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van Munster S; Frederiks C; Nieuwenhuis . Incidence and outcomes of poor healing after RFA for early Barrett's neoplasia. Endoscopy. 2021 Jun 01.
Although endoscopic eradication therapy with radiofrequency ablation (RFA) is effective in most Barrett's Esophagus (BE) patients, some might experience poor healing (PH) and/or poor squamous regeneration (PSR). We aimed to evaluate PH/PSR incidence and treatment outcomes. METHODS: We included all patients treated with RFA for early BE neoplasia, from a nationwide Dutch registry based on a joint treatment protocol. PH was defined as active inflammatory changes or visible ulcerations >=3 months post-RFA, PSR as <50% squamous regeneration, and treatment success as complete eradication of BE (CE-BE). Results 1,386 patients (median BE C2M5) underwent RFA with baseline low-grade dysplasia (27%), high-grade dysplasia (30%), or early cancer (43%). In all 134 patients with PH (10%), additional time and acid suppression resulted in complete esophageal healing. 67/134 (50%) had normal regeneration with 97% CE-BE. In total, 74 patients had PSR (5%). As compared to patients with normal squamous regeneration, PSR patients had a higher risk for treatment failure (64% versus 2%, RR 27 [95% CI 18-40]) and progression to advanced disease (15% versus <1%, RR 30 [95% CI 12-81]). Higher BMI, longer BE, reflux esophagitis, and <50% squamous regeneration after baseline endoscopic resection were independently associated with PSR in multivariable logistic regression. CONCLUSIONS In half of the patients with poor healing, additional time and acid suppression may lead to normal squamous regeneration and excellent treatment outcomes. However, if patients experience poor squamous regeneration, the risk for treatment failure and progression to advanced disease is significantly increased with a relative risk of 27 and 30, respectively. Meulen LWT; van der Zander QEW; Bogie RMM. Evaluation of polypectomy quality indicators of large, nonpedunculated colorectal polyps in a nonexpert, bowel cancer screening cohort. Gastrointestinal Endoscopy. 2021 Jun 14.
BACKGROUND: With the introduction of the national bowel cancer screening program, the detection of sessile and flat colonic lesions >=20 mm in size, defined as large nonpedunculated colorectal polyps (LNPCPs), has increased. Aim of this study was to examine the quality of endoscopic treatment of LNPCPs in the Dutch screening program. METHODS: This investigation comprised 2 related, but separate, substudies (one with a cross-sectional design; one with a longitudinal design). The first examined prevalence and characteristics of LNPCPs in data from the national Dutch screening cohort, from February 2014 until January 2017. The second, with screening data from five endoscopy units in the Southern part of the Netherlands from February 2014 until August 2015, examined performance on important quality indicators (technical and clinical successes, recurrence rate, adverse event rate, and surgery referral rate). All patients were part of the national Dutch screening cohort. RESULTS: In the national cohort, a LNPCP was detected in 8% of participants. Technical and clinical successes decreased with increasing LNPCP size, from 93% and 96% in 20 to 29 mm lesions to 85% and 86% in 30 to 39 mm lesions and to 74% and 81% in >=40 mm lesions (p<0.001; p=0.034). Cumulative recurrence rate at 12 months increased with LNPCP size, from 9% to 22% and 26% in the respective size groups (p=0.095). Adverse event rate was 5%. Overall surgical referral rate for noninvasive LNPCPs was 7%. CONCLUSIONS: In this performance of 2 substudies, it was shown that quality parameters for endoscopic resection of large polyps in the Dutch screening cohort are not reached, especially in >=30 mm polyps. Endoscopic resection of large polyps could benefit from additional training, quality monitoring, and centralization either within or between centers. Copyright © 2021 American Society for Gastrointestinal Endoscopy. Li B; Shi Q; Xu EP . Prediction of a technically difficult colonic ESD: a novel clinical score model. Gastrointestinal Endoscopy. 2020 Nov 19.
BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is a promising technique for removing superficial GI tumors, but ESD is technically difficult. The aims of this study were to establish a clinical score model for grading technically difficult colorectal ESD. METHODS: Data on patients, lesions, and outcomes of colorectal ESD at 2 centers were analyzed. The objective parameter of successful ESD within 60 minutes was set as an endpoint to evaluate the difficulty. Independent predictors of difficulty in the derivation cohort were identified by multiple logistic regression analysis and used to develop a clinical score. We validated the score model in the validation cohort. RESULTS: The clinical score comprised tumor size of 30 to 50 mm (1 point) or >=50 mm (2 points), at least two-thirds circumference of the lesion (2 points), location in the cecum (1 point), flexure (2 points) or dentate line (1 point), and laterally spreading tumor nongranular lesions (1 point). Areas under the receiver operator characteristic curves for the score model were comparable (derivation [.70] vs internal validation [.69] vs external validation [.69]). The probability of successful ESD within 60 minutes in easy (score = 0), intermediate (score = 1), difficult (score = 2-3), and very difficult (score >=4) categories were 75.0%, 51.3%, 35.6%, and 3.4% in the derivation cohort; 73.3%, 47.9%, 31.8%, and 16.7% in the internal validation cohort; and 79.5%, 66.7%, 43.3%, and 20.0% in the external validation cohort, respectively. CONCLUSIONS: This clinical score model accurately predicts the probability of successful ESD within 60 minutes and can be applied to grade the technical difficulty before the procedure. Pei Q; Qiao H; Zhang M . Pocket-creation versus conventional ESD in the colon: a meta-analysis. Gastrointestinal Endoscopy. 93(5):1038-1046.e4, 2021 05.
BACKGROUND AND AIMS: The pocket-creation method (PCM) is a newly developed strategy for colorectal endoscopic submucosal dissection (ESD). However, its superiority over the conventional method (CM) has not been established. The aim of this meta-analysis was to evaluate the efficacy and safety of PCM-ESD compared with CM-ESD for superficial colorectal neoplasms (SCNs). METHODS: Literature searches were conducted using the Pubmed, Embase, and Cochrane Library databases, and a meta-analysis was performed. The primary outcome was the R0 resection rate, and the secondary outcomes were the en bloc resection rate, dissection speed, procedure time, and adverse event rate. RESULTS: Five studies (2 randomized controlled trials and 3 retrospective studies) with 1481 patients were included in our meta-analysis. The pooled analysis showed that PCM-ESD achieved a higher R0 resection rate (93.5% vs 78.1%; odds ratio [OR], 3.4; 95% confidence interval [CI], 1.3-8.9; I2 = 58%), a higher en bloc resection rate (99.8% vs 92.8%; OR, 9.9; 95% CI, 2.7-36.2; I2 = 0), a shorter procedure time (minutes) (mean difference [MD], -11.5; 95% CI, -19.9 to -3.1; I2 = 72%), a faster dissection speed (mm2/min) (MD, 3.6; 95% CI, 2.8-4.5; I2 = 0), and a lower overall adverse event rate (4.4% vs 6.6%; OR, 0.6; 95% CI, 0.3-1.0; I2 = 0) compared with CM-ESD. CONCLUSIONS: This meta-analysis showed that PCM-ESD improves the efficacy and safety compared with CM-ESD for superficial colorectal neoplasms Imai K; Hotta K; Ito S; Yamaguchi . Tip-in Endoscopic Mucosal Resection for 15- to 25-mm Colorectal Adenomas: A Single-Center, Randomized Controlled Trial (STAR Trial). American Journal of Gastroenterology. 2021 May 26.
INTRODUCTION: One-piece endoscopic mucosal resection (EMR) for lesions >15 mm is still unsatisfactory, and attempted 1-piece EMR for lesions >25 mm can increase perforation risk. Therefore, modifications to ensure 1-piece EMR of 15- to 25-mm lesions would be beneficial. The aim of this study was to investigate whether Tip-in EMR, which anchors the snare tip within the submucosal layer, increases en bloc resection for 15- to 25-mm colorectal lesions compared with EMR. METHODS: In this prospective randomized controlled trial, patients with nonpolypoid colorectal neoplasms of 15-25 mm in size were recruited and randomly assigned in a 1:1 ratio to undergo Tip-in EMR or standard EMR, stratified by age, sex, tumor size category, and tumor location. The primary endpoint was the odds ratio of en bloc resection adjusted by location and size category. Adverse events and procedure time were also evaluated. RESULTS: We analyzed 41 lesions in the Tip-in EMR group and 41 lesions in the EMR group. En bloc resection was achieved in 37 (90.2%) patients undergoing Tip-in EMR and 30 (73.1%) who had EMR. The adjusted odds ratio of en bloc resection in Tip-in EMR vs EMR was 3.46 (95% confidence interval: 1.06-13.6, P = 0.040). The Tip-in EMR and EMR groups did not differ significantly in adverse event rates (0% vs 4.8%) or median procedure times (7 vs 5 minutes). DISCUSSION: In this single-center randomized controlled trial, we found that Tip-in EMR significantly improved the en bloc resection rate for nonpolypoid lesions 15-25 mm in size, with no increase in adverse events or procedure time. Kemper G; Turan AS; Schoon EJ; . Endoscopic techniques to reduce recurrence rates after colorectal EMR: systematic review and meta-analysis. [Review]. Surgical Endoscopy. 2021 Jun 02.
