Endoscopic balloon catheter dilatation via retrograde or static technique is safe and effective for cricopharyngeal dysfunction

AIM To evaluate the safety and efficacy of upper esophageal sphincter(UES) dilatation for cricopharyngeal(CP) dysfunction. To determine if:(1) indication for dilatation; or(2) technique of dilatation correlated with symptom improvement.METHODS All balloon dilatations performed at our institution from over a 3-year period were retrospectively analyzed for demographics, indication and dilatation site. All dilatations involving the UES underwent further review to determine efficacy, complications, and factors that predict success. Dilatation technique was separated into static(stationary balloon distention) and retrograde(brusque pull-back of a fully distended balloon across the UES).RESULTS Four hundred and eighty-eight dilatations were reviewed. Thirty-one patients were identified who underwent UES dilatation. Median age was 63 years(range 27-81)and 55% of patients were male. Indications included dysphagia(28 patients), globus sensation with evidence of UES dysfunction(2 patients) and obstruction to echocardiography probe with cricopharyngeal(CP)bar(1 patient). There was evidence of concurrent oropharyngeal dysfunction in 16 patients(52%) and a small Zenker's diverticula(≤ 2 cm) in 7 patients(23%). Dilator size ranged from 15 mm to 20 mm. Of the 31 patients, 11 had dilatation of other esophageal segments concurrently with UES dilatation and 20 had UES dilatation alone.Follow-up was available for 24 patients for a median of 2.5 mo(interquartile range 1-10 mo), of whom 19 reported symptomatic improvement(79%). For patients undergoing UES dilatation alone, follow-up was available for 15 patients, 12 of whom reported improvement(80%).Nineteen patients underwent retrograde dilatation(84%response) while 5 patients had static dilatation(60%response); however, there was no significant difference in symptom improvement between the techniques(P = 0.5).Successful symptom resolution was also not significantly affected by dilator size, oropharyngeal dysfunction,Zenker's diverticulum, age or gender(P > 0.05). The only complication noted was uvular edema and a shallow ulcer after static dilatation in one patient, which resolved spontaneously and did not require hospital admission.CONCLUSION UES dilatation with a through-the-scope balloon by either static or retrograde technique is safe and effective for the treatment of dysphagia due to CP dysfunction. To our knowledge, this is the first study evaluating retrograde balloon dilatation of the UES.

End-stage renal disease is associated with increased post endoscopic retrograde cholangiopancreatography adverse events in hospitalized patients

AIM To determine if end-stage renal disease (ESRD) is a risk factor for post endoscopic retrograde cholangio-pancreatography (ERCP) adverse events (AEs). METHODS We performed a retrospective cohort study using the Nationwide Inpatient Sample (NIS) 2011-2013. We identified adult patients who underwent ERCP using the International Classification of Diseases 9^(th) Revision (ICD-9-CM). Included patients were divided into three groups: ESRD, chronic kidney disease (CKD), and control. The primary outcome was post-ERCP AEs including pancreatitis, bleeding, and perforation determined based on specific ICD-9-CM codes. Secondary outcomes were length of hospital stay, in-hospital mortality, and admission cost. AEs and mortality were compared using multivariate logistic regression analysis.RESULTS There were 492175 discharges that underwent ERCP during the 3 years. The ESRD and CKD groups contained 7347 and 39403 hospitalizations respectively, whereas the control group had 445424 hospitalizations. Post-ERCP pancreatitis (PEP) was significantly higher in the ESRD group (8.3%) compared to the control group (4.6%) with adjusted odd ratio (aOR) = 1.7 (95% CI: 1.4-2.1, ~aP < 0.001). ESRD was associated with significantly higher ERCP-related bleeding (5.1%) compared to the control group 1.5% (aOR = 1.86, 95%CI: 1.4-2.4, ~aP < 0.001). ESRD had increased hospital mortality 7.1% vs 1.15% in the control OR = 6.6 (95%CI: 5.3-8.2, ~aP < 0.001), longer hospital stay with adjusted mean difference (aMD) = 5.9 d (95% CI: 5.0-6.7 d, ~aP < 0.001) and higher hospitalization charges aMD = $+82064 (95%CI: $68221-$95906, ~aP < 0.001). CONCLUSION ESRD is a risk factor for post-ERCP AEs and is associated with higher hospital mortality. Careful selection and close monitoring is warranted to improve outcomes.

