Introduction

Gastroenterology is a medical specialty that includes several areas of study. Endoscopy occupies a central role in professional practice, whether in hospitals or in the private sector. The quality of initial training and the different needs of trainees are key to the quality of care delivered to the population. This study aims to assess endoscopic training experience during fellowship.

Aims & Methods

This is a cross-sectional, multicenter study conducted on gastroenterology residents practicing endoscopy and in the final phase of their curriculum (6th, 7th and 8th semesters). Postgraduated doctors have been excluded from the study. An electronic survey made by Google Forms and was sent nationwide on January 9, 2024. The survey consisted of 42 questions divided into 3 parts: The first part focused on the participants' socio-demographic data and their endoscopic experience, the second part focused on the quality of training of core endoscopic skills (cognitive and motor skills) during fellowship where a 5-point Likert scale was used to express residents' satisfaction with their skills, ranging from 1="very dissatisfied", 2="dissatisfied", 3="neither satisfied nor dissatisfied", 4="satisfied" and 5="very satisfied". The third part included questions in which participants expressed their needs and expectations for improving their training in endoscopy. A statistical analysis using the Student-t test and the Fisher’s exact test were performed. P values of <0.05 were considered statistically significant. Data were analyzed using Jamovi (Version 2.3).

Results

We were able to collect data from 56 respondents. Most were female residents n=40 (71.4) with a mean age of 29.2 ± 2.5 years. The majority of fellows started practicing EGD in their 4th semester (91.1%), and colonoscopy in their 6th semester (57%). On average, the fellows are supervised by 5 senior doctors, including 2 who practice interventional endoscopy. Furthermore, 37.5% of participants report performing approximately more than 100 EGDs, 14.2% more than 100 colonoscopies, 80.4% report that they have performed less than 20 endoscopic variceal ligation and 14.3% have performed more than 10 polypectomies. An average rating score of 3.34 (1= very dissatisfied; 5= very satisfied) concerning the quality of training and feedback on cognitive aspects of endoscopy was found and we reported greatest emphasis for Procedure indication/contraindication and least on Capsule endoscopy interpretation.
The quality of training in technical aspects of endoscopy was rated higher (average rating score of 3.5). We reported greatest emphasis for Withdrawal/mucosal inspection and least on Esophageal dilation.
A significant association between motor skills and cognitive skills was found with a p<0.001.
Finally, to improve their training, 87.5% of respondents considered simulation to be important/very important, 98.2% of respondents intend to complete their endoscopy training at the end of their curriculum, and 87.5% are prepared to finance such a project (median: 1000 USD [1000;3000]).

Conclusion

Despite a significant improvement in training sites and technical facilities, training in endoscopy in healthcare institutions does not yet provide all the cognitive and technical skills required to enable fellows to be fully autonomous. With the development of endoscopic procedures, it seems essential for fellows to be able to perform more standard endoscopic procedures such as polypectomy and mucosectomy by the end of their curriculum. This may involve introducing regular endoscopy conferences and simulation training as a part of the curriculum.

Clinical Case Summary

A 68-year-old woman presented after 24 hours of painless jaundice, preceded by 48 hours of dark urine and pale stools without pruritis. No history of weight loss, recent foreign travel, or high risk behaviours. She denied any illicit drug or alcohol abuse. Her co-morbidities included pre-diabetes, and obesity and only took over-the-counter vitamin supplementation with no new or regular prescribed therapies. On clinical examination, she was fully alert with jaundice with no stigmata of chronic liver disease and haemodynamic stable.

