscopes compared to reusable ones for routine colon examinations.

Methods: This randomized controlled, noninferiority study was conducted at two endoscopy centers. Patients requiring colonoscopy were randomly assigned to either the disposable or reusable colonoscope group. The primary outcome was the successful completion rate of colonoscopy between the groups, with a noninferior margin of -10%. Secondary outcomes included image characteristics, technical maneuverability, colonoscopy performance measures, and adverse events.

Results: A total of 116 patients underwent colonoscopy (58 in each group). The successful completion rate of colonoscopy was 100% in both groups (difference: 0% [95% confidence interval -6.21% to 6.21%]), confirming noninferiority. Although the disposable colonoscope group had lower performance scorings in imaging characteristics, technical maneuverability, and longer operating time compared to the reusable colonoscope group, no significant differences were observed in cecal intubation rate, polyp detection rate, polyp characteristics, or adverse event rate. Additionally, experienced endoscopists achieved proficiency with disposable colonoscopes after approximately 10 cases, requiring minimal training.

Conclusion: With further technical advancements, disposable colonoscopes may serve as a safe and viable alternative to reusable colonoscopes for routine colon examinations in certain clinical scenarios.

Immunoglobulin G4 (IgG4)-related sclerosing cholangitis (IgG4-SC) is a distinct form of sclerosing cholangitis frequently associated with autoimmune pancreatitis and is recognized as a biliary manifestation of IgG4-related disease. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) are key diagnostic modalities for IgG4-SC. Cholangiocarcinoma and primary sclerosing cholangitis (PSC) are significant mimickers of IgG4-SC. ERCP is employed to evaluate narrowing of the bile duct, with cholangiograms of IgG4-SC classified into four types. This cholangiographic classification is crucial for differential diagnosis. Characteristic cholangiographic findings of IgG4-SC include diffuse or segmental strictures of the intrahepatic or extrahepatic bile ducts and intrahepatic strictures associated with autoimmune pancreatitis. ERCP is particularly useful for differentiating IgG4-SC from PSC because their cholangiographic features differ. EUS and intraductal ultrasonography (IDUS) are used to assess thickening of the bile duct wall. Characteristic IDUS findings in IgG4-SC include circular and symmetrical wall thickening, smooth outer and inner margins, and homogeneous internal echoes at stricture sites. Additionally, bile duct wall thickening at nonstricture sites is a typical IDUS feature of IgG4-SC. Bile duct biopsy is used to evaluate pathological findings, although its diagnostic yield for IgG4-SC is limited; its primary role is to exclude malignant biliary strictures. Duodenal papilla biopsy serves as a supplementary diagnostic tool for IgG4-SC. EUS and tissue acquisition also aid in diagnosing autoimmune pancreatitis as part of other organ involvement. Thus, endoscopic techniques play critical roles in the diagnosis of IgG4-SC.

Objectives: Remimazolam is a general anesthetic with a short elimination half-life and its pharmacokinetics are less affected by liver and kidney function. It may be useful for sedation during endoscopic procedures in patients. This single-arm clinical trial aimed to evaluate the efficacy and safety of remimazolam for sedation in patients undergoing endoscopic procedures.

Methods: Patients undergoing endoscopic procedures were included in this study. Remimazolam was administered intravenously with opioid analgesics, and the endoscopic procedure was started after an efficient level of sedation (Modified Observer's Assessment of Alertness/Sedation score ≤3) was achieved. The primary end-point for efficacy was the sedation success rate during the endoscopic procedures. Data on adverse events were collected for safety evaluation.

Results: Sixty-two patients were included in the analysis. The sedation success rate of 93.5% (84.3-98.2%) exceeded the threshold success rate of 80% (P = 0.004). In all, 98.4% of patients were appropriately sedated before endoscope insertion. The median time from the first dose of remimazolam to achieving sedation was 4.0 min, while the median time from the end of the endoscopic procedure to being deemed ready to leave the room was 2.0 min. Adverse events were observed in 22 cases (35.5%). The severity of adverse events was moderate in five cases (8.1%), mild in 17 cases (27.4%), and there was no severe case.

Conclusion: Sedation with remimazolam plus opioid analgesics was effective and well tolerated, regardless of endoscopic procedure site. These findings suggest that remimazolam is a useful sedative during endoscopic procedures.