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

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

Gastric endoscopic submucosal dissection (ESD) has become increasingly popular worldwide as a less invasive curative treatment for early gastric cancer. However, ESD requires highly endoscopic technical skills, and it is important for trainees to develop effective training methods for ESD. ESD training is generally conducted using extracted porcine digestive tracts, but there are several issues regarding ethics, costs, infection, and logistics. In collaboration with KOTOBUKI Medical, we have developed the G-Master, a training model that can simulate ESD in several locations in the stomach. Since G-Master uses plant-derived mucous membrane sheet, there is no contamination and training can be easily performed using endoscope units and devices that are commonly used in clinical practice. Although the G-Master has enabled pre-training before actual ESD at facilities that have adopted it, it is unclear whether it contributes to the improvement of endoscopic technical skills of trainees. In this study, we clarified the usefulness of the G-Master training for inexperienced ESD trainees.

Aims & Methods

The ESD data were collected for the first through fifth gastric ESD cases performed from March 2018 through February 2022 by 15 ESD-inexperienced endoscopists at five participating centers. The ESD data were divided into two groups, one with G-Master training and one without G-Master training and the endpoints were compared retrospectively. The endpoints were procedure speed, perforation rate, operator changing rate, and en bloc resection rate, endoscopists experiences, and clinicopathological features. The resection speed was calculated as the resected area of the specimen divided by the procedure time (mm2/min). The group with G-Master training was defined as the group of trainees who always had at least one ESD training session with G-Master before each ESD. The group without G-Master training was defined as the group of trainees who had never done G-Master ESD training.

Results

A total of 75 gastric ESD cases were enrolled, with 25 cases in the group with G-Master training performed by 5 ESD-inexperienced endoscopists and 50 cases in the group without G-Master training performed by 10 ESD-inexperienced endoscopists. There was no difference between the two groups in endoscopists experiences including the years after graduation from medical school, the number of esophagogastroduodenoscopies and colonoscopies performed, and clinical features of gastric ESD cases including the location or size. In the group with G-Master training, the median procedure speed for all cases was significantly faster (with vs without G-Master: 13.1 mm2/min vs. 8.1 mm2/min, p>0.001). And the procedure speed of the training group was linearly improved from the initial to the last cases (with vs without G-Master: initial case; 11.8 mm2/min vs 8.5 mm2/min, last case; 23.1 mm2/min vs 12.0 mm2/min). Additionally, the rates of perforation (0 case (0%) vs 1 case (2%)) and operator change to expert (5 cases (20%) vs 15 cases (30%)) were lower. There was no difference in en bloc resection rate between the two groups.

Conclusion

It was suggested that performing G-Master training before actual ESD could improve the endoscopic technical skills of trainees who are inexperienced in ESD.

Introduction

Esophageal or gastric perforation is associated with systemic inflammatory response syndrome (SIRS), which can lead to multi-organ dysfunction and mortality in up to 50% of cases. Endoscopic vacuum therapy involves the use of a catheter with a sponge attached to its distal end, connected to a machine that applies negative pressure, allowing for continuous drainage of the perforation site and potentially promoting healing of the transmural defect. Previous series have reported promising results, indicating the potential effectiveness of this therapy in managing esophageal perforations. To evaluate the efficacy of endoscopic vacuum treatment in patients with primary or secondary gastroesophageal perforations.

Aims & Methods

Single-center retrospective cohort study on patients treated for gastroesophageal perforation between March 2019 and September 2022. The inclusion criteria for the study were patients with gastroesophageal perforation resulting from spontaneous rupture or iatrogenic damage (post-surgical or post-endoscopic treatment). The primary outcomes of the study were the success rate of endoscopic therapy, the length of hospital stay, and the specific survival at 30 and 90 days. The success rate of endoscopic therapy was assessed by considering the treatment successful if it led to the resolution of the fistula following vacuum endoscopic therapy. Secondary endpoints included the need for intensive care unit (ICU) stay between the start of vacuum endoscopic therapy and the patient's discharge.

Results

27 patients, with a mean age of 69.8 years (95% CI 65.4-74.3), including 9 (33.3%) women, underwent endoscopic treatment with vacuum therapy for esophageal perforation. The causes of perforation were as follows: 6 (22.2%) cases were primary (Boerhaave syndrome), 15 (55.5%) cases were post-surgical (post-surgical anastomosis), and 6 (22.2%) cases were post-endoscopic treatment (endoscopic dilatation). Among the patients, 13 (48.1%) had previously undergone surgery for cancer, with 69.2% of them receiving intrathoracic stomach interposition reconstruction and the remaining patients undergoing reconstruction according to Roux-en-Y procedure. The treatment was successful in 21 (77.7%) patients, with a 14 days (9.0-24.4, 95% CI) median duration of treatment, and 4 (3-7, 95% CI) median number of endoscopic devices used per patient. One patient (3.7%) died within 30 days, and another one (3.7%) within 90 days. A total of 10 (38.4%) patients required an ICU stay, and there were no readmissions within 30 days. No procedure-related complication was reported.