Liver tests at presentation (normal in 2020) were ALT 766 U/L, AST 984 U/L, bilirubin 463, ALP 314 U/L. PT 35.3s, APTT 45.5s, TT 26.2s and albumin was 33 g/L. Haemoglobin (139 g/L), platelet count (158 x109/L), and normal eosinophil count (0.89 x109/L). Renal function was unremarkable. Arterial blood gas demonstrated a pH 7.4, Lactate 1.8, glucose 6. CT scan demonstrated moderate volume ascites and a grossly dilated gallbladder. No intra- or extra-hepatic duct dilatation and patent vasculature. Homogenous ANA 1:400, strongly positive SMA, polyclonal gammopathy (IgG 18.8, IgM 5.5, IgA 4.2) and negative AMA/ LKM. Viral hepatitis screen was negative. Given the severity of hepatic failure, she was referred for consideration of transplantation.

This lady presented with an acute hepatocellular pattern of liver injury with hepatic failure. It came to light that her injury was a consequence of exposure to ashwagandha. Although her exposure was in 2021, a latency period prior to drug-related injury is not unusual. Previous case series have shown similar patterns of injury with ashwagandha but no hepatic failure.

1. How do we overcome the challenges distinguishing drug-induced liver injury as a cause of acute hepatic failure, particularly when markers of alternative aetiology are present?
2. What is the role of steroids in patients ?
2. What is the relationship between DILI from herbal/ dietary supplementation and acute liver failure?

References

1. Katarey D, Verma S. Drug-induced liver injury. Clin Med. 2016;16(Suppl 6):s104-s109. doi:10.7861/clinmedicine.16-6-s104
2. Chalasani N, Bonkovsky HL, Fontana R, et al. Features and Outcomes of 899 Patients With Drug-Induced Liver Injury: The DILIN Prospective Study. Gastroenterology. 2015;148(7):1340-52.e7. doi:10.1053/j.gastro.2015.03.006
3. Paul S, Chakraborty S, Anand U, et al. Withania somnifera (L.) Dunal (Ashwagandha): A comprehensive review on ethnopharmacology, pharmacotherapeutics, biomedicinal and toxicological aspects. Biomed Pharmacother. 2021;143:112175. doi:10.1016/j.biopha.2021.112175
4. Mandlik Ingawale DS, Namdeo AG. Pharmacological evaluation of Ashwagandha highlighting its healthcare claims, safety, and toxicity aspects. J Diet Suppl. 2021;18(2):183-226. doi:10.1080/19390211.2020.1741484
5. Björnsson HK, Björnsson ES, Avula B, et al. Ashwagandha-induced liver injury: A case series from Iceland and the US Drug-Induced Liver Injury Network. Liver Int. 2020;40(4):825-829. doi:10.1111/liv.14393

Introduction

Insulinomas are rare, functioning neuroendocrine neoplasms that cause non-ketotic hypoglycemia due to hyperinsulinism. Surgery is considered the gold-standard treatment, although endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has been recently described as a less invasive, efficient therapeutic option for these tumors. In this study, we aim to compare post-procedural outcomes of surgical resection versus EUS-RFA for pancreatic insulinomas.

Aims & Methods

All patients who underwent surgical resection or EUS-RFA for pancreatic insulinoma in our Institution were included in the study, and data from all procedures were retrospectively recorded and statistically analyzed. EUS-RFA was indicated for all subjects either unfit for surgery or unwilling to undergo surgical treatment. Patients’ baseline characteristics, location, size of insulinomas, procedural time, and intra- and postoperative outcomes were compared.

Results

From April 2012 to July 2022, 11 and 10 patients with pancreatic insulinoma underwent surgical resection and EUS-RFA, respectively. The median age was 65.5 (51-84) and 37 years (28-72, p<0.001) for the EUS-RFA and surgery cohorts, respectively. As a whole, 15 (71.4%) out of 21 were female. The median tumor size was 15mm (8-30) for the surgical group and 11mm (8-19) for the EUS-RFA group (p=0.17). The majority of the insulinomas were located in the pancreatic body (28.6%) and tail (28.6%), with no statistical difference between the two groups (p=0.16). Operative time was significantly longer in the surgical population (280min, 120-372) as compared to the endoscopic one (28min,18-40, p<0.001). Clinical success, defined as the normalization of glucose blood levels, was reached in all cases. The complication rate was significantly higher in the surgical group compared to the endoscopic group (7-63.6% vs 1-10%, p=0.01). Specifically, 7 patients in the surgical cohort developed a pancreatic fistula while one patient in the EUS-RFA population had self-limiting bleeding after the procedure. One patient of the surgical cohort underwent reoperation for an infected abdominal fluid collection.

