Trending Topics in Gastroenterology | GastroAGI

Conventional and underwater ESD for superficial colorectal neoplasms

The study compared conventional endoscopic submucosal dissection (CESD) and underwater endoscopic submucosal dissection (UESD) for removing superficial colorectal neoplasms (SCNs). UESD was hypothesized to offer procedural advantages by utilizing buoyancy to lift lesions, potentially reducing dependence on gravity and improving visualization. The primary endpoint was dissection speed, calculated as the specimen area divided by total procedure time. The trial randomized 139 patients, with 69 undergoing CESD and 70 undergoing UESD. Results showed no significant difference in median dissection speed between the two techniques (CESD: 17.4 mm²/min vs. UESD: 19.9 mm²/min; P=0.19). However, multivariate analysis revealed that the lesion’s position relative to gravity influenced dissection speed. CESD was more effective for lesions on the nongravity side, while UESD performed better for lesions on the gravity side. Both techniques achieved high safety outcomes, with en bloc resection and no perforations. In conclusion, neither technique universally outperformed the other, but tailoring the method to lesion orientation could improve procedural efficiency.

Origami method for duodenal ESD

The Origami Method (OGM) is a modified double-layered suturing technique developed specifically for closing large mucosal defects following duodenal endoscopic submucosal dissection (ESD). Duodenal ESD is a minimally invasive procedure used to remove lesions or tumors from the duodenum but often results in sizeable defects. These defects pose significant risks, including perforation and bleeding, making effective closure techniques critical. ### Key Features of the Origami Method: 1. **Double-Layered Closure**: - The technique involves folding the muscle layer inward and securing it with through-the-scope clips. This creates a double-layered closure that enhances stability and promotes better healing of the defect. 2. **Improved Stability**: - The inward folding of the muscle layer ensures that the closure is robust and durable, minimizing the risk of postoperative complications. 3. **Efficient Procedure**: - The median closure time for OGM is reported to be only 16 minutes, demonstrating its practicality and efficiency in clinical settings. 4. **Safety and Durability**: - In a study of 28 patients, OGM achieved complete closure in 96% of cases (27 out of 28), including the largest lesion with a defect size of 110 mm. - Follow-up endoscopy conducted in 21 patients within 3–5 days post-procedure confirmed that the folded muscle layer remained intact in all cases. - No complications related to clipping were observed, including zero cases of clip-induced perforations, delayed perforations, or delayed bleeding. ### Study Details: - **Patient Pool**: - The study included 28 patients treated between June 2022 and April 2023 at a tertiary hospital. - Lesions in the duodenal bulb or involving the major papilla were excluded from the analysis. - **Defect Size**: - The median defect size was 38 mm, ranging from 26 to 110 mm, indicating the method's capability to handle large defects effectively. ### Advantages of the Origami Method: 1. **High Success Rate**: - Achieved a near-perfect closure rate of 96%. 2. **Safety**: - No complications related to the closure technique were reported. 3. **Durability**: - The folded muscle layer remained intact during follow-up, demonstrating reliable postoperative healing. 4. **Efficiency**: - The median closure time was relatively short, at 16 minutes. ### Clinical Implications: The Origami Method offers a promising alternative to conventional closure techniques for managing large duodenal defects caused by ESD. Its ability to provide reliable, safe, and durable closures makes it highly feasible for clinical use, especially in challenging cases involving large mucosal defects. In summary, OGM represents a significant advancement in duodenal ESD defect management, combining practicality, safety, and effectiveness to reduce postoperative risks and improve patient outcomes.

