Introduction

Currently, endoscopic retrograde appendicitis therapy (ERAT) is indicated only for acute uncomplicated appendicitis, though its utility can be extended to patients who are poor surgical candidates in more complex appendiceal disease such as those with periappendiceal abscess. Current treatments of periappendiceal abscess include emergency surgery, nonsurgical management with or without percutaneous drainage, and interval appendectomy after nonsurgical management. Herein, we highlight the utility of ERAT, which allows for interventional, noninvasive management of periappendiceal abscess without surgery.

Aims & Methods

The aim of this study was to evaluate the safety and efficacy of ERAT for treating periappendiceal abscess.
Twenty-four consecutive periappendiceal abscess patients were evaluated between May 2017 and May 2022 at three tertiary care Hospitals in China. The diagnosis of periappendiceal abscess was confirmed by direct colonoscopy imaging and computed tomography (CT) and/or ultrasonography (US). The baseline characteristics of all the patients, procedure success rate, procedure time, postoperative length of hospital stay, complications, and recurrence rate were recorded.

Results

The success rate of ERAT was 95.8% (intubation failed in one patient due to the closure/blockage of the appendix opening). All the patients (100%) patients had abdominal tenderness, 56. 5% had abdominal rebound pain, 21.7% had fever, and 86.9% patients had elevated white blood cells before the ERAT. The mean procedure time was 33.79 minutes with standard deviation (SD) of 17.1 min. The mean length of postoperative hospital stay was 5.4 (SD 2.6) days. Time to relief of abdominal pain after the ERAT was 28.2±19.4 hours. After the ERAT procedure WBC get back to normal range in 2.2±1.3 days. No complication observed in any of the patient. Antibiotics were routinely administered for 3 days after the ERAT. We followed up the patients at 3, 6, 12, 24 and 36 months respectively. Recurrence occurred in 8.7% of the patents at mean 26.9 (SD 10) months of follow-up.

Conclusion

Preliminary evidence suggests that ERAT is safe and effective alternative option for treating periappendiceal abscess, making it a valuable addition to the armamentarium of interventional endoscopy. The practice of ERAT currently remains predominantly limited to the Eastern world. As the treatment paradigm of appendicitis evolves, it is crucial that novel techniques such as ERAT be evaluated at a global scale alongside the evolving standard of care therapies.

Disclosure

None to declare

Introduction

The purpose of this study is to compare the efficacy and clinical outcomes of simplified endoscopic retrograde appendicitis treatment and Conventional endoscopic retrograde appendicitis treatment for uncomplicated acute appendicitis patients.

Aims & Methods

The simplified endoscopic retrograde appendicitis therapy(SERAT) refers to the simplification of the operation process on the basis of conventional endoscopic retrograde appendicitis treatment(ERAT), without the need for appendicography and general anesthesia. We used propensity score matching (1:1) to compare the application of SERAT and ERAT in uncomplicated acute appendicitis patients among three hospitals from May 2017 to Jan 2022. Among 614 hospitalized uncomplicated acute appendicitis patients, 286 underwent SERAT (Group A), and 254 patients underwent ERAT (Group B). In order to adjust for baseline differences and select bias, treatment results and complications were compared after propensity score matching.

Results

After 1:1 PSM, 198 well matched patients in each group were evaluated. The median operation time for the SERAT group was 26.4 ± 7.5 minutes, while for the ERAT group, it was 41.3 ± 15.5 minutes. The difference between the two groups was statistically significant. There was no significant difference in the success rate of intubation, time to abdominal pain relief, duration of normalization of inflammatory markers (including WBC count and CRP level), and length of hospitalization between the SERAT and ERAT groups (P=0.456, P=0.265, P=0.357, P=0.156, respectively). The median hospitalization cost in the SERAT group was 6836.9 RMB, significantly lower than the ERAT treatment group's hospitalization cost of 113371.5RMB. The follow-up recurrence rate in the SERAT group was 9.13%, higher than that in the ERAT group, which was 6.91%.

Conclusion

Compared with conventional ERAT, the simplified ERAT is technically feasible for the treatment of uncomplicated acute appendicitis patients. SERAT can reduce hospitalization costs but to some extent increase readmission rates within an acceptable range.

