Endoscopic ultrasonography-guided endoscopic treatment of pancreatic pseudocysts and walled-off necrosis:New technical developments

In the last decades,the treatment of pancreatic pseudocysts and necrosis occurring in the clinical context of acute and chronic pancreatitis has shifted towards minimally invasive endoscopic interventions.Surgical procedures can be avoided in many cases by using endoscopically placed,Endoscopic ultrasonography-guided techniques and drainages.Endoscopic ultrasound enables the placement of transmural plastic and metal stents or nasocystic tubes for the drainage of peripancreatic fluid collections.The development of selfexpanding metal stents and exchange free delivering systems have simplified the drainage of pancreatic fluid collections.This review will discuss available therapeutic techniques and new developments.

Ultrasonographic imaging of inflammatory bowel disease in pediatric patients

Inflammatory bowel disease(IBD) is one of the most common chronic gastrointestinal diseases in pediatric patients.Choosing the optimal imaging modality for the assessment of gastrointestinal disease in pediatric patients can be challenging.The invasiveness and patient acceptance,the radiation exposure and the quality performance of the diagnostic test need to be considered.By reviewing the literature regarding imaging in inflammatory bowel disease the value of ultrasound in the clinical management of pediatric patients is highlighted.Transabdominal ultrasound is a useful,noninvasive method for the initial diagnosis of IBD in children;it also provides guidance for therapeutic decisions and helps to characterize and predict the course of the disease in individual patients.Ultrasound techniques including color Doppler imaging and contrast-enhanced ultrasound are promising imaging tools to determine disease activity and complications.Comparative studies between different imaging methods are needed.

Repeat endoscopic retrograde cholangiopancreaticography after failed initial precut sphincterotomy for biliary cannulation

AIM: To investigate the outcome of repeating endoscopic retrograde cholangiopancreaticography (ERCP) after initially failed precut sphincterotomy to achieve biliary cannulation.

Intraductal papillary mucinous neoplasm in chronic calcifying pancreatitis:Egg or hen?

Intraductal papillary mucinous neoplasm(IPMN)is an increasingly reported entity.Extensive pancreatic calcification is generally thought to be a sign of chronic pancreatitis,but it may occur simultaneously with IPMN leading to diagnostic difficulties.We report a case of a patient initially diagnosed with chronic calcifying pancreatitis who was later shown to have a malignant IPMN.This case illustrates potential pitfalls in the diagnosis of IPMN in the case of extensive pancreatic calcification as well as clues that may lead the clinician to suspecting the diagnosis.The possible mechanisms of the relation between pancreatic calcification and IPMN are also reviewed.

Addition of senna improves quality of colonoscopy preparation with magnesium citrate

AIM: To prospectively investigate the effectiveness and patient’s tolerance of two low-cost bowel cleansing preparation protocols based on magnesium citrate only or the combination of magnesium citrate and senna. METHODS: A total of 342 patients who were referred for colonoscopy underwent a colon cleansing protocol with magnesium citrate alone (n = 160) or magnesium citrate and senna granules (n = 182). The colonoscopist rated the overall efficacy of colon cleansing using an established score on a 4-point scale. Patients were questioned before undergoing colonoscopy for side effects and symptoms during bowel preparation. RESULTS: The percentage of procedures rescheduled because ofinsufficient colon cleansing was 7% in the magnesium citrate group and 4% in the magnesium citrate/senna group (P = 0.44). Adequate visualization of the colonic mucosa was rated superior under the citramag/senna regimen (P = 0.004). Both regimens were well tolerated, and did not significantly differ in the occurrence of nausea, bloating or headache.However, abdominal cramps were observed more often under the senna protocol (29.2%) compared to the magnesium citrate only protocol (9.9%, P < 0.0003). CONCLUSION: The addition of senna to the bowel preparation protocol with magnesium citrate significantly improves the cleansing outcome.

Sonographic signs of neutropenic enterocolitis

AIM： To investigate the sonographic features at time of diagnosis and follow-up in patients with neutropenic enterocolitis. METHODS： The sonographic findings in 14 patients with neutropenic enterocolitis were described and evaluated regarding symptoms and clinical outcome. RESULTS： In all patients with neutropenic enterocolitis, the ileocoecal region was involved with wall thickening 〉10 mm. A transmural inflammatory pattern, hypervascularity of the thickened bowel wall and free abdominal fluid were the common findings. The sonographically revealed thickness of the bowel wall was associated with lethal outcome （P〈0.03）. In the 11 surviving patients, the improvement of clinical symptoms was accompanied by progressive reduction of intestinal wall thickness. CONCLUSION： High-end sonography of the bowel is a helpful tool for diagnosis, assessment of prognosis and follow-up of patients with neutropenic enterocolitis. The ultrasonographically revealed bowel thickness reflects the severity and the course of the disease, and seems to be predictive for the clinical outcome.

