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

Esophageal anastomotic stricture is a common complication after esophagogastric anastomosis, primarily characterized by inability to eat or difficulty swallowing.

Aims & Methods

This study aims to compare the efficacy and safety of endoscopy radial incision (ERI) technique versus endoscopic balloon dilation (EBD) in treating refractory esophageal anastomotic strictures. A retrospective analysis was conducted on patients who underwent endoscopic treatment for esophageal anastomotic stricture from January 2020 to June 2024. Based on inclusion and exclusion criteria, data were collected and analyzed, including preoperative stricture duration, preoperative treatment history, pre-and postoperative swallowing difficulty symptoms (Barthe score), improvement in anastomotic diameter, and occurrence of intraoperative and postoperative complications, to assess efficacy and safety.

Results

A total of 109 patients were included in the study, with 46 in the ERI group and 63 in the EBD group. All patients successfully completed the endoscopic procedures. The average operation time for the ERI group was 10.15±5.23 minutes, with an average of 2.26±0.76 incisions made. No adverse events such as bleeding or perforation occurred in either group during or after the procedure. There were no significant differences in preoperative dysphagia score (3.58±0.76 vs. 3.22±0.63) or anastomotic diameters (0.30±0.02 vs. 0.29±0.03) between the two groups. On postoperative 1 week, 3 months, 6 months, and 1 year, the effective symptom relief rates for the ERI group were 100%, 76.1%, 47.8%, and 41.3%, respectively, while the effective symptom relief rates for the EBD group were 100%, 39.7%, 28.6%, and 20.6%.

Conclusion

The ERI technique is a safe and feasible method for treating refractory esophageal anastomotic strictures, with superior efficacy compared to EBD.

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

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

Peroral Endoscopic Myotomy (POEM) is an effective treatment for esophageal motility disorders, particularly achalasia. POEM also demonstrated a good safety and efficacy profile in patients with prior treatment failure (PTF). However, long-term data of POEM for this selective group have been underexplored. This study aims to compare long-term outcomes of POEM in patients with and without PTF.

Aims & Methods

This is a retrospective analysis of a prospectively maintained cohort of patients who underwent POEM for esophageal motility disorders at a single high-volume center between March 2012 and March 2024. Patients who had completed at least 6 months of follow-up were included. Baseline data included demographics, type of esophageal motility disorder, esophageal shape, and pre-POEM Eckardt score (ES). Procedural data included procedural time, adverse events and length of hospitalization. Follow-up data included clinical failure (defined as ES ≥ 4), gastroesophageal reflux disease (GERD) symptoms, erosive esophagitis > B grade at esophagogastroduodenoscopy (EGD) and acid exposure time (AET) > 6% at pH-impedance monitoring. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression to identify factors associated with clinical failure. A 1:1 PSM without replacement was performed, and weighted regression analyses were used to evaluate outcomes.

Results

595 patients underwent POEM during the study period. A total of 564 patients (median age 57 years, 57.3% male) with at least 6 months of follow-up after POEM for esophageal motility disorders (12.7% achalasia I, 76.6% achalasia II, 6.4% achalasia III, 4.2% other non-achalasia disorders) were included in the analysis. One-hundred eight (19.1%) patients had undergone previous treatments (37% Heller myotomy, 39% pneumatic balloon dilation, 15% POEM, 9% Botulinum toxin injection). No significant difference was observed in terms of median procedural time (70 minutes (IQR 55;85) vs 71 minutes (IQR 56;86)) and adverse events (4.6% vs 1.8%) between primary POEM patients and those with PTF (P = ns). Globally, over a median follow-up of 36 months (range 6-60), 72 (12.7%) clinical failures were reported. After matching, 130 patients (65 per group) were analyzed for clinical failure. In the matched cohort, clinical failure occurred more frequently in PTF patients compared to controls (24.6% vs 10.8%). In a weighted Cox regression model, PTF was associated with a significantly higher risk of clinical failure (HR 2.20; 95% CI 1.05–5.36; p = 0.04). Regarding reflux-related outcomes, no statistically significant differences were observed between groups after matching: clinical reflux (38.2% vs 30.3%, p = 0.41), severe esophagitis (34.2% vs 24.7%, p = 0.29), and pathological AET >6% (45.9% vs 45.9%, p = 1.00).