Conclusion

In the current pilot study, the findings support the feasibility and safety of endoscopic vacuum therapy as a treatment modality for both primary and secondary gastro-esophageal perforations.

References

• Kuehn F, Schiffmann L, Rau BM, Klar E. Surgical endoscopic vacuum therapy for anastomotic leakage and perforation of the upper gastrointestinal tract. J Gastrointest Surg 2012
• Pattynama LMD, Eshuis WJ, van Berge Henegouwen MI, Bergman J, Pouw RE. Vacuum-stent: A combination of endoscopic vacuum therapy and an intraluminal stent for treatment of esophageal transmural defects. Front Surg 2023
• Luttikhold J, Pattynama LMD, Seewald S, et al. Endoscopic vacuum therapy for esophageal perforation: a multicenter retrospective cohort study. Endoscopy 2023

Disclosure

Dr Valente and Dr Arnelo are consultant to Boston Scientific. Dr Arnelo is Consultant to Ambu

Introduction

Although diagnosis of gastric intestinal metaplasia (IM) using image-enhanced endoscopy is spreading, it has the disadvantage that special training is required and the accuracy depends on individual ability and experience. Therefore, we developed and validated an artificial intelligence (AI) model for diagnosing IM, and subsequently, compared its diagnostic accuracy with that of endoscopists.

Aims & Methods

This study included 6,487 white-light endoscopic (WLE) images from 1,454 patients with histologically confirmed IM from a single tertiary referral center in Korea between 2016 and 2020 (training/validation/test set, n=5,764/650/91, respectively). Histopathological diagnoses, including the presence and grade of IM, were set as the gold standard. The performance parameters of the AI-assisted IM diagnostic (AI-IM) model were compared with those of visual diagnoses by independent endoscopists (11 experts and 20 non-experts).

Results

The AI-IM model showed an accuracy of 0.813 (95% confidence interval (CI), 0.718–0.887), sensitivity of 0.891 (95% CI, 0.788–0.955), specificity of 0.630 (95% CI, 0.424–0.806), area under the curve of 0.760 (95% CI, 0.659–0.843), and weighted average F1-score of 0.809 (95% CI, 0.680–0.897). On comparative analysis, the diagnostic accuracy of the AI-IM model was superior to both experts (0.711 [95% CI, 0.702–0.720], P=0.017) and non-experts (0.664 [95% CI, 0.654–0.673], P<0.001). Other parameters of performance were also found to be significantly better.

Conclusion

The AI-IM model shows favorable diagnostic accuracy compared to both experts and non-experts in diagnosing gastric IM based on WLE images.

Introduction

Capsule endoscopy (CE) is an important non-invasive diagnostic modality for the evaluation of small bowel and colon. However, in patients with gastrointestinal tract anatomy altered by surgical interventions, there can be a higher risk of incomplete examination of small bowel and colon.

Aims & Methods

The aim of our study was to evaluate the rate of complete examination and diagnostic yield of CE, in patients with previous gastrointestinal surgery, as well as the impact of endoscopic placement of CE using the AdvanCE device.
Retrospective, cohort study, including patients submitted to CE of the small bowel or colon, detailing patients with previous gastrointestinal surgeries and with endoscopic placement of CE.

Results

A total of 642 patients was included, 17 with previous gastrointestinal surgery (2.6%), from which 9 with gastric bypass and Y-de-Roux (with 3 having esophagojejunostomy and 6 gastrojejunostomy), 3 patients with Bilroth II, 2 with Bilroth I e 3 patients with sleeve gastrectomy.
Endoscopic placement of CE was performed at the discretion of the responsible gastroenterologist and occurred in 8 patients (1.2%). It was 13.3 times more likely to be performed in patients with previous gastrointestinal surgery (11.8% vs 1.0%, p=0.017).
In patients without endoscopic placement of CE, the rate of complete examination of the gastrointestinal tract, adequate bowel preparation and diagnostic yield was comparable between those with and without previous gastrointestinal surgery: 86.7% vs 85.3% (p=1.000), 73.3% vs 78.1% (p=0.751) e 40% vs 38% (p=0.875), respectively.
In patients with gastrointestinal surgery, the rate of complete examination of the gastrointestinal tract was comparable between patients with and without endoscopic placement of CE: 50.0% vs 86.7% (p=0.331). The rate of complete examination of the gastrointestinal tract, adequate bowel preparation and diagnostic yield was not influenced by the different types of surgery, considering patients with gastric bypass vs Y-de-Roux vs Bilroth II: 75.0% vs 80.0% vs 66.7% (p=0.915), 50.0% vs 60.0% vs 66.7% (p=0.902) e 25.0% vs 20.0% vs 66.7% (p=0.363), respectively.

Conclusion

CE is effective, even in patients with previous gastrointestinal surgery, with diagnostic yield and rate of complete examination of the gastrointestinal tract similar to other patients, regardless of the type of surgery. Endoscopic placement of CE with AdvanCE device does not seem to improve outcomes in patients with previous gastrointestinal surgery.