BACKGROUND: Colorectal EMR is an effective, safe, and minimally invasive treatment for large lateral spreading and sessile polyps. The reported high recurrence rate of approximately 20% is however one of the major drawbacks. Several endoscopic interventions have been suggested to reduce recurrence rates. We conducted a systematic review and meta-analysis to assess the efficacy of endoscopic interventions targeting the EMR margin to reduce recurrence rates. METHODS: We searched in PubMed and Ovid for studies comparing recurrence rates after interventions targeting the EMR margin with standard EMR. The primary outcome was the recurrence rate at the first surveillance colonoscopy (SC1) assessed histologically or macroscopically. For the meta-analysis, risk ratios (RRs) were calculated and pooled using a random effects model. The secondary outcome was post-procedural complication rates. RESULTS: Six studies with a total of 1335 lesions were included in the meta-analysis. The techniques performed in the intervention group targeting the resection margin were argon plasma coagulation, snare tip soft coagulation, extended EMR, and precutting EMR. The interventions reduced the adenoma recurrence rate with more than 50%, resulting in a pooled RR of 0.37 (95% CI 0.18, 0.76) comparing the intervention group with the control groups. Overall post-procedural complication rates did not increase significantly in the intervention arm (RR 1.30; 95% CI 0.65, 2.58). CONCLUSION: Interventions targeting the EMR margin decrease recurrence rates and may not result in more complications Chung CS; Chen KH; Chen KC; . Peroral endoscopic tumor resection (POET) with preserved mucosa technique for management of upper gastrointestinal tract subepithelial tumors. Surgical Endoscopy. 35(7):3753-3762, 2021 Jul.
Background: Third space endoscopy technique facilitates therapeutic endoscopy in subepithelial space. This study aimed to investigate peroral endoscopic tumor resection (POET) with preserved mucosa technique for upper gastrointestinal tract subepithelial tumors (UGI-SETs) removal. Methods: Between February 2011 and December 2019, consecutive patients with SETs of esophagus and stomach who underwent POET for enlarging size during follow-up, malignant endoscopic ultrasound features or by patient's request were enrolled. Demographic, endoscopic and pathological data were analyzed retrospectively. Results: Totally 18 esophageal (mean ± SD age, 55.23 ± 4.15 year-old, 38.89% female) and 30 gastric (52.65 ± 2.43 year-old, 53.33% female) SETs in 47 patients (one with both esophageal and gastric lesions) were resected. The mean (± SD) endoscopic/pathological tumor size, procedure time, en-bloc/complete resection rate, and hospital stays of esophageal and gastric SET patients were 12.36 (± 7.89)/11.86 (± 5.67) and 12.57 (± 6.25)/12.35 (± 5.73) mm, 14.86 (± 6.15) and 38.21 (± 15.29) minutes, 88.89%/94.44% and 86.77%/93.30%, and 4.14 (± 0.21) and 4.17 (± 0.20) days, respectively. The overall complication rate was 18.75%, including 6 self-limited fever and 3 pneumoperitoneum relieved by needle puncture. There was no mortality or recurrence reported with mean follow-up period of 23.74 (± 4.12) months. Conclusions: POET is a safe and efficient third space endoscopic resection technique for removal of UGI-SETs less than 20 mm. Long term data are warranted to validate these results. Matsueda K; Kanesaka T; Kitamura et al.. Favorable long-term outcomes after EMR for duodenal non-ampullary duodenal NET’s. Journal of Gastroenterology & Hepatology. 2021 Jun 17.