Conclusion

POEM remains a highly effective, safe and durable treatment option for esophageal motility disorders with optimal long-term outcomes. However, patients with PTF undergoing POEM had a significantly higher risk of clinical failure. These findings highlight the need for closer monitoring and potential enhanced interventions for these patients.

Introduction

Endoscopic ultrasound (EUS) has broadened its diagnostic and therapeutic scopes, as it is able to target lesions <3mm. High-frequency radial EUS-miniprobes exhibit procedural time reduction, improving image quality and maneuverability. EndoSound Vision System (EndoSound, Oregon, USA) is a new EUS (N-EUS) portable device that fastens onto a standard gastroscope, enabling a free working channel. It is an affordable alternative to conventional-EUS devices; and a promising opportunity to shorten the difficult EUS learning curve.

Aims & Methods

We aim to determine the feasibility and effectiveness of N-EUS in terms of anatomical structures appropriate identification in comparison with conventional-EUS. This prospective study included patients ≥18 years-old undergoing EUS evaluation in June-November 2023 by eight endoscopists from different institutions from South and North America. Patients underwent two consecutive procedures: First, a conventional EUS with a linear-array echoendoscope (Pentax EG38-J1OUT, Pentax Medical, Germany). Then, a different endoscopist performed EUS using the N-EUS coupled to a video gastroscope with therapeutic access (EG29-i10, Pentax Medical, USA). A post-procedure ad-hoc survey was completed by the second endoscopist, to assess N-EUS acceptability in terms of endoscopists’ experience using this device.

Results

Thirty-one patients underwent conventional EUS and N-EUS: 16/31 performed by first-time N-EUS users, 15/31 by endoscopists with prior N-EUS exposure, with median procedural times of 30 and 15 minutes, respectively (p=.04). Main EUS indication was chronic dyspepsia (35.5%). Identified structures during N-EUS were the liver/gallbladder/common bile duct (30/31, 96.8%), full pancreas (29/31, 93.5%), kidneys/left kidney (24/31, 77%; 13/15 endoscopists with prior exposure vs 11/16 first-time N-EUS users; p<.001), left adrenal gland (20/31, 64.5%). Gallbladder (GB) was unobserved in 8 cases, 7/8 had prior cholecystectomy. Evaluation position was 54.8% supine; 3/31 switched to left lateral. All procedures were completed with 100% clinical and technical success, requiring navigation changes in 51.6%, mainly in first-time N-EUS users (p=.001). FNB tissue sampling was achieved in 100% cases. Endoscopists’ experience was predominantly described as “meeting clinical expectations”. The ad-hoc survey showed high psychometrics, with homogeneity among surveyed endoscopists, without redundancy (Cronbach’s alpha of .91), and a good construct validity (Kaiser-Meyer-Olkin Criterion of .728 and Barlett´s test p-value =.0005). When comparing both procedures, appropriate identification of GB or lack of, full pancreas, left/both kidneys and left adrenal gland was 31/31 vs 30/31, 31/31 vs 29/31, 31/31 vs 24/31 (p=.0233), and 29/31 vs 20/31 (p=.0158), respectively. Considering conventional EUS as a gold standard, the observed agreement of N-EUS to identify these structures were 96.8%, 93.5%, 77.4% and 64.5%, correspondingly. Observed agreement for kidneys and left adrenal gland increased when sub-analyzing the cases assessed by endoscopists with prior N-EUS exposure: 81.2% and 76.9%, respectively.