Disclosure

None

Introduction

Mediastinal lesions develop from structures located in the mediastinal compartments and the paravertebral areas. The diagnosis of these lesions is primarily based on imaging studies such as computed tomography and magnetic resonance imaging, which confirm the presence of the lesions and suspected metastatic disease

Aims & Methods

This study aims to assess the factors that determine the diagnostic accuracy and yield of endoscopic ultrasound (EUS) in diagnosing mediastinal lesions. This multicenter study involved a list of centres providing EUS services across ten countries all over the globe. The appropriate information was collected regarding EUS-FNA and EUS-FNB procedures, including nature of the lesion, needle types, needle passes, and complications of the techniques. The frequency/percentage conveyed data on the qualitative variables. The p-values were obtained using the Chi-square two-tailed exact test. The significance of the analysis was defined as p<0.05. All the syntheses were performed using the Statistical Package for the Social Sciences (SPSS version 27; SPSS Inc., Chicago, IL).

Results

A total of 439 participants were involved in this study, 255 (58.1%) males and 184 (41.9%) females, with a mean age of 55.7314.93 years. The average accuracy from the valid matched cases between EUS, cytopathy, and final diagnosis (300 out of 331) was 90.63%. EUS-FNA and EUS-FNB diagnostic yield was influenced by needle types, needle size, number of needle passes, and lesion size. Needles with smaller diameters (22G) offered greater diagnostic yield than needles with larger diameters (19G). However, the diagnostic matching accuracy of EUS in relation to needle sizes was statistically insignificant (p= 0.774). A minimal number of needle passes (between 2 and 4) showed a higher diagnostic yield than a higher number of needle passes (>5) with more diagnostic matching accuracy (p = 0.009). EUS-FNB accounted for a 0.5% complication incidence rate each for fever, pain, thoracic pain, and hemorrhage. Patients undergoing EUS-FNA, EUS-FNB, or both procedural examinations had no significant complications (p = 0.085) Table 1.

Table 1: Incidence rate of complications associated with EUS examination techniques

Conclusion

The diagnostic yield of EUS procedures is affected by needle types, number of needle passes, lesion size, and needle size. Besides, EUS-FNA and EUS-FNB are infrequently associated with serious complications, these techniques are safe and offer higher diagnostic yield when utilised responsibly by endosonographers.

References

1- Gadour E, Awad A, Hassan Z, Shrwani KJ, Miutescu B, Okasha HH. Diagnostic and therapeutic role of endoscopic ultrasound in liver diseases: A systematic review and meta-analysis. World J Gastroenterol. 2024 Feb 21;30(7):742-758. doi: 10.3748/wjg.v30.i7.742. PMID: 38515947; PMCID: PMC10950627.
2- Okasha HH, El-Meligui A, Pawlak KM, Żorniak M, Atalla H, Abou-Elmagd A, Abou-Elenen S, El-Husseiny R, Alzamzamy A. Practical approach to linear EUS examination of the mediastinum. Endosc Ultrasound. 2021 Nov-Dec;10(6):406-413. doi: 10.4103/EUS-D-21-00019. PMID: 34854401; PMCID: PMC8785678.

Introduction

Post surgical fistulas of the upper digestive tract(UDT) are associated with significant morbidity and mortality.

Aims & Methods

We aimed to evaluate the efficacy and safety of a primarily endoscopic management of post surgical fistulas of the UDT.
We performed a multicentre retrospective analysis in which 126 consecutive patients underwent primarily endoscopic management of post surgical fistula between March 2009 and January 2022. Factors associated with successful fistula closure and adverse events were evaluated. Qualitative variables were expressed as percentages and evaluated with Chi-square test. Quantitative variables were evaluated for normal and non-normal distribution. Non-normal quantitative variables were expressed as median (min-max) and evaluated with Mann-Whitney´s test. Logistic regression analysis was performed to determine factors associated with fistula closure and adverse events. P value <0,05 was considered statistically significant (IBM SPSS 28).