Endoscopic ultrasound-guided drainage of pancreatic walled-off necrosis using self-expanding metal stents without fluoroscopy

AIM To investigate whether endoscopic ultrasound(EUS)-guided insertion of fully covered self-expandable metal stents in walled-off pancreatic necrosis(WOPN) is feasible without fluoroscopy.METHODS Patients with symptomatic pancreatic WOPN undergoing EUS-guided transmural drainage using self-expandable and fully covered self expanding metal stents(FCSEMS) were included. The EUS visibility of each step involved in the transmural stent insertion was assessed by theoperators as "visible" or "not visible":(1) Access to the cyst by needle or cystotome;(2) insertion of a guide wire;(3) introducing of the diathermy and delivery system;(4) opening of the distal flange; and(5) slow withdrawal of the delivery system until contact of distal flange to cavity wall. Technical success was defined as correct positioning of the FCSEMS without the need of fluoroscopy.RESULTS In total, 27 consecutive patients with symptomatic WOPN referred for EUS-guided drainage were included. In 2 patients large traversing arteries within the cavity were detected by color Doppler, therefore the insertion of FCSEMS was not attempted. In all other patients(92.6%) EUS-guided transgastric stent insertion was technically successful without fluoroscopy. All steps of the procedure could be clearly visualized by EUS. Nine patients required endoscopic necrosectomy through the FCSEMS. Adverse events were two readmissions with fever and one self-limiting bleeding; there was no procedure-related mortality. CONCLUSION The good endosonographic visibility of the FCSEMS delivery system throughout the procedure allows safe EUS-guided insertion without fluoroscopy making it available as bedside intervention for critically ill patients.

Tunneled biopsy is an underutilised,simple,safe and efficient method for tissue acquisition from subepithelial tumours

BACKGROUND Tissue acquisition from subepithelial lesions is often attempted by endoscopic ultrasound(EUS)-sampling as conventional endoscopic biopsy usually fails to reach deeper layers of the gastrointestinal wall.AIM To investigate the utilisation,safety and diagnostic yield of an intensified“biteon-bite”tunnel biopsy technique.METHODS In this retrospective cohort study,all patients presenting with subepithelial masses in the upper gastrointestinal tract from March 2013 to July 2019 were included.Data were analysed for size and location of the subepithelial mass,use of intensified tunnel biopsy protocol(more than 10 double bite-on-bite biopsies)or superficial conventional biopsies,histology and imaging results,occurrence of readmission and adverse events after endoscopy.RESULTS Two hundred and twenty-nine patients with subepithelial lesions were included.Superficial conventional biopsies were taken in 117 patients and were diagnostic only in one lipoma(0.9%).Tunnel biopsies taken in 112/229(48.9%)patients were significantly more likely to provide histological diagnosis(53.6%;P<0.001).For lesions≥10mm the diagnostic yield of tunnel biopsies further increased to 41/67(61.2%).No immediate or delayed complications were reported.Only 8 of the 51 endoscopists(15.7%)regularly attempted tunnel biopsies.CONCLUSION Tunnel biopsy is a simple,safe and efficient but underutilised diagnostic modality for tissue acquisition in subepithelial masses.It should be routinely attempted at the initial endoscopy.

Artificial intelligence in endoscopy:The challenges and future directions

Artificial intelligence based approaches,in particular deep learning,have achieved state-of-the-art performance in medical fields with increasing number of software systems being approved by both Europe and United States.This paper reviews their applications to early detection of oesophageal cancers with a focus on their advantages and pitfalls.The paper concludes with future recommendations towards the development of a real-time,clinical implementable,interpretable and robust diagnosis support systems.

合理的检查诊断幽门螺旋杆菌感染

本文探讨如何检测幽门螺旋杆菌感染及何时判断治疗是否有效。 一名32岁的护士，间断上腹不适5个月余，空腹时尤甚。患者否认体重减轻、反复呕吐、吞咽困难、发热以及排便习惯改变等，亦没有证据表明存在消化道出血。患者无用药史，包括非甾体类抗炎药等非处方药物。患者无吸烟史，每周饮酒约4个单位（译者注：125ml、浓度为8％的酒为1个单位）。腹部检查提示上腹轻压痛。