Conclusion

N-EUS is a safe, effective, and feasible tool for EUS evaluation, with high acceptability by endoscopists. Prior ex-vivo training may be warranted for first-time N-EUS users.

References

1. LeBlanc JK. An overview of endoscopic ultrasound equipment. Minerva Gastroenterol Dietol. 2008 Jun;54(2):177-87. PMID: 18319690 .
2. Varas Lorenzo, M.J., Abad Belando, R. and Sánchez-Vizcaíno Mengual, E. (2018), Miniprobe Endoscopic Sonography for Gastrointestinal Tract Assessment: A Case Series of 1451 Procedures. J Ultrasound Med, 37: 293-303. https://doi.org/10.1002/jum.14330
3. Deprez PH. Choice of endosonographic equipment and normal endosonographic anatomy. Best Pract Res Clin Gastroenterol. 2009;23(5):623-37. doi: 10.1016/j.bpg.2009.07.001 . PMID: 19744628 .

Disclosure

Carlos Robles-Medranda is a key opinion leader and consultant for Pentax Medical, Boston Scientific, Steris, Medtronic, Motus, Micro-tech, G-Tech Medical Supply, CREO Medical, EndoSound, and mdconsgroup. All other authors declare no conflicts of interest.

Introduction

Malignant gastric outlet obstruction (GOO) can arise from a spectrum of malignancies, including gastroduodenal, pancreaticobiliary, colorectal, breast, and lung cancers. Typically, GOO heralds a grim prognosis and manifests with symptoms such as nausea, bloating, vomiting, and abdominal pain. Presently, laparoscopic gastroenterostomy (L-GE) stands as the preferred therapeutic modality; however, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) employing lumen apposing metal stents has emerged as a promising minimally invasive alternative. Comparative studies directly assessing the efficacy of EUS-GE versus L-GE remain scarce.

Aims & Methods

We aimed to compare EUS-GE with L-GE for the treatment of GOO using a propensity score-matched analysis.
In a retrospective, multicenter analysis, consecutive patients were enrolled between April 2019 and April 2024 from two academic centers and one primary care facility. To mitigate selection bias, propensity score matching was employed, taking into account factors such as underlying malignancy, tumor stage, and clinical performance status. Clinical success, defined as a reduction of gastric outlet obstruction (GOO) symptom scores by ≥1, served as the primary outcome measure. Secondary endpoints included technical success, time to oral intake, occurrence of adverse events (AEs), length of hospital stay, and 30-day mortality.

Results

A total of 94 patients underwent EUS-GE, while 78 patients underwent L-GE, as per initial screening. Propensity score matching resulted in 72 patients allocated to each group in a 1:1 ratio. The mean age of the study cohort was 68.2±12.3 years, with 59.7% being female. Clinical success rates were 90.2% for EUS-GE and 82.2% for L-GE (p=0.25). Technical success rates were 95.2% for EUS-GE and 100% for L-GE (p=0.06). The mean duration of hospital stay was significantly shorter for EUS-GE compared to L-GE (10.1±13.4 days vs. 15.5±10.5 days; p<0.001). Less AE were observed in the EUS-GE group compared to the L-GE group, both in total (4.8% vs. 22%; p=0.01) and in serious AE (1.6% vs. 6.7%; p=0.3). The 30-day mortality rate was 11.3% in the EUS-GE group and 17.8% in the L-GE group.

Conclusion

In patients presenting with malignant GOO, EUS-GE showed a tendency towards enhanced clinical success, although not statistically significant, while maintaining comparable technical success rates to L-GE. Notably, clinical recovery post-intervention and hospital stay duration were notably shorter in the EUS-GE cohort, accompanied by a significantly lower incidence of adverse events. Consequently, EUS-GE stands poised to emerge as a preferred therapeutic option for GOO. Nevertheless, further prospective, randomized trials are imperative to validate these retrospective findings.

Disclosure

ME, CG, TB, HN received consultation fees and study support from Boston Scientific, USA. The other authors have nothing to declare.