BACKGROUND AND AIM: The long-term outcomes of endoscopic resection for non-ampullary duodenal neuroendocrine tumors are limited. We aimed to clarify it. METHODS: Consecutive patients with non-ampullary duodenal neuroendocrine tumors endoscopically treated at our institute between January 2005 and June 2020 were included in this retrospective study. En bloc and R0 resection rates and adverse events were evaluated as short-term outcomes of endoscopic resection. The 5-year overall and recurrence-free survival rates of patients after endoscopic resection were calculated as long-term outcomes. RESULTS: Of 34 patients with 34 lesions, 33 patients (97%) underwent endoscopic mucosal resection and one (3%) underwent endoscopic submucosal dissection. En bloc resection was achieved in 33 lesions (97%). R0 resection was achieved in 20 lesions (59%). The median tumor size was 6 mm (range: 3-13). Thirty-one lesions (91%) and three lesions (9%) were classified as G1 and G2, respectively. Lymphovascular invasion was observed in six lesions (18%). Intraprocedural perforation occurred in four patients (12%) who were conservatively treated with endoscopic closure. All 34 patients were followed up without additional treatment after endoscopic resection, and no recurrence or metastasis developed during the median follow-up period of 3.5 years 47.9 months (range: 9.0-187.1). The 5-year overall survival and recurrence-free survival rates were 87.1% and 100%, respectively. CONCLUSIONS: Endoscopic resection provided a favorable long-term prognosis for patients with non-ampullary duodenal neuroendocrine tumors without lymph node metastasis. Troelsen FS; Sorensen HT; Crockett SD. Characteristics and survival of patients with IBD and PCCRC (post-colonoscopy colorectal cancers). Clinical Gastroenterology & Hepatology. 2021 May 26.
BACKGROUND AND AIMS: Post-colonoscopy colorectal cancers (PCCRCs) account for up to 50% of colorectal cancers (CRCs) in patients with inflammatory bowel disease (IBD). We investigated characteristics of IBD patients with PCCRC and their survival. METHODS: We identified IBD patients (ulcerative colitis [UC] and Crohn's Disease [CD]) diagnosed with CRC from 1995 to 2015. We defined PCCRC as diagnosed between 6 and 36 months, and detected CRC (dCRC) as diagnosed within 6 months after colonoscopy. We computed prevalence ratios (PRs) comparing PCCRC vs. dCRC and followed patients from the diagnosis of PCCRC/dCRC until death, emigration, or study end. Mortality was compared using Cox proportional hazards regression models adjusted for sex, age, year of CRC diagnosis, and stage. The main analyses focused on patients with UC. RESULTS: Among 23,738 UC patients undergoing colonoscopy, we identified 352 patients with CRC, of whom 103 (29%) had PCCRC. Compared with dCRC, PCCRC was associated with higher prevalence of metastatic cancer (33% vs. 20%; PR: 1.64, 95% confidence interval [CI]: 1.13-2.38), cancers exhibiting mismatch repair deficiency (79% vs. 56%; PR: 1.40, 95% CI: 1.13-1.72), and proximally located cancers (54% vs. 40%; PR: 1.34, 95% CI: 1.06-1.69). The one- and five -year adjusted hazard ratios (HRs) of death for PCCRC vs. dCRC among UC patients were 1.29 (95% CI: 0.77-2.18) and 1.24 [95% CI: 0.86-1.79), respectively. CONCLUSION: The characteristics of UC-related PCCRC suggest tumor biology as an important factor in the progression to cancer. However, the prognosis of PCCRC appears similar to that of dCRC. Nicoara-Farcau O; Han G; Rudler M. Effects of Early Placement of Transjugular Portosystemic Shunts in Patients With High-Risk Acute Variceal Bleeding: a Meta-analysis of Individual Patient Data. Gastroenterology. 160(1):193-205.e10, 2021 01.
