Introduction

Endoscopic treatment using peroral/anal flexible endoscopy and dedicated through-the-scope electrocautery devices has been developed as a less-invasive intraluminal surgery. However, pure endoscopic treatment has limitations for lesions at the deeper layer or excessively close to the mouth/anus. Conversely, surgical approach sometimes leads to wider resection and subsequent decreases in the patient’s quality of life. Collaborative surgery by both endoscopists and surgeons is considered effective for providing less-invasive local resection of gastrointestinal tumours to offset limitations either in pure endoscopic treatments or surgical intervention.

Aims & Methods

To investigate the feasibility and safety of this approach, we here retrospectively evaluated the clinical outcomes of collaborative surgery with endoscopists and surgeons. We consecutively collected data of patients who underwent collaborative surgery for lesions located from the laryngopharynx to the anus between October 2017 and December 2023. Collaborative surgery was indicated after the agreement on both flexible endoscopists and surgeons, considering possible benefits of the cooperation in terms of invasiveness, technical difficulty, and safety. Laryngopharyngeal lesions and cervical oesophageal cancer were removed using the ESD technique under laryngeal expansion using a curved laryngoscope by the otolaryngologist’s manipulation. With gastrointestinal surgeons, subepithelial tumours in the gastrointestinal tract and deeply invasive gastric cancers were removed in a full-layered fashion, followed by surgical suturing. Large duodenal cancers were principally treated by ESD followed by sero-muscular suturing for the reinforcement of the mucosal defects. In large anal canal cancer with pagetoid spread, a dermatologist externally dissected the perianally expanded area following ESD from the rectal side. Collaboration completeness, technical success, procedure time, postoperative hospitalization period, and occurrence of adverse events were analyzed.

Results

Collaboration surgery was performed for 134 lesions (33 laryngopharyngeal, 2 oesophageal, 89 gastric, 8 duodenal, and 2 recto-anal lesions, respectively) in 131 patients. Collaboration completeness was achieved in 129 lesions (96%). The en-bloc resection and pathological R0 resection of lesions were obtained in 127 (95%) and 124 (93%) lesions, respectively. The mean procedure time was 188 min. Patients were discharged on the mean postoperative day of 11. Five patients (4%) developed relevant postoperative adverse events.

Conclusion

The results indicated that collaborative surgery by endoscopists and surgeons was feasible and safe, and should contribute to providing less-invasive treatment than conventional approaches. The frequency of adverse events was considered acceptable. Collaborative surgery is worth considering as a flexible and reliable surgical option when cooperation should outperform a single treatment by either of endoscopists or surgeons. To establish this concept, further accumulation of cases and pieces of evidence by well-designed studies is desired.

Introduction

Currently, the Japanese guidelines for GISTs suggest endoscopic ultrasound-guided fine-needle aspiration for sampling the tissue of subepithelial tumors (SETs) and as a first-line technique. Mucosal incision-assisted biopsy (MIAB) is another tissue sampling technique; in this technique, the mucous membrane covering the SET is cut to expose and sample the tissue directly under direct visualization. However, the Japanese guidelines do not clearly state how to handle this technique, and the MIAB procedure has not been standardized, especially in technical aspects, the need for local injection to the submucosa before mucosal incision to prevent perforation, and the need for acid secretion inhibitors to prevent postoperative bleeding.

Aims & Methods

This systematic review and meta-analysis aimed to evaluate diagnostic ability and examine the efficacy of countermeasures to adverse events of MIAB for gastric SETs. We performed a literature search and identified 533 relevant articles. Eleven articles, including 339 lesions, were ultimately used in the meta-analysis. The primary endpoint was the pathological diagnostic rate of MIAB for gastric SETs, and the secondary endpoint was the incidence of adverse events. The efficacy of acid secretion inhibitors in preventing postoperative bleeding and that of local injection before incision to prevent perforation were also examined.

