Submucosal tunnel endoscopy:Peroral endoscopicmyotomy and peroral endoscopic tumor resection

Peroral endoscopic myotomy(POEM) is an innovative,minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy(LHM), not only for all types of esophageal achalasia [classical(Ⅰ), vigorous(Ⅱ), spastic(Ⅲ), Chicago Classification], but also for advanced sigmoid type achalasia(S1 and S2), failed LHM, or other esophageal motility disorders(diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction(EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection(POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors(submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives.

Artificial intelligence and inflammatory bowel disease: Where are we going?

Inflammatory bowel diseases,namely ulcerative colitis and Crohn’s disease,are chronic and relapsing conditions that pose a growing burden on healthcare systems worldwide.Because of their complex and partly unknown etiology and pathogenesis,the management of ulcerative colitis and Crohn’s disease can prove challenging not only from a clinical point of view but also for resource optimization.Artificial intelligence,an umbrella term that encompasses any cognitive function developed by machines for learning or problem solving,and its subsets machine learning and deep learning are becoming ever more essential tools with a plethora of applications in most medical specialties.In this regard gastroenterology is no exception,and due to the importance of endoscopy and imaging numerous clinical studies have been gradually highlighting the relevant role that artificial intelligence has in inflammatory bowel diseases as well.The aim of this review was to summarize the most recent evidence on the use of artificial intelligence in inflammatory bowel diseases in various contexts such as diagnosis,follow-up,treatment,prognosis,cancer surveillance,data collection,and analysis.Moreover,insights into the potential further developments in this field and their effects on future clinical practice were discussed.

Endocytoscopic visualization of squamous cell islands within Barrett's epithelium

AIM: To study the endocytoscopic visualization of squamous cell islands within Barrett's epithelium. METHODS: Endocytoscopy (ECS) has been studied in the surveillance of Barrett's esophagus, with controversial results. In initial studies, however, a soft catheter type endocytoscope was used, while only methylene blue dye was used for the staining of Barrett's mucosa. Integrated type endocytoscopes (GIF-Q260 EC, Olympus Corp, Tokyo, Japan) have been recently developed, with the incorporation of a high-power magnifying endocytoscope into a standard endoscope together with narrow-band imaging (NBI). Moreover, double staining with a mixture of 0.05% crystal violet and 0.1% of methylene blue (CM) during ECS enables higher quality images comparable to conventional hematoxylin eosin histopathological images.RESULTS: In vivo endocytoscopic visualization of papillary squamous cell islands within glandular Barrett's epithelium in a patient with long-segment Barrett's esophagus is reported. Conventional white light endoscopy showed typical long-segment Barrett's esophagus, with small squamous cell islands within normal Barrett's mucosa, which were better visualized by NBI endoscopy. ECS after double CM staining showed regular Barrett's esophagus, while higher magnification (×480) revealed the orifices of glandular structures better. Furthermore, typical squamous cell papillary protrusion, classified as endocytoscopic atypia classification (ECA) 2 according to ECA, was identified within regular glandular Barrett's mucosa. Histological examination of biopsies taken from the same area showed squamous epithelium within glandular Barrett's mucosa, corresponding well to endocytoscopic findings. CONCLUSION: To our knowledge, this is the first report of in vivo visualization of esophageal papillary squamous cell islands surrounded by glandular Barrett's epithelium.

Use of artificial intelligence in improving adenoma detection rate during colonoscopy:Might both endoscopists and pathologists be further helped

Colonoscopy remains the standard strategy for screening for colorectal cancer around the world due to its efficacy in both detecting adenomatous or precancerous lesions and the capacity to remove them intra-procedurally.Computeraided detection and diagnosis(CAD),thanks to the brand new developed innovations of artificial intelligence,and especially deep-learning techniques,leads to a promising solution to human biases in performance by guarantying decision support during colonoscopy.The application of CAD on real-time colonoscopy helps increasing the adenoma detection rate,and therefore contributes to reduce the incidence of interval cancers improving the effectiveness of colonoscopy screening on critical outcome such as colorectal cancer related mortality.Furthermore,a significant reduction in costs is also expected.In addition,the assistance of the machine will lead to a reduction of the examination time and therefore an optimization of the endoscopic schedule.The aim of this opinion review is to analyze the clinical applications of CAD and artificial intelligence in colonoscopy,as it is reported in literature,addressing evidence,limitations,and future prospects.