POEM training in Europe- ESGE Statement

The European Society of Gastrointestinal Endoscopy (ESGE) has issued a comprehensive Position Statement regarding the training curriculum for performing peroral endoscopic myotomy (POEM) in Europe. POEM is an advanced endoscopic procedure that is now recognized as a first-line treatment for achalasia and other spastic esophageal motility disorders. Given the high level of technical expertise required and the potential risks of significant adverse events, ESGE stresses the importance of a structured, standardized training program to ensure safe and effective practice. ### Key Highlights of the ESGE POEM Training Curriculum: #### 1. **Training Foundations** - Trainees must develop a strong theoretical foundation before performing POEM. This includes: - Understanding the pathophysiology of achalasia and other spastic esophageal motility disorders. - Being proficient in diagnostic techniques, such as high-resolution manometry, which is critical for diagnosing and managing these conditions. - Familiarity with expected treatment outcomes and strategies for managing complications. #### 2. **Prerequisites for Training** - Trainees should already have advanced endoscopic skills, particularly in techniques such as Endoscopic Mucosal Resection (EMR) or Endoscopic Submucosal Dissection (ESD). These skills are directly transferable to the submucosal dissection required for POEM. - For those without prior ESD experience, training should include at least **20 simulated POEM procedures** on ex vivo or animal models before progressing to human cases. #### 3. **Observational Training** - Trainees are advised to observe at least **20 live POEM procedures** at expert centers. This allows them to gain insight into the technical nuances, procedural steps, and decision-making processes involved in POEM. #### 4. **Hands-On Clinical Training** - Trainees should perform a minimum of **10 supervised human POEM cases** under the guidance of experienced mentors. - It is recommended to begin with straightforward cases, avoiding complex or high-risk cases during the early stages of training. - The goal is for trainees to be able to independently complete all steps of the POEM procedure by the end of their training. #### 5. **Competency Evaluation** - Competency is assessed based on: - Procedural success. - Clinical outcomes (e.g., improvement in symptoms and quality of life). - Low rates of adverse events. - The evaluation should ensure that the trainee can perform the procedure safely and effectively. #### 6. **Quality Assurance and Continuous Improvement** - Centers offering POEM training are encouraged to maintain prospective registries of their procedures. These registries will help monitor the quality of training, track clinical outcomes, and ensure continuous improvement in the field. #### 7. **Consensus-Based Development** - The recommendations in the ESGE Position Statement were developed through a systematic review of the literature and a Delphi consensus process. This involved collaboration with expert POEM endoscopists from across Europe to ensure the curriculum is both evidence-based and practical. ### Conclusion: The ESGE emphasizes that the structured training program outlined in this Position Statement is crucial for maintaining high standards of care and patient safety in the practice of POEM. By adhering to these recommendations, trainees can develop the necessary skills and knowledge to perform POEM with precision and confidence, ultimately improving patient outcomes.

Biliary drainage prior to pancreatoduodenectomy with EUS-guided choledochoduodenostomy versus conventional ERCP

The study compared two methods of preoperative biliary drainage for patients undergoing pancreatoduodenectomy: endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) and conventional endoscopic retrograde cholangiopancreatography (ERCP). Preoperative biliary drainage is often necessary but can lead to complications that complicate surgery. EUS-CDS has been proposed as a safer alternative to ERCP, but its impact on surgical outcomes and complexity was unclear. The study analyzed 937 patients across eight Dutch centers, with 42 undergoing EUS-CDS and 895 undergoing ERCP before surgery. Major postoperative complications occurred in 19% of EUS-CDS patients compared to 33% of ERCP patients, suggesting a trend toward fewer major complications with EUS-CDS (relative risk 0.50), although this difference was not statistically significant. Secondary outcomes, such as overall complications, bile leaks, and pancreatic fistulas, were similar between the two groups. Propensity score-matched analysis confirmed these findings, indicating no significant difference in postoperative risk between the techniques. Surgeons reported that prior EUS-CDS rarely made surgery more challenging, with most finding it not (45%) or only slightly (31%) more difficult. Only 24% found it clearly or severely more complex. Overall, EUS-CDS appears to be a safe and effective preoperative biliary drainage method, with no significant impact on postoperative complications or surgical complexity.