Results

Nine studies were performed in Japan and two in South Korea, of which only two were prospective studies. The mean age of the patients was 60.7 years, and 48.4% were male. In all studies, endoscopic ultrasound was performed to assess tumors before incision-assisted biopsy. The mucosal incision procedure was the same in all studies: The mucosal incision on the tumor was made, and tissue was sampled directly from the tumor using biopsy forceps; however, in all cases in eight articles and six cases in one article, a local injection of saline or glycerol into the submucosa before the mucosal incision was performed. Nine articles reported the closure of the incision using clips. The mean tumor diameter was 20.6 mm, and the pathological results included 150 GISTs, 70 leiomyomas, 11 schwannomas, 37 ectopic pancreas, three lipomas, three cases of inflammatory fibrotic polyp, two malignant lymphoma lesions, two glomus tumors, one neuroendocrine tumor, one adenocarcinoma, one old hematoma, and one renal cell carcinoma. In all cases in six articles and some in two, an intravenous or oral gastric acid suppressant such as esomeprazole or vonoprazan was administered after treatment. The pooled pathological diagnostic rate of MIAB for gastric SETs was 86.0% (95% confidence interval [CI]: 78.6–93.4; I² = 96%). The adverse event rate of the pooled population was 0.3% (95% CI: −1.15 – 1.76; I² = 0%). The acid secretion inhibitors significantly reduced postoperative bleeding (odds ratio: 0.06, 95% CI: 0.01– 0.66, P = 0.02). Perforation occurred in 0% and 2.6% of the local injection and non-local injection cohorts, respectively, and the pathological diagnostic rates were 50% and 66.7%, respectively.

Conclusion

MIAB is a reliable technique with a favorable diagnostic rate and few adverse events. Acid secretion inhibitors effectively prevent postoperative bleeding, but the effectiveness of local injection remains unclear. This technique is considered a robust tissue sampling method for gastric SETs.

References

None

Introduction

Endoscopic Vacuum Therapy (EVT) and Fully Covered Metal Stents (FC-SEMS) are standard treatments for anastomotic leaks (AL) following upper gastrointestinal (UGI) surgery^1-3. Recently, a new hybrid device combining an FC-SEMS with a polyurethane EVT sponge (VACStent) has been introduced, showing promising results⁴. However, there is not comparative data between VACStent and traditional endoscopic methods for ALs.

Aims & Methods

In this retrospective study, all patients with AL after UGI oncologic surgery who underwent EVT or VACStent at a tertiary academic center from March 2015 to September 2024 were included. The two endoscopic techniques were compared. The primary outcome was clinical success (CS), with secondary outcomes including number of devices used, treatment duration, and adverse events (AEs).

Results

Over 114 months, 103 patients [92 EVT, 11 VACStent] were enrolled. Of these, 74.8% had AL following Ivor-Lewis esophagectomy. The two cohorts did not differ significantly in terms of comorbidities, neoadjuvant treatment, leak number/median size, or rates of redo-surgery before endoscopic management. Both EVT and VACStent were used as first-line treatments in a similar rate of patients (79.3% vs. 90.9%, p=0.36).
The EVT group had a higher CS rate than the VACStent group, though this difference was not statistically significant (72.8% vs. 54.5%, p=0.21). Compared to the EVT group, the VACStent group required significantly fewer endoscopic sessions (1±0.7 vs. 3±2.5, p<0.001) and had a shorter mean treatment duration (12.1±11.2 vs. 14.1±12.9 days, p=0.62). Additionally, a significantly lower proportion of patients in the VACStent group required admission to the intensive care unit (ICU) (27.3% vs. 84.4%, p<0.001). In the EVT group, three adverse events were recorded (one bleeding episode and two sponge dislodgments), while no AEs were reported in the VACStent group (p=0.54) (Table 1).

Table 1 EVT vs ​VACStent: Outcomes

Conclusion

In this retrospective study, EVT and VACStent showed comparable success in treating post-UGI surgery leaks. VACStent was associated with a reduced need for ICU admission and fewer endoscopic sessions. Larger comparative data are warranted to define the role of VACStent in the treatment of leaks after UGI surgery.

