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Objectives

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) for focal liver lesions has gained attention as an alternative to percutaneous biopsy. Although the outcomes of EUS-TA for focal liver lesions have been reported to be favorable, no studies have focused on small focal liver lesions (≤2 cm). The aim of this study was to evaluate the outcomes of EUS-TA for small focal liver lesions (≤2 cm).

Methods

The details of EUS-TA performed for focal liver lesions between 2016 and 2022 were retrospectively reviewed. The outcomes were compared between cases involving ≤2 cm lesions and those involving >2 cm lesions. The primary outcomes were diagnostic ability and adverse events.

Results

EUS-TA for focal liver lesions was performed in 109 cases. Of the 109 cases, 32 (29.3%) involved ≤2 cm lesions and 77 (70.6%) involved >2 cm lesions. Right lobe lesions and transduodenal puncture were significantly fewer in the ≤2 cm group. There were no significant differences in needle gauge, needle type, or number of punctures between the groups. The sensitivity, specificity, and accuracy rates were 96.8%, 100%, and 96.8%, respectively, in the ≤2 cm group and 97.4%, 100%, and 97.4%, respectively, in the >2 cm group, with no significant differences between the groups. There was no difference in adverse events between the groups (0% in the ≤2 cm group and 2.3% in the >2 cm group).

Conclusions

EUS-TA for small focal liver lesions measuring ≤2 cm has favorable outcomes, which are similar to those for lesions measuring >2 cm.

Objectives

Appropriate sedative and analgesic selection is essential to reduce patient discomfort and body movement to safely conduct endoscopic ultrasonography (EUS). However, few cases have examined sedation with propofol in EUS, and few studies the need for combined analgesia. In this study, we retrospectively evaluated the usefulness and safety of propofol without analgesics for sedation in biliopancreatic observational EUS.

Methods

This single-center retrospective study included 516 observational biliopancreatic EUS procedures using propofol alone performed between April 2021 and March 2023. The primary and secondary endpoints were the observational biliopancreatic EUS results obtained with propofol alone and adverse event occurrence, respectively.

Results

The median examination time and total propofol dose were 22 (range: 10–67) min and 186.5 (range: 50–501) mg, respectively. The median starting Richmond Agitation-Sedation Scale and Visual Analog Scale scores were −5 (range: −5–1) and 0 (range: 0–10), respectively. The median recovery time was 22 (range: 5–80) min. Adverse events occurred in 60 (11.6%) patients. Trainee-performed examination (odds ratio [OR] 3.52, 95% confidence interval [CI]: 1.63–7.60, p = 0.0014) and examination length (>22 min; OR 1.67, 95% CI: 0.95–2.92, p = 0.07) were risk factors for adverse events.

High body mass index (OR 1.87, 95% CI: 1.10–3.16, p = 0.02) and extended examination time (OR 4.23, 95% CI: 2.08–8. 57, p < 0.001) were risk factors for delayed recovery.

Conclusions

During observational biliopancreatic EUS, propofol is useful as a single sedative and offers high patient satisfaction and relative safety.

Objectives

Among subepithelial lesions (SELs), gastrointestinal stromal tumors (GISTs) should be identified and surgically treated at an early stage. However, it is difficult to diagnose SELs smaller than 20 mm. In recent years, endoscopic ultrasound (EUS) elastography (EUS-EG) and contrast-enhanced harmonic EUS (CH-EUS) have been reported to be useful for the diagnosis of SELs, although the diagnostic accuracy of a combination of EUS techniques with image enhancement is unknown.

Methods

Patients with SELs who underwent EUS-guided tissue acquisition, EUS shear-wave elastography (EUS-SWE), EUS strain elastography (EUS-SE), and CH-EUS from January 2019 to June 2023 were enrolled. To assess the diagnostic accuracy for differentiating GISTs from other SELs, shear-wave velocity on EUS-SWE, the strain ratio on EUS-SE, and vascularity on CH-EUS were determined and their diagnostic accuracies were compared.