Radical Endoscopic Resection of high risk T1 esophageal adenocarcinoma

Radical Endoscopic Resection (ER) is a minimally invasive procedure that is used to treat early-stage esophageal adenocarcinoma (EAC), specifically high-risk T1 EAC. T1 esophageal adenocarcinoma refers to a cancer that is confined to the innermost layers of the esophagus. The "T1" designation is part of the tumor-node-metastasis (TNM) cancer staging system and indicates that the tumor has invaded the lamina propria, muscularis mucosae, or submucosa of the esophagus but has not spread to deeper layers, lymph nodes, or distant organs. High-risk T1 EAC refers to cases where there are specific features that increase the likelihood of lymph node metastasis (LNM) or recurrence. These risk factors may include: 1. **Invasion into the submucosa (T1b tumors)**: Tumors that extend deeper into the submucosal layer are associated with a higher risk of lymph node involvement compared to tumors confined to the mucosa (T1a). 2. **Poor tumor differentiation**: Poorly differentiated tumors are more aggressive and have a greater potential to spread. 3. **Lymphovascular invasion (LVI)**: The presence of cancer cells in lymphatic or blood vessels increases the risk of metastasis. 4. **Tumor size and other pathological features**: Larger tumors or those with specific histological features may also be considered higher risk. ### Role of Radical Endoscopic Resection (ER) in High-Risk T1 EAC Radical Endoscopic Resection involves the complete removal of the tumor from the esophageal wall with negative deep margins (no cancer cells at the edges of the removed tissue). This procedure is considered an organ-preserving alternative to esophagectomy, a more invasive surgical procedure that involves removing part or all of the esophagus. The role of Radical ER in high-risk T1 EAC is as follows: 1. **Curative Intent**: For carefully selected patients, Radical ER can serve as a curative treatment by completely removing the cancerous lesion, provided there is no evidence of lymph node involvement or distant metastasis. 2. **Pathological Staging**: After the tumor is removed, the excised tissue is analyzed to assess the depth of invasion, tumor differentiation, and presence of lymphovascular invasion. This information helps determine the risk of lymph node metastasis and guides further management. 3. **Minimally Invasive Approach**: Compared to esophagectomy, Radical ER is less invasive, has fewer complications, and allows patients to preserve their esophagus, which improves quality of life. 4. **Alternative to Surgery**: For patients who are not good candidates for surgery due to age, comorbidities, or personal preference, Radical ER followed by close endoscopic surveillance is a viable and safe alternative. ### Study Findings on Long-Term Outcomes The study you referenced evaluated the long-term outcomes of patients with high-risk T1 EAC who underwent Radical ER. The key findings were: 1. **Surgery After ER**: - Among 26 patients who underwent additional esophagectomy after Radical ER, 19% had residual T1 cancer in the surgical specimen. - 8% were found to have lymph node metastases. - This indicates that a small proportion of patients may still have residual disease or undetected lymph node involvement even after Radical ER. 2. **Endoscopic Surveillance**: - 80 patients were followed with endoscopic surveillance after Radical ER without undergoing additional surgery. - Over a median follow-up of 47 months, 6% developed metastases, and 5% died due to EAC. 3. **Risk of Metastasis and Mortality**: - The combined metastasis rate across all patients was 7%, with 6% experiencing lymph node metastasis and 5% succumbing to EAC-related mortality. - These findings suggest that the risk of hidden lymph node spread is relatively low after complete endoscopic removal of the tumor. ### Implications of the Study The study highlights that Radical ER followed by endoscopic surveillance is a reasonable and safe management strategy for selected high-risk T1 EAC patients. However, careful patient selection is crucial to ensure that those with higher risks of lymph node metastasis are appropriately identified and managed. For some patients, additional surgery (esophagectomy) may still be necessary to address the risk of residual cancer or lymph node involvement. ### Considerations for Future Research The study emphasizes the need for further prospective research to refine patient selection criteria and optimize management strategies. This includes identifying which patients are most likely to benefit from endoscopic surveillance versus additional surgery after Radical ER. In summary, Radical Endoscopic Resection plays a critical role in the management of high-risk T1 esophageal adenocarcinoma by offering a less invasive, organ-preserving treatment option with curative potential for carefully selected patients. However, long-term outcomes depend on accurate staging, risk stratification, and close follow-up.

