Use of endoscopic ultrasound-guided gallbladder drainage as a rescue approach in cases of unsuccessful biliary drainage

This narrative review provides an overview of the utilization of endoscopic ultrasound-guided gallbladder drainage(EUS-GBD)as a salvage approach in cases of unsuccessful conventional management.EUS-GBD is a minimally invasive and effective technique for drainage in patients with acute cholecystitis with high risk of surgery.The procedure has demonstrated impressive technical and clinical success rates with low rates of adverse events,making it a safe and effective option for appropriate candidates.Furthermore,EUS-GBD can also serve as a rescue option for patients who have failed endoscopic retrograde cholangiopancreatography or EUS biliary drainage for relief of jaundice in malignant biliary stricture.However,patient selection is critical for the success of EUS-GBD,and proper patient selection and risk assessment are important to ensure the safety and efficacy of the procedure.As the field continues to evolve and mature,ongoing research will further refine our understanding of the benefits and limitations of EUS-GBD,ultimately leading to improved outcomes for patients.

Endoscopic ultrasound and magnetic resonance imaging for re-staging rectal cancer after radiotherapy

AIM： To compare the sensitivity and specificity of two imaging techniques, endoscopic ultrasound （EUS） and magnetic resonance imaging （MRI）, in patients with rectal cancer after neoadjuvant chemoradiation therapy. And we compared EUS and MRI data with histological findings from surgical specimens. METHODS： Thirty-nine consecutive patients （51.3% Male; mean age： 68.2 ＋ 8.9 years） with histologically confirmed distal rectal cancer were examined for staging. All patients underwent EUS and MRI imaging before and after neoadjuvant chemoradiation therapy. RESULTS： After neoadjuvant chemoradiation, EUS and MRI correctly classified 46% （18/39） and 44% （17/39） of patients, respectively, in line with their histological T stage （P 〉 0.05）. These proportions were higher for both techniques when nodal involvement was considered： 69% （27/39） and 62% （24/39）. When patients were sorted into T and N subgroups, the diagnostic accuracy of EUS was better than MRI for patients with T0-T2 （44% vs 33%, P 〉 0.05） and NO disease （87% vs 52%, P = 0.013）. However, MRI was more accurate than EUS in T and N staging for patients with more advanced disease after radiotherapy, though these differences did not reach statistical significance. CONCLUSION： EUS and MRI are accurate imaging techniques for staging rectal cancer, However, after neoadjuvant RT-CT, the role of both methods in the assessment of residual rectal tumors remains uncertain.

Endoscopy-guided ablation of pancreatic lesions:Technical possibilities and clinical outlook

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP)-guided ablation procedures are emerging as a minimally invasive therapeutic alternative to radiological and surgical treatments for locally advanced pancreatic cancer (LAPC), pancreatic neuroendocrine tumours (PNETs), and pancreatic cystic lesions (PCLs). The advantages of treatment under endoscopic control are the real-time imaging guidance and the possibility to reach a deep target like the pancreas. Currently, radiofrequency probes specifically designed for ERCP or EUS ablation are available as well as hybrid cryotherm probe combining radiofrequency with cryotechnology. To date, many reports and case series have confirmed the safety and feasibility of that kind of ablation technique in the pancreatic setting. Moreover, EUS-guided fine-needle injection is emerging as a method to deliver ablative and anti-tumoral agents inside the tumuor. Ethanol injection has been proposed mostly for the treatment of PCLs and for symptomatic functioning PNETs, and the use of gemcitabine and paclitaxel is also interesting in this setting. EUS-guided injection of chemical or biological agents including mixed lymphocyte culture, oncolytic viruses, and immature dendritic cells has been investigated for the treatment of LAPC. Data on the long-term efficacy of these approaches, and large prospective randomized studies are needed to confirm the real clinical benefits of these techniques for the management of pancreatic lesions.