Results

The median age was 57(17-89) years and 73(60%) patients were female. Main Indications for surgery were obesity in 73(58%) and cancer in 46(36%) (of which 32(70%) were gastric cancer). The median time between surgery and fistula diagnosis was 7(1-387) days. Average size of fistula orifice was 7(1-30)mm.
Fistulas were located in the esophagus in 8 patients (6.3%), gastric cardia in 46 (36.5%), stomach non-cardia in 21 (16.7%), esophago-gastric or esophago-jejunal anastomosis in 9 (7.1%), gastro-jejunal anastomosis in 39 (31.0%), small intestine in 2 (1.6%) and unknown in 1 (0.8%).
Endoscopic interventions included placement of a covered metallic stent in 98(78%) patients (fully-covered n=46, partially covered n=37, both fully and partially covered n=15), clips in 58 (47%) patients (OTSC n=37, TTSC n=17, both OTSC and TTSC n=4) and argon plasma in 16(13%) patients.
Early adverse events (<1week) occurred in 22(17%) and included stent migration (n=10), sepsis (n=6), gastrointestinal bleeding (n=5) and death (n=1). Late adverse events occurred in 31(20%) patients, namely stricture (n=11), mucosal overgrowth (n=6), migration (n=4), vomiting (n=3), stent fracture (n=2), perforation and right hemicolectomy (n=1) and death (n=4). After a median follow up of 25 (1-147) months, 32(25%) died, but only 15(12%) due to fistula (3 due to aorto-esophageal fistula and the others due to sepsis), 12(10%) due to neoplasia and 5 due to other causes.
Need for surgical reinterventions (p=0.002) was associated with early adverse events. Late adverse events were less frequent in patients with clip placement (p=0.011).
Clinical success defined as definitive fistula closure was documented in 106(84%) patients after a median of 8(1-192) weeks and required a median of 3(1-13) endoscopies. Factors predictive of fistula closure were female gender (p=0.01), indication for surgery (p=0.02), lower C reactive protein(p=0.003), lower urea (p=0.006), lower AST(p=0.003) and lower ALT(p=0.002).

Conclusion

The primarily endoscopic approach to management of UDT post surgical fistulas was clinically successful in >80% of the patients with a good safety profile.

Introduction

Endoscopic submucosal dissection (ESD) has become a common treatment method for superficial esophageal cancer, allowing complete resection and accurate postoperative pathological evaluation, especially for relatively larger lesions^{1, 2}. However, resection of larger lesions, especially circumferential lesions, can be time-consuming and challenging. The resected tissue can obstruct the esophageal lumen, leading to limited working space and poor visibility, thereby increasing the risk of adverse events such as perforation and muscular injury³. In recent years, several auxiliary traction techniques have been emerged, including positional adjustment traction, hemostatic clip elastic band traction, snare traction, line traction, and magnet anchor traction, which significantly improve the visibility of the submucosal layer during dissection and enhance the efficiency of the procedure ^4-5. Among these techniques, snare traction allows bidirectional traction through "push and pull" maneuvers, offering flexibility and practicality in clinical practice. However, due to the difficulty and limited cases of circumferential esophageal ESD, there is currently no published literature demonstrating the advantages of snare traction-assisted ESD over traditional ESD techniques.

Aims & Methods

This study aims to investigate the efficacy and safety of snare traction assisted ESD for the management of circumferential superficial esophageal cancer. A total of 68 patients who underwent ESD for circumferential superficial esophageal cancer were included in this study. All the patients were divided into two groups based on whether the snare traction was used or not; the snare traction group (S-ESD, group n=35) and the control group (C-ESD, group n=33).

Results

There was no significant difference in the size of the resected area between the groups [21.98 (18.30, 27.00) cm² vs 24.00 (15.28, 30.72) cm², P=0.976]. The snare traction group had a shorter dissection time [92.00 (74.00, 121.00) min vs 110.00 (92.50, 137.00) min, P=0.017] and a faster resection speed [0.28±0.13 cm²/min vs 0.22±0.11cm²/min, P=0.040] compared to the control group. There were no statistically significant differences between the two groups in terms of hospital stay, cost, en bloc resection rate, R0 resection rate, curative resection rate，bleeding rate, perforation rate, stricture rate, and recurrence rate (P>0.05).

Conclusion

Snare traction-assisted ESD is a safe and efficient approach for the treatment of circumferential superficial esophageal cancer. Its advantages includes shorter procedure so the anesthesia requirement, clear operative filed view, improved mucosal dissection efficiency, simple, and easily accessible equipment.