Gloucester Comfort Scale scores

The Gloucester Comfort Scale (GCS) is a clinician-assessed scoring system used to evaluate patient comfort during procedures such as colonoscopy. It is a 1–5 scale, with higher scores indicating greater discomfort or pain experienced by the patient. The GCS is widely used by clinicians to rate patient comfort based on their observations during the procedure. However, the study you referenced highlights significant limitations in the accuracy of GCS scores when compared to patient-reported experiences. Key findings regarding GCS scores from the study: 1. **Discrepancies Between Clinician and Patient Scores**: Clinicians often underestimated or overestimated patient discomfort and pain levels when using the GCS. Specifically: - Discomfort was underestimated in 30% of patients and overestimated in 21%. - Pain was underestimated in 29% of patients and overestimated in 16%. 2. **Underestimation in Moderate-to-Severe Cases**: The mismatch was particularly pronounced in patients with moderate-to-severe symptoms (scores ≥3). Among these patients: - Clinicians underestimated discomfort in 92% of cases. - Clinicians underestimated pain in 90% of cases. 3. **Low Agreement Between Clinician and Patient Scores**: Statistical analysis showed weak alignment between clinician-reported GCS scores and patient-reported measures: - Cohen’s kappa values indicated minimal agreement for discomfort (κ = 0.34) and weak agreement for pain (κ = 0.47). 4. **Recommendation for Improvement**: The study suggests that the GCS alone may not accurately reflect patients' true experiences of discomfort and pain during colonoscopy. To improve patient-centered care, it recommends incorporating patient-reported experience measures (PREMs), such as the Newcastle ENDOPREM, which directly capture patients' perceptions on a similar 1–5 scale. In summary, while the Gloucester Comfort Scale is a commonly used tool, its reliability is limited when it comes to accurately assessing discomfort and pain from the patient's perspective. Integrating patient-reported measures alongside clinician assessments is strongly advised to ensure a more accurate and holistic evaluation of patient comfort during medical procedures.

Optical assessment of scars after EMR - STAR-LNPCP Trial

The STAR-LNPCP trial conducted a multicenter study to assess the reliability of optical assessment as a follow-up method for scars after piecemeal endoscopic mucosal resection (EMR) of large colorectal polyps (≥20 mm). The study aimed to determine whether routine biopsy is still necessary during the 6-month follow-up, especially in community hospital settings where evidence has been limited. Traditionally, follow-up included tattoo placement and routine biopsies to detect recurrence, but expert centers have suggested that careful optical assessment may suffice, potentially avoiding unnecessary biopsies. ### Key Details of the STAR-LNPCP Trial: 1. **Study Design**: - Post-hoc analysis of the STAR-LNPCP trial. - Conducted across 30 Dutch community hospitals between 2019 and 2022. - Included 1277 scar assessments after piecemeal EMR. 2. **Scar Identification**: - Scar identification was highly successful, achieved in 95% of cases (1215 out of 1277). - Tattoo placement did not impact the ability to locate scars. 3. **Routine Biopsy**: - Routine biopsies were performed in 86% of cases (1050 out of 1215 scars). - Recurrence was detected in 19% of biopsied scars. 4. **Optical Assessment Findings**: - Optical diagnosis showed a **negative predictive value (NPV)** of 98%, meaning if the scar appeared normal to the endoscopist, there was a 98% chance that no recurrence was present. - Diagnostic accuracy was high at 93%, with a **Cohen's kappa** of 0.78, indicating substantial agreement between optical assessment and histological biopsy results. - Positive predictive value was 74%, but false positives were more common when clips had been used during the initial procedure (11% vs. 5%). 5. **Performance of Dedicated Endoscopists**: - Dedicated endoscopists performed better than non-specialized endoscopists: - Higher scar identification rate (96% vs. 88%). - Fewer missed recurrences. 6. **Implications**: - The study supports that routine biopsies and tattoo placement can be safely omitted during follow-up when scars are evaluated by well-trained, dedicated endoscopists. - Optical assessment alone is highly reliable for ruling out recurrence, simplifying follow-up and reducing unnecessary procedures. ### Conclusion: The STAR-LNPCP trial demonstrated that optical assessment is a robust and effective method for follow-up of scars after piecemeal EMR of large colorectal polyps. With a high negative predictive value and diagnostic accuracy, routine biopsy may no longer be necessary, particularly when performed by skilled endoscopists. This approach can streamline follow-up in community hospital settings, reduce patient burden, and minimize unnecessary interventions.