References

1. Mandarino FV, Barchi A, Leone L, et al. Endoscopic vacuum therapy versus self-expandable metal stent for treatment of anastomotic leaks < 30 mm following oncologic Ivor-Lewis esophagectomy: a matched case-control study. Surg Endosc. 2023;37(9):7039-7050. doi:10.1007/s00464-023-10213-8
2. Mandarino FV, Barchi A, D'Amico F, et al. Endoscopic Vacuum Therapy (EVT) versus Self-Expandable Metal Stent (SEMS) for Anastomotic Leaks after Upper Gastrointestinal Surgery: Systematic Review and Meta-Analysis. Life (Basel). 2023;13(2):287. Published 2023 Jan 19. doi:10.3390/life13020287
3. Mandarino FV, Barchi A, Fanti L, et al. Endoscopic vacuum therapy for post-esophagectomy anastomotic dehiscence as rescue treatment: a single center case series. Esophagus. 2022;19(3):417-425. doi:10.1007/s10388-022-00912-x
4. Dell'Anna G, Fanti L, Fanizza J, et al. VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New "Kid on the Block" Who Marries the Best of Old Techniques-A Review. J Clin Med. 2024;13(13):3805. Published 2024 Jun 28. doi:10.3390/jcm13133805

Introduction

Current guidelines provided information on the management of patients with gastrointestinal bleeding, in particular focusing on admission, endoscopic management and medical treatment during the hospital stay. So far, 11-15% of patients treated for GIB required a new hospitalization for a new bleeding episode.

Aims & Methods

The aim of the study is to verify if the management in a dedicated practice after hospital discharge for gastrointestinal bleeding reduces further bleeding and costs. This is an ambispective cohort single center study, including patients observed between May 2022 and September 2023 in our clinical practice dedicated to gastrointestinal bleeding. We enrolled consecutive patients with overt gastrointestinal bleeding or iron deficiency anemia affected by vascular lesions. The effectiveness was defined as a composite endpoint including iron supplementation, blood transfusion, medical treatment and number of hospital stay. Costs were evaluated starting from Diagnosis Related Groups (DRG) codes. The cost effectiveness analysis and ICER has been calculated using the ICERconf.EXE software (Software Prescriptions, c/o Bob Obenchain, California, USA).

Results

In our institute 602 patients with gastrointestinal bleeding were evaluated between May 2022 and September 2023, of these 79 were included in the study. The mean age was 73.8 years (SD±10,8), 46% were female. The source of bleeding was angiodysplasia in 63% of patients, GAVE in 9% (Gastric Antral Vascular Ectasia), erosions in 9%. After the introduction in the dedicated practice, the re-bleeding decrease from 1.3 episodes to 0.2 episodes, p<0.001. The cost average after the practice was 4074 euro (SD ±5485), the average cost before the practice was 4885 euro (SD ±4567), it has been observed a cost saving after the management in the dedicated practice, C diff= -751 euro. The average effectiveness after practice was 8.7 (SD±1.06) and the average effectiveness before the practice was 7.3 (SD ±1.3) with the E diff= 1.47, p<0.001.

Conclusion

The dedicated practice for patients with gastrointestinal bleeding provides effectiveness in reducing transfusion, iron supplementation and hospitalization with a consistent cost reduction.

Introduction

Peroral endoscopic myotomy (POEM) is a less invasive endoscopic treatment for stenotic diseases caused by oesophageal motility dysfunction. During this procedure, the insufflation gas supplied from the endoscope migrates to the abdominal cavity, resulting in pneumoperitoneum. For excessive pneumoperitoneum, transabdominal puncture should be performed to rapidly decrease the intraabdominal pressure. However, the timing of puncture depends subjectively on the operator’s decision.