Results

Forty-three patients were enrolled. When the cut-off value was set at 3.27 m/s, the sensitivity, specificity, and diagnostic accuracy of shear-wave velocity were 28.6%, 86.2%, and 34.9%, respectively. When the cut-off value was set at 3.79, the sensitivity, specificity, and diagnostic accuracy of the strain ratio were 93.1%, 64.3%, and 83.7%, respectively. The sensitivity, specificity, and diagnostic accuracy of CH-EUS were 79.3%, 92.3%, and 83.7%, respectively. When EUS-SE was combined with CH-EUS, the sensitivity and diagnostic accuracy were the highest among binary combinations of image enhancement modalities.

Conclusions

EUS-SE and CH-EUS are useful for differentiating GISTs from other SELs. Furthermore, the use of both modalities may further improve the identification of GISTs.

Objectives

The introduction of lumen-apposing metal stents (LAMSs) has revolutionized the field of therapeutic endoscopic ultrasound. This study aims to evaluate the efficacy and safety of LAMS in creating an endoscopic ultrasound-guided anastomosis between two segments of the gastrointestinal (GI) tract.

Methods

Data from all consecutive LAMS procedures for anastomosis creation between two segments of the GI, conducted between October 2019 and February 2024, were retrospectively analyzed for technical success (defined as correct deployment of the LAMS in the target), clinical success (defined as achievement of the intended clinical goal), and adverse events.

Results

A total of 145 LAMS procedures were performed in 136 patients. Indications for LAMS procedures included the need for endoscopic access to or reversal of surgically excluded segments of the GI tract (n = 73, 50.3%), and the alleviation of any GI outflow obstruction (n = 72, 49.7%). The overall technical and clinical success rates were very high (97.2% and 95.2%, respectively). Adverse events were observed in 20/145 (13.8%) cases, including 11 (7.6%) minor events (AGREE <3) and nine (6.2%) major events (AGREE ≥3). Major events included stent migration (n = 1), persisting fistula (n = 3), and bleeding (n = 4). All adverse events were successfully managed, and there were no procedure-related deaths. Loss of LAMS patency occurred in 4/145 (2.8%) cases and could be endoscopically managed in all cases.

Conclusions

The creation of anastomoses with LAMS between two segments of the GI tract appears to be effective and safe, with a low reintervention rate due to loss of LAMS patency.

Objectives

Few reports have detailed improvements in the quality of colonoscopies with continuous training post-fellowship completion. We examined the changes in colonoscopy performance among trainees during our advanced endoscopy training program.

Methods

Screening or surveillance colonoscopies performed by 11 trainees who participated in our 3-year advanced endoscopy training program between April 2015 and March 2020 were retrospectively analyzed. Quality and efficiency metrics of colonoscopies were evaluated annually.

Results

Altogether, 297, 385, and 438 colonoscopies were enrolled in the first, second, and third training years, respectively. The mean insertion times were 8.6, 7.6, and 6.9 min in the first, second, and third training years, respectively, with significant improvement from the first to second year (p = 0.03) and from the first to third year (p < 0.01). The adenoma detection rate, proximal adenoma detection rate, and mean number of adenomas per patient exhibited a tendency to improve annually; however, the difference was not significant. Polypectomy efficiency was 10.5%, 11.2%, and 13.0%, with significant improvements from the first to third year (p < 0.01) and from the second to third year (p = 0.02). Insertion time and polypectomy efficiency showed significant improvements, especially among trainees experienced with <500 colonoscopies.

Conclusions

Through our advanced endoscopy training program, there has been an improvement in the quality and efficiency of colonoscopy for trainees who have completed their fellowships, particularly those with <500 colonoscopies.

Objectives

Malignant double obstruction, defined as the simultaneous presence of biliary and gastric outlet obstruction, represents a challenging clinical scenario. Previous retrospective experiences have demonstrated shorter dysfunction-free survival (DyFS) of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) versus EUS-hepaticogastrostomy (EUS-HGS) in this setting, but no prospective evidence is available.

Methods

Twenty consecutive patients with malignant double obstruction, treated with EUS-gastroenterostomy (and EUS-guided biliary drainage, following a previously failed ERCP, were enrolled in a prospective observational study (ClinicalTrials.gov NCT04813055) comparing EUS-CDS versus EUS-HGS. Efficacy and safety were evaluated, with Biliary Dysfunctions as the primary outcome and DyFS using Kaplan-Meier estimates as a primary measure.