EUS-guided gallbladder drainage in patients with cirrhosis

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is a minimally invasive procedure that has proven to be safe and effective for treating symptomatic gallbladder disease in patients with cirrhosis. Cirrhotic patients are traditionally considered high-risk for surgical procedures due to their compromised liver function, increased bleeding risk, and susceptibility to complications. EUS-GBD provides an alternative to surgery, offering relief from gallbladder-related symptoms and inflammation without the need for more invasive interventions. A multicenter study compared outcomes of EUS-GBD in cirrhotic (47 patients) and non-cirrhotic (123 patients) individuals. Both groups showed similar rates of technical success (97.9% vs. 95.1%) and clinical success (93.6% vs. 94.9%), with rare adverse events and comparable survival rates. Acute cholecystitis was more prevalent in cirrhotic patients, reflecting their higher disease burden. Overall, EUS-GBD demonstrated equivalent safety and effectiveness in cirrhotic and non-cirrhotic patients, establishing it as a viable option for gallbladder drainage in cirrhosis.

Hemostatic powder TC-325 in Maliganant upper GI bleeding

Hemostatic powder TC-325 has emerged as a promising treatment option for malignant upper gastrointestinal bleeding (MUGIB), which is one of the most difficult types of GI bleeding to manage. MUGIB often results from cancer-related lesions that bleed heavily and are resistant to control using standard endoscopic therapy (SET). TC-325 has demonstrated clinical superiority over SET in terms of quicker and more reliable control of bleeding, and recent research has explored its cost-effectiveness as a first-line treatment in the United Kingdom. ### Clinical Effectiveness of TC-325: 1. **Immediate Hemostasis**: TC-325 showed higher rates of immediate bleeding control compared to SET. This means that patients treated with TC-325 experienced faster stabilization of their bleeding, reducing the risk of complications. 2. **Lower Rebleeding Rates**: Patients who received TC-325 had fewer instances of rebleeding within a 30-day period compared to those treated with SET. This reduces the need for repeat interventions. 3. **Reduced Need for Additional Procedures**: Because TC-325 is more effective in controlling bleeding, it minimizes the need for further treatments such as additional endoscopic procedures, radiotherapy, surgery, or transcatheter arterial embolization. These additional interventions are often costly and carry higher risks for patients. ### Cost-Effectiveness of TC-325: 1. **Financial Savings**: The use of TC-325 resulted in an average cost savings of £245.88 per patient compared to SET. This is due to fewer repeat procedures, hospital readmissions, and shorter hospital stays. 2. **Quality-Adjusted Life Years (QALY)**: TC-325 provided a small but meaningful improvement in QALY (0.001), reflecting enhanced patient outcomes and quality of life. 3. **Consistency Across Scenarios**: Sensitivity analyses showed that TC-325 remained cost-saving and effective in 80.1% of simulated scenarios, reinforcing its reliability and robustness across varying conditions. ### Advantages of TC-325: - **Reduced Rebleeding**: By effectively controlling bleeding, TC-325 helps avoid the complications associated with recurrent bleeding episodes. - **Lower Overall Costs**: Fewer interventions and shorter hospital stays lead to significant cost savings for healthcare systems. - **Improved Patient Outcomes**: Faster bleeding control and fewer complications improve the overall quality of care and patient experience. ### Implications for the UK Healthcare System: The study used official 2023–2024 NHS cost data to ensure realistic estimates of the financial impact. With its dual benefits of clinical effectiveness and cost savings, TC-325 is recommended as a cost-effective, reliable first-line treatment for MUGIB in the UK. Its adoption could improve patient outcomes while reducing the financial burden on healthcare systems. ### Conclusion: TC-325 hemostatic powder is a groundbreaking advancement in the management of malignant upper GI bleeding. By offering superior bleeding control, fewer repeat interventions, and cost savings, TC-325 is both clinically and economically advantageous compared to standard endoscopic therapy. Its strong performance across various scenarios makes it an ideal first-line treatment for MUGIB in the UK healthcare setting.

