Endoscopic submucosal dissection(ESD) is well established in Asia as a modality for selected advancedlesions of both the upper and lower gastrointestinal tract, but ESD has not attained the same niche in the West due ...Endoscopic submucosal dissection(ESD) is well established in Asia as a modality for selected advancedlesions of both the upper and lower gastrointestinal tract, but ESD has not attained the same niche in the West due to a variety of reasons. These include competition from traditional surgery, minimally invasive surgery and endoscopic mucosal resection. Other obstacles to ESD introduction in the West include time commitment for learning and doing procedures, a steep learning curve, special equipment, lack of mentors, cost issues, interdisciplinary conflicts, concern regarding complications and lack of support from institutions and interfacing departments. There are intrinsic differences in pathology prevalence(e.g., early gastric cancer) between the two regions that are less conducive for ESD implementation in the West. We will elaborate on these issues and suggest measures as well as a protocol to overcome these obstacles and hopefully allow introduction of ESD as a tenable option for appropriate patients.展开更多
AIM To systematically review safety/efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography(ERCP) performed during pregnancy, considering fetal viability, fetal teratogenicity, premature delivery, and f...AIM To systematically review safety/efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography(ERCP) performed during pregnancy, considering fetal viability, fetal teratogenicity, premature delivery, and future postpartum development of the infant.METHODS Systematic computerized literature search performed using PubMed with the key words "ERCP" and "pregnancy". Two clinicians independently reviewed the literature, and decided on which articles to incorporate in this review based on consensus and preassigned priorities. Large clinical trials, meta-analyses, systematic reviews, and controlled trials were assigned higher priority than review articles or small clinical series, and individual case reports were assigned lowest priority. Dr. Cappell has formal training and considerable experience in conducting systematic reviews, with 4 published systematic reviews in peer-reviewed journals indexed in PubM ed during the last 2 years, and with a PhD in neurophysiology that involved 5 years of training and research in biomedical statistics.RESULTS Advances in imaging modalities, including abdominal ultrasound, MRCP, and endoscopic ultrasound, have generally obviated the need for diagnostic ERCP in nonpregnant and pregnant patients. Clinical experience with performing ERCP during pregnancy is burgeoning, with > 500 cases of therapeutic ERCP reported in the literature, aside from a national registry study of 58 patients. These studies show that therapeutic ERCP has a very high rate of technical success in clearing the bile duct of gallstones, and has a relatively low and acceptable rate of maternal and fetal complications. The great majority of births after therapeutic ERCP are full-term, have normal birth weights, and are healthy. A recent trend is performing ERCP without radiation to eliminate radiation teratogenicity. Systematic literature review reveals 147 cases of ERCP without fluoroscopy in 8 clinical series. These studies demonstrate extremely high technical success in endoscopically removing choledocholithiasis, favorable maternal outcomes with rare maternal ERCP complications, and excellent fetal outcomes. ERCP without fluoroscopy generally confirms proper biliary cannulation by aspiration of yellow bile per sphincterotome or leakage of yellow bile around an inserted guide-wire.CONCLUSION This systematic literature review reveals ERCP is relatively safe and efficacious during pregnancy, with relatively favorable maternal and fetal outcomes after ERCP. Recommendations are provided about ERCP indications, special ERCP techniques during pregnancy, and prospects for future research.展开更多
Endoscopic submucosal dissection(ESD)represents an organ-preserving alternative to surgical resection of early gastric cancer.However,even with ESD yielding en-bloc resection specimens,there are concerns regarding tum...Endoscopic submucosal dissection(ESD)represents an organ-preserving alternative to surgical resection of early gastric cancer.However,even with ESD yielding en-bloc resection specimens,there are concerns regarding tumor spread such as with larger lesions,ulcerated lesions,undifferentiated pathology and submucosal invasion.Sentinel node navigational surgery(SNNS)when combined with ESD offers a minimally invasive alternative to the traditional extended gastrectomy and lymphadenectomy if lack of lymph node spread can be confirmed.This would have a clear advantage in terms of potential complications and quality of life.However,SNNS,though useful in other malignancies such as breast cancer and melanoma,may not have a sufficient sensitivity for malignancy and negative predictive value in EGC to justify this as standard practice after ESD.The results of SNNS may improve with greater standardization and more involved dissection,technological innovations and more experience and validation such that the paradigm for post-ESD resection of EGC may change and include SNNS.展开更多
文摘Endoscopic submucosal dissection(ESD) is well established in Asia as a modality for selected advancedlesions of both the upper and lower gastrointestinal tract, but ESD has not attained the same niche in the West due to a variety of reasons. These include competition from traditional surgery, minimally invasive surgery and endoscopic mucosal resection. Other obstacles to ESD introduction in the West include time commitment for learning and doing procedures, a steep learning curve, special equipment, lack of mentors, cost issues, interdisciplinary conflicts, concern regarding complications and lack of support from institutions and interfacing departments. There are intrinsic differences in pathology prevalence(e.g., early gastric cancer) between the two regions that are less conducive for ESD implementation in the West. We will elaborate on these issues and suggest measures as well as a protocol to overcome these obstacles and hopefully allow introduction of ESD as a tenable option for appropriate patients.