BACKGROUND & AIMS: Compared with drugs plus endoscopy, placement of transjugular portosystemic shunt within 72 hours of admission to the hospital (early or preventive transjugular intrahepatic portosystemic shunt [TIPS], also called preemptive TIPS) increases the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survive for 1 year. However, the benefit of preemptive TIPS is less clear for patients with a Child-Pugh score of B and active bleeding (CP-B+AB). We performed an individual data meta-analysis to assess the efficacy of preemptive TIPS in these patients and identify factors associated with reduced survival of patients receiving preemptive TIPS. METHODS: We searched publication databases for randomized controlled trials and observational studies comparing the effects of preemptive TIPS versus endoscopy plus nonselective beta-blockers in the specific population of high-risk patients with cirrhosis and acute variceal bleeding (CP-B+AB or Child-Pugh C, below 14 points), through December 31, 2019. We performed a meta-analysis of data from 7 studies (3 randomized controlled trials and 4 observational studies), comprising 1327 patients (310 received preemptive TIPS and 1017 received drugs plus endoscopy). We built adjusted models to evaluate risk using propensity score for baseline covariates. Multivariate Cox regression models were used to assess the factors associated with survival time. The primary endpoint was effects of preemptive TIPS versus drugs plus endoscopy on 1-year survival in the overall population as well as CP-B+AB and Child-Pugh C patients. RESULTS:
Cox analysis of patients who received preemptive TIPS showed that patients could be classified into 3 categories for risk of death, based on age, serum level of creatinine, and Child-Pugh score. In each of these risk categories, preemptive TIPS increased the proportion of patients who survived for 1 year, compared with drugs plus endoscopy. CONCLUSIONS: In a meta-analysis of data from 1327 patients with cirrhosis, acute variceal bleeding, and Child-Pugh score between 10 and 13 points or CP-B+AB, preemptive TIPS increased the proportion who survived for 1 year, in both subgroups separately, compared with drugs plus endoscopy. Triantafyllou K; Gkolfakis P; Gralnek IM. ESGE Guideline on acute LOWER gastrointestinal bleeding. Endoscopy. 2021 Jun 01.
1. ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment. Strong recommendation, low quality evidence. 2. ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of <= 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation. Strong recommendation, moderate quality evidence. 3. ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of <= 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7-9 g/dL is desirable. Strong recommendation, low quality evidence. 4. ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of <= 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of >= 10 g/dL is desirable. Strong recommendation, low quality evidence. 5. ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes. Strong recommendation, low quality of evidence. 6. ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding. Strong recommendation, low quality evidence. 7. ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available. Strong recommendation, low quality evidence. 8. ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding. Strong recommendation, low quality evidence. 9. ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding. Strong recommendation, moderate quality evidence. 10. ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist(clopidogrel, ticagrelor, prasugrel) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated. Strong recommendation, low quality evidence. Kamani L; Kalwar H. Ergonomic Injuries in Endoscopists and Their Risk Factors. Clinical Endoscopy. 54(3):356-362, 2021 May.
BACKGROUND/AIMS: Prolonged repetitive strain caused by the continuous performance of complex endoscopic procedures enhances the risk of ergonomic injuries among health-care providers (HCPs), specifically endoscopists. This study aimed to assess the risk factors of ergonomic injuries among endoscopists and non-endoscopists. METHODS: This cross-sectional study was conducted at the Gastroenterology Department of Liaquat National Hospital, Karachi, Pakistan. A total of 92 HCPs were enrolled, of whom 61 were involved in endoscopic procedures and 31 were non-endoscopists. Data were collected through a self-administered questionnaire during national gastroenterology conferences and analyzed using SPSS version 22 (IBM Corp. Chicago, IL, USA). RESULTS: Of the total study population, 95.08% of endoscopists were observed to have ergonomic injuries, whereas only 54.83% of non-endoscopists had ergonomic injuries (p<0.00). The most common injury associated with musculoskeletal (MSK) pain sites was back (41%), leg (23%), and hand (19.7%) pain among endoscopists. Of 28 endoscopists performing >=20 procedures/week, 26 had MSK injury. However, 95.08% of endoscopists had developed MSK injury irrespective of working hours (>5 or <5 hr/wk). CONCLUSION: Endoscopists are at high risk of developing ergonomic injuries, representing the negative potential of the endoscopy-associated workload. To overcome these issues, an appropriate strategic framework needs to be designed to avoid occupational compromises.
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6/7/2021 22:23:57
MSK and RSI poses a risk to Endoscopists and should be an area of interest in NHS Trusts. Leave a Reply. |
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