Bariatric and metabolic endoscopy: ESGE Technical Review

The "Bariatric and Metabolic Endoscopy: ESGE Technical Review" provides a detailed and comprehensive overview of endoscopic bariatric and metabolic therapies (EBMTs), which are minimally invasive treatment options for obesity and related metabolic diseases. The review focuses on the latest advancements in this field, offering clinicians practical guidance on the use, safety, and effectiveness of these therapies. ### Key Highlights of the Review: #### 1. **Types of Endoscopic Bariatric and Metabolic Therapies (EBMTs):** - **Stomach-Based Therapies:** - **Intragastric Balloons (IGBs):** These devices occupy space in the stomach, causing a feeling of fullness and reducing food intake. - **Endoscopic Sleeve Gastroplasty (ESG):** A procedure that uses sutures to reduce stomach volume and mimic the effects of surgical sleeve gastrectomy. - **Aspiration Therapy:** A reversible technique that involves placing a device to aspirate ingested food from the stomach, reducing calorie absorption. - **Small-Bowel–Based Therapies:** - **Duodenal Mucosal Resurfacing (DMR):** A procedure that modifies the duodenal lining, potentially improving glucose metabolism and insulin sensitivity. - **Bypass Sleeves (Endoluminal Sleeves):** Devices that act as a barrier to prevent contact between food and the proximal small intestine, mimicking the effects of surgical bypass. #### 2. **Mechanisms of Action:** - The review explains how each therapy works to promote weight loss and improve metabolic health. These mechanisms include: - Restriction of food intake. - Alteration of gut hormones. - Changes in nutrient absorption and metabolism. #### 3. **Indications and Patient Selection:** - EBMTs are recommended for patients with obesity (BMI ≥ 30 kg/m²) who have not achieved sufficient results with lifestyle modifications or pharmacotherapy. They may also be suitable for patients who are not candidates for bariatric surgery or prefer less invasive options. - Patient selection is critical, and the review emphasizes the importance of multidisciplinary care, including dietitians, psychologists, and medical professionals. #### 4. **Effectiveness and Safety:** - EBMTs demonstrate promising outcomes for weight loss and metabolic improvements, particularly in controlling type 2 diabetes and other obesity-related conditions. - While they carry a lower risk compared to surgical interventions, common adverse events include nausea, vomiting, abdominal pain, and, in rare cases, more serious complications. - The review discusses strategies to manage complications and prevent weight regain, which remains a challenge in some patients. #### 5. **Evidence and Research Gaps:** - The review highlights the need for more high-quality, randomized controlled trials and long-term follow-up studies to better understand the durability of outcomes and to establish the precise role of EBMTs in clinical practice. - There is a call for standardized protocols and guidelines to optimize the use of these therapies. #### 6. **Practical Guidance for Clinicians:** - The review serves as a technical guide for healthcare providers, detailing the proper techniques for performing EBMTs and offering recommendations for their safe and effective application. - It underscores the importance of individualized treatment plans and the integration of EBMTs into a comprehensive obesity management strategy. ### Conclusion: The ESGE Technical Review positions EBMTs as an emerging and valuable tool in the fight against obesity and metabolic diseases. While these therapies show significant potential due to their minimally invasive nature and favorable safety profile, their long-term efficacy and role in the broader treatment pathway require further investigation. This review provides clinicians with the knowledge and framework necessary to incorporate EBMTs into modern obesity care, ensuring patient safety and optimal outcomes.