References

1 Ishihara R, Arima M, Iizuka T et al. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer. Dig Endosc. 2020; 32: 452-93.
2 Draganov PV, Wang AY, Othman MO, Fukami N. Aga institute clinical practice update: Endoscopic submucosal dissection in the united states. Clin Gastroenterol Hepatol. 2019; 17: 16-25.e1.
3 Zhang W, Zhai Y, Chai N et al. Endoscopic submucosal tunnel dissection and endoscopic submucosal dissection for large superficial esophageal squamous cell neoplasm: Efficacy and safety study to guide future practice. Surg Endosc. 2018; 32: 2814-21.
4 Fukami N. What we want for esd is a second hand! Traction method. Gastrointest Endosc. 2013; 78: 274-6.
5 Jin P, Yu Y, Fu KI, Yu DL, Li AQ, Sheng JQ. A new traction method with use of the snare as a "second hand" during endoscopic submucosal dissection. Endoscopy 2015; 47 Suppl 1 UCTN: E286-7.

Introduction

Gastric outlet obstruction (GOO) is a debilitating condition commonly caused by malignant or benign diseases, impairing gastric emptying and nutritional status. While surgical gastrojejunostomy (SGJ) has traditionally been the standard palliative approach, endoscopic ultrasound-guided gastrojejunostomy (EUSGJ) has recently emerged as a minimally invasive alternative. This systematic review and meta-analysis aimed to compare the efficacy and safety of EUSGJ versus SGJ for the management of GOO.

Aims & Methods

A systematic search of PubMed, Embase, Medline, and Cochrane Library was conducted to identify studies directly comparing EUSGJ and SGJ in adult patients with GOO. Nine retrospective studies comprising 1,086 patients (654 EUSGJ; 432 SGJ) were included. Primary outcomes included technical and clinical success, length of hospital stay (LOS), operative time, and overall complication rates. Secondary outcomes included infection, ileus, hemorrhage, perforation, and re-intervention. Meta-analyses were performed using fixed or random effects models depending on data heterogeneity.

Results

EUSGJ was significantly superior to SGJ in terms of technical success (OR = 0.16; 95% CI: 0.05–0.45; p = 0.0006), shorter operative time (MD = –96.89 minutes; 95% CI: –146.16 to –47.61; p < 0.00001), reduced postoperative LOS (MD = –4.79 days; 95% CI: –6.52 to –3.06; p < 0.0001), lower overall complication rates (OR = 0.24; 95% CI: 0.17–0.33; p < 0.00001), reduced postoperative ileus (OR = 0.07; 95% CI: 0.02–0.17; p < 0.00001), and fewer infections (OR = 0.17; 95% CI: 0.08–0.37; p < 0.00001). No statistically significant differences were found regarding clinical success, re-intervention, hemorrhage, or perforation.

Conclusion

EUSGJ demonstrates superior procedural outcomes and safety profiles compared to SGJ in the management of GOO and represents a valuable tool in expert hands. However, further prospective studies and randomized trials are necessary to validate these findings, assess long-term outcomes, and define its role within individualized patient care and clinical guidelines.

Disclosure

No conflict of interest

Introduction

To date, most of the endoscopic trainers are not constructed according to the actual gastric morphology. Therefore, we have developed a new simulator for endoscopic therapy technology, evaluated its efficacy and authenticity in endoscopic operation, and explored the learning curve of novice endoscopic physicians and the training effect.

Aims & Methods

According to the medical image data of actual gastric transverse plane, a relatively standard gastric morphological structure was made by using computer modeling and 3D printing technology. Different endoscopic procedures were simulated by adding different training modules in the structure. First of all, 30 endoscopists with different levels of experience were recruited for the test to evaluate the effectiveness of the trainer, later 20 novice endoscopists were selected for the learning curve test. Finally, 38 novice endoscopists were divided into group A (new simulator) and group B (traditional non-simulated stomach model) for simulated training to observe the technical progress of clinical gastroscopy.

Results

Endoscopists with different levels of experience in each group believe that the training device has high authenticity, substantial convenience, low physical and mental load, and high interest. The higher the level of endoscopists needs the less testing time. The effect of training for novice endoscopists reached the platform stage after 13 times (about 10 hours of training). The control experiment found that group A scored higher than group B in terms of familiarity with endoscopic instruments, understanding of gastric structure, and self-confidence in clinical examination, while there was no significant difference between the two groups in terms of understanding of working principles and proficiency in the operating process.

Conclusion

The novel simulator can truly simulate some endoscopic treatment techniques and distinguish the differences of endoscopists’ techniques. Meanwhile, training in the simulator can significantly shorten the cycle of skill improvement of novice endoscopists.

Disclosure

None