Endoscopic management of benign biliary strictures:Looking for the best stent to place

Benign biliary strictures(BBS)might occur due to different pancreaticobiliary conditions.The etiology and location of biliary strictures are responsible of a wide array of clinical manifestations.The endoscopic approach endoscopic retrograde cholangiopancreatography represents the first-line treatment for BBS,considering interventional radiology and surgery when endoscopic treatment fails or it is not suitable.The purpose of this review is to provide an overview of possible endoscopic treatments for the optimal management of this subset of patients.

Artificial intelligence technologies for the detection of colorectal lesions: The future is now

Several studies have shown a significant adenoma miss rate up to 35%during screening colonoscopy,especially in patients with diminutive adenomas.The use of artificial intelligence(AI)in colonoscopy has been gaining popularity by helping endoscopists in polyp detection,with the aim to increase their adenoma detection rate(ADR)and polyp detection rate(PDR)in order to reduce the incidence of interval cancers.The efficacy of deep convolutional neural network(DCNN)-based AI system for polyp detection has been trained and tested in ex vivo settings such as colonoscopy still images or videos.Recent trials have evaluated the real-time efficacy of DCNN-based systems showing promising results in term of improved ADR and PDR.In this review we reported data from the preliminary ex vivo experiences and summarized the results of the initial randomized controlled trials.

Advanced imaging and artificial intelligence for Barrett's esophagus:What we should and soon will do

Barrett’s esophagus(BE)is a well-established risk factor for esophageal adenocarcinoma.It is recommended that patients have regular endoscopic surveillance,with the ultimate goal of detecting early-stage neoplastic lesions before they can progress to invasive carcinoma.Detection of both dysplasia or early adenocarcinoma permits curative endoscopic treatments,and with this aim,thorough endoscopic assessment is crucial and improves outcomes.The burden of missed neoplasia in BE is still far from being negligible,likely due to inappropriate endoscopic surveillance.Over the last two decades,advanced imaging techniques,moving from traditional dye-spray chromoendoscopy to more practical virtual chromoendoscopy technologies,have been introduced with the aim to enhance neoplasia detection in BE.As witnessed in other fields,artificial intelligence(AI)has revolutionized the field of diagnostic endoscopy and is set to cover a pivotal role in BE as well.The aim of this commentary is to comprehensively summarize present evidence,recent research advances,and future perspectives regarding advanced imaging technology and AI in BE;the combination of computer-aided diagnosis to a widespread adoption of advanced imaging technologies is eagerly awaited.It will also provide a useful step-by-step approach for performing high-quality endoscopy in BE,in order to increase the diagnostic yield of endoscopy in clinical practice.

Microvasculature of the esophagus and gastroesophageal junction: Lesson learned from submucosal endoscopy

Advanced therapeutic endoscopy,in particular endoscopic mucosal resection,endoscopic submucosal dissection,per-oral endoscopic myotomy,submucosal endoscopic tumor resection opened a new era where direct esophageal visualization is possible.Combining these information with advanced diagnostic endoscopy,the esophagus is organized,from the luminal side to outside,into five layers(epithelium,lamina propria with lamina muscularis mucosa,submucosa,muscle layer,adventitia).A specific vascular system belonging to each layer is thus visible: Mucosa with the intra papillary capillary loop in the epithelium and the sub-epithelial capillary network in the lamina propria and,at the lower esophageal sphincter(LES) level with the palisade vessels; submucosa with the drainage vessels and the spindle veins at LES level; muscle layer with the perforating vessels; periesophageal veins in adventitia.These structures are particularly important to define endoscopic landmark for the gastro-esophageal junction,helpful in performing submucosal therapeutic endoscopy.

Percutaneous endoscopic gastrostomy and jejunostomy:Indications and techniques

Nutritional support is essential in patients who have a limited capability to maintain their body weight.Therefore,oral feeding is the main approach for such patients.When physiological nutrition is not possible,positioning of a nasogastric,nasojejunal tube,or other percutaneous devices may be feasible alternatives.Creating a percutaneous endoscopic gastrostomy(PEG)is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk.Many diseases require nutritional support by PEG,with neurological,oncological,and catabolic diseases being the most common.PEG can be performed endoscopically by various techniques,radiologically or surgically,with different outcomes and related adverse events(AEs).Moreover,some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent.These conditions highlight many ethical problems that become difficult to manage as treatment progresses.The aim of this manuscript is to review all current endoscopic techniques for percutaneous access,their indications,postprocedural follow-up,and AEs.