Table 1. Characteristics of patients classified by treatments.

Conclusion

As compared to surgical resection, EUS-RFA for pancreatic insulinomas may be considered a safe and efficient treatment option with a shorter operative time and a lower rate of related complications. Prospective comparative studies are needed to ascertain the role of EUS-RFA as a treatment of choice for selected patients with pancreatic insulinoma.

References

Fahmawi Y, Mehta A, Abdalhadi H et al. Efficacy and safety of endoscopic ultrasound-guided radiofrequency ablation for management of pancreatic lesions: a systematic review and meta-analysis. Transl Gastroenterol Hepatol. 2022 Jul 25;7:30.
Zhao YP, Zhan HX, Zhang TP et al. Surgical management of patients with insulinomas: Result of 292 cases in a single institution. J Surg Oncol. 2011 Feb;103(2):169-74.

Introduction

Endoscopic submucosal dissection (ESD) is a highly effective and safe technique for the resection of superficial colorectal neoplasms, but it can still be technically challenging for lesions in contact with or invading the appendiceal orifice. Until recently, appendicular lesions were considered unresectable or difficult to resect by endoscopy because of the high risk of incomplete resection, perforation or acute appendicitis. Small studies have reported ESD feasibility and efficacy in this particular context, including for lesions deeply invading the appendix. However, strong data about these more complex resections is lacking and the best management strategy for this kind of lesion remains a matter of debate, with upfront surgery still being the first-choice treatment in most western countries.

Aims & Methods

With the present study, we aimed to assess and report the outcomes of ESD for the treatment of lesions in contact with or invading the appendiceal orifice. We prospectively collected data of ESD procedures for appendiceal neoplasia in a multicenter prospective register. En Bloc R0 resection rate was the primary outcome. Morbidity and additional surgery were also reported.

Results

A total of 112 patients were included, comprising 47 (42%) with previous appendectomy. Fifty-six lesions (50%) were type 3 according to Toyonaga classification (15 (13.4%) post-appendectomy). En-bloc and R0 resection rates were 86.6% and 80.4%, with no significant difference associated with different grades of appendiceal invasion (p=0.9 and p=0.4, respectively) or history of previous appendectomy (p=0.3 for both). Curative resection rate was 78.6%. Additional surgery was performed in 16 (14.3%) cases, with 10/16 (62.5%) corresponding to Toyonaga type 3 lesions (p=0.04). This included the treatment of 5 (4.5%) cases of delayed perforation and 1 acute appendicitis. A second case of acute appendicitis and 1 of delayed hemorrhage also observed, both treated conservatively.

Conclusion

To our knowledge, this is the largest reported series of ESDs for the treatment of appendicular lesions. Our results show that ESD is safe and effective in this context, and should thus be considered as a valuable treatment option. New traction strategies and devices should make it progressively less technically challenging and more widely accessible.

Introduction

The need for endoscopic necrosectomy (EN) has increased dramatically, as endoscopic EUS-guided drainage has become gold standard for treatment of pancreatic walled-off-necrosis (WON)[1,2]. Although snares and baskets are commonly used in EN procedures, they can be ineffective and dedicated instruments specifically designed for EN are scarce. Recently, an innovative powered endoscopic debridement system (EndoRotor, Interscope Inc., Northbridge, MA, USA) designed to excise and remove necrotic tissue within the WON was introduced specifically for EN with promising results[3,4]. While the first generation EndoRotor catheter was limited to 3.2 mm diameter, a larger catheter that fits into a large-channel gastroscope with a working channel of 6.0 mm has now been introduced. This study evaluates the clinical outcomes, safety, and feasibility of the novel 6.0 catheter for EN of WON.