Results

Twenty patients (75% with pancreatic cancer, 50% with metastatic disease) with EUS-gastroenterostomy were included (seven EUS-CDS and 13 EUS-HGS). No significant difference was detected at baseline. Technical success was 100% in both groups. EUS-CDS compared to EUS-HGS showed similar clinical success (100% vs. 92.3%, p = 0.5), a higher rate of post-procedural adverse events (42.9% vs. 7.7%, p = 0.067, mostly related to severe/fatal cholangitis in the EUS-CDS group) and a higher rate of biliary dysfunctions during follow-up (71.4% vs. 16.7%, p = 0.002).

DyFS was significantly shorter in the EUS-CDS group (39 [15–62] vs. 268 [192–344] days, p = 0.0023), with a 30-days DyFS probability of 57.1% vs. 100% (hazard ratio = 7.8 [1.4–44.2]).

Conclusions

In this prospective comparison of patients with malignant double obstruction undergoing EUS-gastroenterostomy, treating jaundice with EUS-CDS versus EUS-HGS resulted in a reduced probability of survival without biliary events and an increased risk of biliary dysfunctions (number needed to harm = 1.8), with detection of severe/fatal cholangitis.

Introduction

Although gastric peroral endoscopic myotomy (G-POEM) has shown substantial efficacy in patients with medically refractory gastroparesis (GP), comprehensive long-term data on its effectiveness are lacking.

Methods

We conducted a systematic review and meta-analysis including observational studies assessing long-term efficacy after G-POEM in patients with refractory GP. Our primary outcome was the pooled rate of clinical success 1-year after G-POEM. Secondary outcomes included clinical success at 2 and 3 years and the rate of adverse events according to the American Society for Gastrointestinal Endoscopy classification.

Results

Thirteen studies, involving 952 patients with refractory GP undergoing G-POEM, were eligible. The pooled 1 year-clinical success was 0.72 (95% confidence interval [CI]: 0.56, 0.85, I² = 94.9%). The clinical success was 0.67 (95% CI: 0.47, 0.97, I² = 95.8%) when considering only studies defining success as 1 point decrease in Gastroparesis Cardinal Symptoms Index score and at least 25% decrease in two subscales. For patients who had 1-year success, the pooled clinical success at 2 and 3 years were 0.71 (95% CI: 0.45, 0.92, I² = 94.9%) and 0.58 (95% CI: 0.19, 0.92, I² = 97.1%), respectively. The pooled rate of adverse events was 0.08 (95% CI: 0.06, 0.10, I² = 0%).

Conclusion

G-POEM is associated with successful outcomes in about 70% of treated cases after 1 year, with durable long-term effects lasting up to 3 years. In the future, new uniform outcome definitions and strict patient selection criteria are warranted to delineate G-POEM outcomes more accurately.

Objectives

There are limited reports on the safety of gastrointestinal endoscopic procedures in individuals taking edoxaban, one of the direct oral anticoagulants. We clarified the incidence of delayed bleeding in patients who were on edoxaban in the perioperative period of gastrointestinal endoscopic procedures with a high risk of bleeding.

Methods

This was an investigator-initiated, single-center, open-label, prospective, single-arm study. Patients on warfarin or edoxaban undergoing endoscopy with a high risk of bleeding were enrolled from June 2018 to September 2021. Warfarin was replaced with edoxaban in patients on warfarin. Patients taking other direct oral anticoagulants, and antiplatelet drugs, were excluded. The primary endpoint was severe delayed bleeding (Common Terminology Criteria for Adverse Events [CTCAE] grades III–V) and the secondary endpoints included thromboembolism, all adverse events, any delayed bleeding (CTCAE grades I or II), and hospital stay durations.

Results

Twenty-one patients on edoxaban underwent high-risk endoscopy. Three cases (14%) experienced CTCAE grade III delayed bleeding, requiring endoscopic hemostasis. No CTCAE grade I-II delayed bleeding or thromboembolic events occurred. Cholangitis and aspiration pneumonia (conservatively treated) occurred during the hospital stay. The median length of hospital stay was 8 days (range 3—24 days). Patients with delayed bleeding had higher systolic blood pressure at admission and longer hospital stays.

Conclusions

The delayed bleeding incidence in high-risk endoscopic procedures for patients on edoxaban was acceptable. Higher blood pressure may be associated with increased risk, but further research is needed.