Endoscopic ultrasound-guided ablation of solid pancreatic lesions:A systematic review of early outcomes with pooled analysis

BACKGROUND Endoscopic ultrasound-guided radiofrequency ablation(EUS-RFA)is emerging as a complementary therapeutic approach for pancreatic solid masses.However,results of published data are difficult to interpret because of a retrospective design and small sample size.AIM To systematically review data on EUS-RFA for solid lesions and to pool the results of the different experiences in order to provide more consistent evidence in terms of safety and efficacy.METHODS A comprehensive systematic literature search on the main databases was performed to identify articles in which patients with pancreatic solid lesions underwent EUS-RFA.The primary outcomes were procedure-related adverse events(AEs)and mortality.Secondary outcomes were the technical success rate and the effects on primary tumor growth.Statistical analyses were performed using Stata version 14.0.RESULTS In total,14 studies were included,with 120 patients undergoing 153 ablations of 129 solid pancreatic lesions.The STARmed technology was used in seven studies,the Habib system in six studies,and the HybridTherm probe in one study.The pooled technical success rate was 99.0%(I2:25.82%).The pooled overall AE rate was 8.0%(I2:11.46%).Excluding mild AEs,the pooled rates of serious AEs was 1.0%(I2:0%).No mortality related to the procedure was reported.CONCLUSION The present pooled analysis confirms the safety and feasibility of EUS-RFA.

Endoscopic resection of non-ampullary duodenal adenomas: Is cold snaring the promised land?

Due to the high risk of morbidity and mortality associated with surgical resection in this tract,endoscopic resection(ER)has taken the place of surgical resection as the first line treatment for non-ampullary duodenal adenomas.However,due to the anatomical characteristics of this area,which enhance the risk of post-ER problems,ER in the duodenum is particularly difficult.Due to a lack of data,no ER technique for superficial non-ampullary duodenal epithelial tumours(SNADETs)has yet been backed by strong,high-quality evidence;yet,traditional hot snare-based techniques are still regarded as the standard treatment.Despite having a favourable efficiency profile,adverse events during duodenal hot snare polypectomy(HSP)and hot endoscopic mucosal resection,such as delayed bleeding and perforation,have been reported to be frequent.These events are primarily caused by electrocautery-induced damage.Thus,ER techniques with a better safety profile are needed to overcome these shortcomings.Cold snare polypectomy,which has already been shown as a safer,equally effective pro-cedure compared to HSP for treatment of small colorectal polyps,is being increasingly evaluated as a potential therapeutic option for non-ampullary duodenal adenomas.The aim of this review is to report and discuss the early outcomes of the first experiences with cold snaring for SNADETs.

Role of endoscopic ultrasound in vascular interventions:Where are we now?

From a mere diagnostic tool to an imperative treatment modality,endoscopic ultrasound(EUS)has evolved and revolutionized safer efficient options for vascular interventions.Currently it is an alternative treatment option in the management of gastrointestinal bleeding,primarily variceal type bleeding.Conventional treatment option prior to EUS incorporation had limited efficiency and high adverse events.The characterization and detail provided by EUS gives a cutting edge towards a holistically successful management choice.Data indicates that EUS-guided combination therapy of coil embolization and glue injection has the higher efficacy for the treatment of varices.Conversely,similar treatment options that exist for esophageal and other ectopic variceal bleeding was also outlined.In conclusion,many studies refer that a combination therapy of coil and glue injection under EUS guidance provides higher technical success with fewer recurrence and adverse events,making its adaptation in the guideline extremely favorable.Endo-hepatology is a novel disciple with a promising future outlook,we reviewed topics regarding portal vein access,pressure gradient measurement,and thrombus biopsy that are crucial interventions as alternative of radiological procedures.The purpose of this review is to provide an update on the latest available evidence in the literature regarding the role of EUS in vascular interventions.We reviewed the role of EUS in variceal bleeding in recent studies,especially gastric varices and novel approaches aimed at the portal vein.