Aims & Methods

This retrospective study was performed using prospectively collected data from all patients who underwent EN with the 6.0 catheter between December 2021 and March 2023 at Gastro Unit, Copenhagen University Hospital Hvidovre, a tertiary referral center in Denmark. All patients with symptomatic WON and need for necrosectomy were considered eligible for this study. Technical feasibility, safety, and clinical outcomes were evaluated.

Results

Sixteen patients underwent a total of 25 EN procedures with the 6.0 catheter. The mean age of the patients was 51.8 years (SD 17.7 years) and 11 (68.8%) were male. The etiology of the acute necrotizing pancreatitis was alcohol in 4 patients (25.0%), gall stones in 7 patients (43.8%), post-endoscopic retrograde cholangiopancreatography (ERCP) in 3 patients (18.8%), and idiopathic in 2 patients (12.5%). The mean size of the WON was 27.5 cm (SD 10.5 cm). The median computed tomography severity index (CTSI) was 8.5 (P25-P75: 6.0-9.0) and median modified CTSI (mCTSI) was 9.0 (P25-P75: 8.0-10). Two patients did not achieve clinical resolution (12.5%), as they died from multisystem organ failure before resolution of the WON was achieved. The median length of stay in hospital for the patients who achieved clinical resolution was 56.0 days (P25-P75: 36.5-96.0 days) and the median number of necrosectomy procedures performed to achieve clinical resolution was 5.0 (P25-P75: 2.0-8.5). All patients had EN procedures performed with snares in addition to the procedures with the powered debridement system. Five patients had necrosectomy performed with the 3.2 catheter (31.0%) as well as the 6.0 catheter. The median duration of EN with the 6.0 catheter was 60.0 minutes (P25-P75: 45.0-100 minutes) per procedure.
A device-related adverse event was noted in one instance (4.0%). The patient exhibited symptoms of peritoneal reaction in the hours following the procedure, which may have been caused by perforation of the WON into the peritoneal cavity. The patient was treated with laparoscopic peritoneal lavage and drainage and recovered without further interventions. No other procedure-related adverse events were identified. Malfunction of the catheter was observed in 7 procedures (28.0%).

Conclusion

To perform necrosectomy procedures optimally, dedicated endoscopic instruments designed for debridement of pancreatic WON are required. This study suggests that EN with the novel EndoRotor 6.0 catheter is safe and feasible with promising clinical results for EN of pancreatic WON. To assess the efficacy relative to standard techniques, comparative studies are warranted.

References

[1] Karstensen JG, Novovic S, Hansen EF, et al. EUS-guided drainage of large walled-off pancreatic necroses using plastic versus lumen-apposing metal stents: A single-centre randomised controlled trial. Gut 2022; 0: 1–7. doi:10.1136/gutjnl-2022-328225
[2] Ebrahim M, Werge MP, Hadi A, et al. Clinical outcomes following endoscopic or video-assisted retroperitoneal management of acute pancreatitis with large (>15 cm) walled-off pancreatic necrosis: Retrospective, single tertiary center cohort study. Dig Endosc 2022; 34: 1245–1252. doi:10.1111/den.14295
[3] Stassen PMC, de Jonge PJF, Bruno MJ, et al. Safety and efficacy of a novel resection system for direct endoscopic necrosectomy of walled-off pancreas necrosis: a prospective, international, multicenter trial. Gastrointest Endosc 2022; 95: 471–479. doi:10.1016/J.GIE.2021.09.025
[4] Wiel SE van der, May A, Poley JW, et al. Preliminary report on the safety and utility of a novel automated mechanical endoscopic tissue resection tool for endoscopic necrosectomy: a case series. Endosc Int Open 2020; 08: E274–E280. doi:10.1055/A-1079-5015