Aims & Methods

In this study, we retrospectively analysed the factors leading to pneumoperitoneum and clarified the objective indicators to determine the timing of abdominocentesis. A total of 100 consecutive patients who underwent POEM at our hospital from October 2018 to December 2023 were included. In univariate analyses, patient-related (age, sex, body surface area [BSA], body mass index), disease-related (diagnosis, preoperative Eckardt score), and treatment-related factors (operator's POEM experience, myotomy length, peak end-tidal carbon dioxide concentration [ETCO₂]) were compared between Puncture and Nonpuncture groups. In these parameters, sex and BSA, which correlated with the intraabdominal space, and factors that were supposed to influence the severity of pneumoperitoneum and the need for subsequent abdominocentesis by showing p-values of less than 0.1 were enrolled for subsequent multivariate analyses.

Results

The mean age was 58 (standard deviation [SD], 19) and 51% of them were male. The mean Eckardt score was 6 (SD, 3). Most patients (n = 92, 92%) were diagnosed with oesophageal achalasia. The mean procedure time was 88 min (SD, 35 min). Abdominocentesis was performed in 65 patients (68%), who were allocated into the Puncture group. In the univariate analyses, the peak ETCO₂ was significantly higher in the Puncture group than in the Nonpuncture group (p <0.01). In the multivariate analyses using sex, BSA, and the peak ETCO₂, high peak ETCO₂ was a single independent factor associated with abdominocentesis (odds ratio = 1.25, 95% confidence interval: 1.11–1.41, p <0.01). The receiver operating characteristic curve indicated that the two groups were divided with a maximal area under the curve (0.76) when a cut-off value of the peak ETCO₂ was set at 44.5 mmHg (sensitivity, 0.79; specificity, 0.65).

Conclusion

This study demonstrated that the intraoperative ETCO₂ level was a significant independent factor related to severe pneumoperitoneum in POEM, and 45 mmHg of peak ETCO₂ was an optimal cut-off value to differentiate the Puncture group from the Nonpuncture group. This result should be clinically useful as an objective reference to determine abdominocentesis in patient with pneumoperitoneum due to CO₂ leakage to the abdominal space.

Introduction

​Endocytoscopy (ECS), an ultrahigh-magnification contact-type endoscopy, enables real-time visualization of gastrointestinal mucosal and neoplastic cells. As a result, ECS enhance diagnostic precision as a form of optical biopsy. However, the reliability of ECS diagnosis is contingent upon adequate staining, which remains a considerable challenge in the stomach due to the abundance of mucus and inflammatory exudates that hinder optimal visualization. Weak vital staining can easily reduce the reliability of ECS diagnosis. Texture and Color Enhancement Imaging (TXI), a digital image enhancement modality developed by Olympus, enhances three key imaging elements—brightness, texture, and color tone—to optimize lesion visualization even under suboptimal staining conditions. Consequently, TXI may augment the diagnostic utility of ECS.

Aims & Methods

The aim of this study was to evaluate whether TXI enhances the diagnostic performance of ECS in early gastric cancer. Twenty-eight patients with 30 gastric cancers scheduled for magnifying endoscopic examination at Nippon Medical School Tama Nagayama Hospital between February 2024 and March 2025 were prospectively enrolled. All ECS procedures were performed with GIF-H290EC (Olympus Co., Tokyo, Japan) and the video processors EVIS X1 (Olympus Co., Tokyo, Japan). For in vivo dyeing, double staining with crystal violet and methylene blue was used. ECS was performed with and without TXI in both cancer and non-cancerous legions. ECS observation is performed by first taking photographs without TXI, and then taking photographs of the same area using the TXI. From each lesion, five ECS images with and without TXI were selected, resulting in a blinded and randomized image catalog (comprising 300 images from 30 gastric cancers and 280 images from 28 non-tumor areas). Two endoscopists independently assessed the images using a numerical rating scale (NRS, 0–10) to evaluate the visibility of nuclear atypia and structural cellular atypia. Diagnostic accuracy was assessed against pathological diagnosis as the gold standard. ECS diagnoses were rendered based on previously established criteria, wherein lesions exhibiting high-grade atypia were classified as cancer (Kaise M, et al. Endoscopy. 2015).