Tumors and new endoscopic ultrasound-guided therapies

With the advent of linear echoendoscopes, endoscopic ultrasound (EUS) has become more operative and a new field of oncological application has been opened up. From tumor staging to tissue acquisition under EUS-guided fine-needle aspiration, new operative procedures have been developed on the principle of the EUS-guided puncture. A hybrid probe combining radiofrequency with cryotechnology is now available, to be passed through the operative channel of the echoendoscope into the tumor to create an area of ablation. EUS-guided fine-needle injection is emerging as a method to deliver anti-tumoral agents inside the tumor. Ethanol lavage, with or without paclitaxel, has been proposed for the treatment of cystic tumors in non-resectable cases and complete resolution has been recorded in up to 70%-80%. Many other chemical or biological agents have been investigated for the treatment of pancreatic adenocarcinoma: activated allogenic lymphocyte culture (Cytoimplant), a replication-deficient adenovirus vector carrying the tumor necrosis factor-α gene, or an oncolytic attenuated adenovirus (ONYX-015). The potential advantage of treatment under EUS control is the real-time imaging guidance into a deep target likethe pancreas which is extremely difficult to reach by a percutaneous approach. To date there are no randomized controlled trials to confirm the real clinical benefits of these treatments compared to standard therapy so it seems wise to reserve them only for experimental protocols approved by ethics committees.

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.

Enhanced endoscopic ultrasound imaging for pancreatic lesions: The road to artificial intelligence

Early detection of pancreatic cancer has long eluded clinicians because of its insidious nature and onset.Often metastatic or locally invasive when symptomatic,most patients are deemed inoperable.In those who are symptomatic,multi-modal imaging modalities evaluate and confirm pancreatic ductal adenocarcinoma.In asymptomatic patients,detected pancreatic lesions can be either solid or cystic.The clinical implications of identifying small asymptomatic solid pancreatic lesions(SPLs)of<2 cm are tantamount to a better outcome.The accurate detection of SPLs undoubtedly promotes higher life expectancy when resected early,driving the development of existing imaging tools while promoting more comprehensive screening programs.An imaging tool that has matured in its reiterations and received many image-enhancing adjuncts is endoscopic ultrasound(EUS).It carries significant importance when risk stratifying cystic lesions and has substantial diagnostic value when combined with fine needle aspiration/biopsy(FNA/FNB).Adjuncts to EUS imaging include contrast-enhanced harmonic EUS and EUS-elastography,both having improved the specificity of FNA and FNB.This review intends to compile all existing enhancement modalities and explore ongoing research around the most promising of all adjuncts in the field of EUS imaging,artificial intelligence.

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.

Success and safety of endoscopic treatments for concomitant biliary and duodenal malignant stenosis: A review of the literature

Synchronous biliary and duodenal malignant obstruction is a challenging endoscopic scenario in patients affected with ampullary, peri-ampullary, and pancreatic head neoplasia. Surgical bypass is no longer the gold-standard therapy for these patients, as simultaneous endoscopic biliary and duodenal stenting is currently a feasible and widely used technique, with a high technical success in expert hands. In recent years, endoscopic ultrasonography(EUS) has evolved from a diagnostic to a therapeutic procedure, and is now increasingly used to guide biliary drainage, especially in cases of failed endoscopic retrograde cholangiopancreatography(ERCP). The advent of lumen-apposing metal stents(LAMS) has expanded EUS therapeutic options, and changed the management of synchronous bilioduodenal stenosis. The most recent literature regarding endoscopic treatments for synchronous biliary and duodenal malignant stenosis has been reviewed to determine the best endoscopic approach, also considering the advent of an interventional EUS approach using LAMS.

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.

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.

Fractal nature of human gastrointestinal system:Exploring a new era

The morphological complexity of cells and tissues,whether normal or pathological,is characterized by two primary attributes:Irregularity and self-similarity across different scales.When an object exhibits self-similarity,its shape remains unchanged as the scales of measurement vary because any part of it resembles the whole.On the other hand,the size and geometric characteristics of an irregular object vary as the resolution increases,revealing more intricate details.Despite numerous attempts,a reliable and accurate method for quantifying the morphological features of gastrointestinal organs,tissues,cells,their dynamic changes,and pathological disorders has not yet been established.However,fractal geometry,which studies shapes and patterns that exhibit self-similarity,holds promise in providing a quantitative measure of the irregularly shaped morphologies and their underlying self-similar temporal behaviors.In this context,we explore the fractal nature of the gastrointestinal system and the potential of fractal geometry as a robust descriptor of its complex forms and functions.Additionally,we examine the practical applications of fractal geometry in clinical gastroenterology and hepatology practice.

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.