Endoscopic foregut surgery and interventions:The future is now.The state-of-the-art and my personal journey

In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic,the content will progress as follows: "lessons learned", "technical considerations"and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years.Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver,pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease(GERD), achalasia, esophageal diverticula, Barrett's esophagus(BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors.For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy(POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique(Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection(ESD)which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies(radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy.Importantly, in regard to early gastric cancer and submucosal tumors(SMTs) of the stomach, ESD and full thickness resection(FTR) can excise these lesions enbloc and endoscopic suturing is now used to close large defects and perforations.For treatment of patients with malignant gastric outlet obstruction(GOO),endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty(ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound(EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.

Diabetes mellitus as a risk factor for gastrointestinal cancer among American veterans

AIM:To assess the risk of biliary and pancreatic cancers in a large cohort of patients with type 2 diabetes mellitus(DM) .METHODS:Eligibility for this study included patients with type 2 DM(ICD-9 code 250.0) who were discharged from Department of Veteran Affairs hospitals between 1990 and 2000.Non-matched control patients without DM were selected from the same patient treatment files during the same period.Demographic information included age,sex and race.Secondary diagnoses included known risk factors based on their ICD-9 codes.By multivariate logistic regression,the occurrence of biliary and pancreatic cancer was compared between case subjects with DM and controls without DM.RESULTS:A total of 1172496 case and control subjects were analyzed.The mean age for study and control subjects was 65.8 ± 11.3 and 64.8 ± 12.6 years,respectively.The frequency of pancreatic cancer in subjects with DM was increased(0.9%) in comparison to control subjects(0.3%) with an OR of 3.22(95% CI:3.03-3.42) .The incidence of gallbladder andextrahepatic biliary cancers was increased by twofold in diabetic patients when compared to controls.The OR and 95% CI were 2.20(1.56-3.00) and 2.10(1.61-2.53) ,respectively.CONCLUSION:Our study demonstrated that patients with DM have a threefold increased risk for developing pancreatic cancer and a twofold risk for developing biliary cancer.

Endoscopic ultrasound-through-the-needle biopsy in pancreatic cystic lesions: A large single center experience

BACKGROUND Establishing a diagnosis of pancreatic cystic lesions(PCLs)preoperatively still remains challenging.Recently,endoscopic ultrasound(EUS)-through-the-needle biopsy(EUS-TTNB)using microforceps in PCLs has been made available.AIM To assess the efficacy and safety of EUS-TTNB in the diagnosis of PCLs.METHODS We retrospectively collected data of patients with PCLs who underwent both EUS-fine-needle aspiration(FNA)for cytology and EUS-TTNB at our institution since 2016.EUS-FNA for cytology was followed by EUS-TTNB in the same session.Evaluation of the cyst location,primary diagnosis,adverse events,and comparison between the cytologic fluid analyses and histopathology was performed.Technical success of EUS-TTNB was defined as visible tissue present after biopsy.Clinical success was defined as the presence of a specimen adequate to make a histologic or cytologic diagnosis.RESULTS A total of 56 patients(mean age 66.9±11.7,53.6%females)with PCLs were enrolled over the study period.The mean cyst size was 28.8 mm(12-85 mm).The EUS-TTNB procedure was technically successful in all patients(100%).The clinical success rate using EUS-TTNB was much higher than standard EUS-FNA,respectively 80.4%(45/56)vs 25%(14/56).Adverse events occurred in 2 patients(3.6%)who developed mild pancreatitis that resolved with medical therapy.Using TTNB specimens,23 of 32 cases(71.9%)with intraductal papillary mucinous neoplasm were further differentiated into gastric type(19 patients)and pancreaticobiliary type(4 patients)based on immunochemical staining.CONCLUSION EUS-TTNB for PCLs was technically feasible and had a favorable safety profile.Furthermore,the diagnostic yield for PCLs was much higher with EUS-TTNB than standard EUS-FNA cytology and fluid carcinoembryonic antigen.EUSTTNB should be considered as an adjunct to EUS-FNA and cytologic analysis in the diagnosis and management of PCLs.