Results

The overall accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for EGC diagnosis by the two endoscopists were 82.5%, 84.3%, 80.7%, 81.3%, and 83.8%, respectively. The rate of interobserver agreement between the two endoscopists was high, with a kappa coefficient of κ = 0.797. Notably, diagnostic accuracy was significantly higher in the TXI images compared to the non-TXI images (85.2% vs. 79.0%, p = 0.0027). While the NRS scores for structural atypia did not differ significantly between the TXI and non-TXI images (4.90 vs. 4.87, p = 0.61), the NRS scores for nuclear atypia were significantly elevated in the TXI images (6.88 vs. 5.88, p < 0.0001).

Conclusion

​The integration of TXI with ECS significantly enhances the visualization of nuclear atypia and improves diagnostic accuracy in the diagnosis of gastric cancer. This synergistic approach facilitates superior optical biopsy capabilities, enhancing its clinical utility in the endoscopic diagnosis of early gastric cancer.

References

Kaise M, Ohkura Y, Iizuka T, Kimura R, Nomura K, Kuribayashi Y, et al. Endocytoscopy is a promising modality with high diagnostic accuracy for gastric cancer. Endoscopy. 2015;47:19–25.

Introduction

Barrett’s esophagus (BE) is known to be a precursor of esophageal and gastroesophageal junctional adenocarcinoma¹. Adenocarcinoma of the esophagus based on BE is still relatively rare in Japan, but the Westernization of dietary habits, the increase in obese patients, and the eradication of Helicobacter pylori (HP) infection may increase the number of cases in the future. In Japan, the prevalence of long-segmented BE (LSBE), which is common in the Western world, is relatively low, whereas SSBE is frequently observed². Atrophic gastritis (AG) caused by HP infection is also frequently observed in Japan, and the diagnosis of Japanese SSBE may be modulated by HPinfection/AG. In this study, we retrospectively investigated whether the morphology of SSBE could be influenced by HP status.

Aims & Methods

In our institution, 60 patients who had endoscopic ultra-short segmented Barrett’s esophagus (USBE; length of <1cm) were retrospectively collected and divided into two groups: 30 cases with AG caused by current HP infection (AG group) or without AG (non-AG group). As patient characteristics, we investigated age, sex, presence of reflux esophagitis (RE), presence of hiatus hernia, and use of proton pump inhibitor (PPI) therapy from the medical records. To objectively evaluate the roughness of the SCJ, we compared the morphology of USBE by measuring the respective perimeters of EGJ and SCJ, followed by the calculation of the SCJ/EGJ ratio. As a sub-analysis in the AG group, the SCJ/EGJ ratio was similarly compared in terms of the degree of AG (closed-type, n = 3; open-type, n = 27) according to the Kimura-Takemoto classification.

Results

In terms of patient characteristics, the median age was higher in the AG group than in the non-AG group (72 years old vs. 49 years old, p <0.001), and RE was less common in the AG group than in the non-AG group (3% vs. 36%, p = 0.004). There were no statistical differences between the two groups in sex, presence of hiatus hernia, and use of PPI. The mean SCJ/EGJ ratio was significantly higher in the AG group than in the non-AG group (2.26 vs. 1.43, p <0.001). In the sub-analysis, the mean SCJ/EGJ ratio was likely to be higher in open-type atrophy than in closed-type atrophy (2.33 vs. 1.58, p = 0.092).

Conclusion

In endoscopically diagnosed USBE, the circumference of SCJ appeared rough in the AG group, which suggested that the morphology of BE is influenced by HP infection and subsequent AG development. Particularly in Japan, simple rough margins of SCJ influenced by HP/AG may be estimated as USBE. In diagnosing BE, the morphological characteristics of SCJ and the HP/AG status should be taken into consideration.

References

1. Haggitt RC et al. Barrett's esophagus, dysplasia, and adenocarcinoma. Hum Pathol. 1994; 25: 982-93.
2. Manabe N et al. Does short-segment columnar-lined esophagus elongate during a mean follow-up period of 5.7 years? Dig Endosc. 2011; 23: 166-72.

Disclosure

There is no conflict of interest in this study.