文摘AIM To systematically review safety/efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography(ERCP) performed during pregnancy, considering fetal viability, fetal teratogenicity, premature delivery, and future postpartum development of the infant.METHODS Systematic computerized literature search performed using PubMed with the key words "ERCP" and "pregnancy". Two clinicians independently reviewed the literature, and decided on which articles to incorporate in this review based on consensus and preassigned priorities. Large clinical trials, meta-analyses, systematic reviews, and controlled trials were assigned higher priority than review articles or small clinical series, and individual case reports were assigned lowest priority. Dr. Cappell has formal training and considerable experience in conducting systematic reviews, with 4 published systematic reviews in peer-reviewed journals indexed in PubM ed during the last 2 years, and with a PhD in neurophysiology that involved 5 years of training and research in biomedical statistics.RESULTS Advances in imaging modalities, including abdominal ultrasound, MRCP, and endoscopic ultrasound, have generally obviated the need for diagnostic ERCP in nonpregnant and pregnant patients. Clinical experience with performing ERCP during pregnancy is burgeoning, with > 500 cases of therapeutic ERCP reported in the literature, aside from a national registry study of 58 patients. These studies show that therapeutic ERCP has a very high rate of technical success in clearing the bile duct of gallstones, and has a relatively low and acceptable rate of maternal and fetal complications. The great majority of births after therapeutic ERCP are full-term, have normal birth weights, and are healthy. A recent trend is performing ERCP without radiation to eliminate radiation teratogenicity. Systematic literature review reveals 147 cases of ERCP without fluoroscopy in 8 clinical series. These studies demonstrate extremely high technical success in endoscopically removing choledocholithiasis, favorable maternal outcomes with rare maternal ERCP complications, and excellent fetal outcomes. ERCP without fluoroscopy generally confirms proper biliary cannulation by aspiration of yellow bile per sphincterotome or leakage of yellow bile around an inserted guide-wire.CONCLUSION This systematic literature review reveals ERCP is relatively safe and efficacious during pregnancy, with relatively favorable maternal and fetal outcomes after ERCP. Recommendations are provided about ERCP indications, special ERCP techniques during pregnancy, and prospects for future research.
文摘Endoscopic submucosal dissection(ESD)represents an organ-preserving alternative to surgical resection of early gastric cancer.However,even with ESD yielding en-bloc resection specimens,there are concerns regarding tumor spread such as with larger lesions,ulcerated lesions,undifferentiated pathology and submucosal invasion.Sentinel node navigational surgery(SNNS)when combined with ESD offers a minimally invasive alternative to the traditional extended gastrectomy and lymphadenectomy if lack of lymph node spread can be confirmed.This would have a clear advantage in terms of potential complications and quality of life.However,SNNS,though useful in other malignancies such as breast cancer and melanoma,may not have a sufficient sensitivity for malignancy and negative predictive value in EGC to justify this as standard practice after ESD.The results of SNNS may improve with greater standardization and more involved dissection,technological innovations and more experience and validation such that the paradigm for post-ESD resection of EGC may change and include SNNS.