Percutaneous transluminal angioplasty balloons for endoscopic ultrasound-guided pancreatic duct interventions

BACKGROUND Endoscopic ultrasound(EUS)-guided main pancreatic duct(PD)access may be used when conventional endoscopic retrograde cholangiopancreatography(ERCP)techniques fail.The use of a percutaneous transluminal angioplasty balloon(PTAB),originally developed for vascular interventions,can be used to facilitate transmural(e.g.,transgastric)PD access and to dilate high-grade pancreatic strictures.AIM To describe the technique,efficacy,and safety of PTABs for EUS-guided PD interventions.METHODS Patients who underwent EUS with use of a PTAB from March 2011 to August 2021 were retrospectively identified from a tertiary care medical center supply database.PTABs included 3-4 French angioplasty catheters with 3-4 mm balloons designed to use over a 0.018-inch guidewire.The primary outcome was technical success.Secondary outcomes included incidence of adverse events(AEs)and need for early reintervention.RESULTS A total of 23 patients were identified(48%female,mean age 55.8 years).Chronic pancreatitis was the underlying etiology in 13(56.5%)patients,surgically altered anatomy(SAA)with stricture in 7(30.4%),and SAA with post-operative leak in 3(13.0%).Technical success was achieved in 20(87%)cases.Overall AE rate was 26%(n=6).All AEs were mild and included 1 pancreatic duct leak,2 cases of post-procedure pancreatitis,and 3 admissions for post-procedural pain.No patients required early re-intervention.CONCLUSION EUS-guided use of PTABs for PD access and/or stricture management is feasible with an acceptable safety profile and can be considered in patients when conventional ERCP cannulation fails.

Endoscopic ultrasound-guided injectable therapy for pancreatic cancer:A systematic review

BACKGROUND Given the low survival rate in pancreatic cancer,new therapeutic techniques have been explored,especially for unresectable or borderline resectable disease.Endoscopic ultrasound(EUS)provides real-time imaging and minimally invasive access for local and targeted injection of anti-tumor agents directly into the pancreatic tumor.Limited studies have been reported using this technique for the treatment of pancreatic ductal adenocarcinoma(PDAC).AIM To evaluate the progress made with EUS-guided injectable therapies in the treatment of PDAC.METHODS All original articles published in English until July 15,2021,were retrieved via a library-assisted literature search from Ovid Evidence-Based Medicine Reviews and Scopus databases.Reference lists were reviewed to identify additional relevant articles.Prospective clinical studies evaluating the use of EUS-guided injectable therapies in PDAC were included.Studies primarily directed at non-EUS injectable therapies and other malignancies were excluded.Retrieved manuscripts were reviewed descriptively with on critical appraisal of published studies based on their methods and outcome measures such as safety,feasibility,and effectiveness in terms of tumor response and survival.Heterogeneity in data outcomes and therapeutic techniques limited the ability to perform comparative statistical analysis.RESULTS A total of thirteen articles(503 patients)were found eligible for inclusion.The EUS-injectable therapies used were heterogeneous among the studies consisting of immunotherapy(n=5)in 59 patients,chemotherapy(n=1)in 36 patients,and viral and other biological therapies(n=7)in 408 patients.Eleven of the studies reviewed were single armed while two were double armed with one randomized trial and one non-randomized comparative study.Overall,the included studies demonstrated EUS-guided injectable therapies to be safe and feasible with different agents as monotherapy or in conjunction with other modalities.Promising results were also observed regarding their efficacy and survival parameters in patients with PDAC.CONCLUSION EUS-guided injectable therapies,including immunotherapy,chemotherapy,and viral or other biological therapies have shown minimal adverse events and potential efficacy in the treatment of PDAC.Comparative studies,including controlled trials,are required to confirm these results in order to offer novel EUS-based treatment options for patients with PDAC.

内镜下胰管支架置入术用于缓解胰腺癌患者的疼痛:系统综述与meta分析

背景:腹痛是一种致人衰弱的症状,大约80%的胰腺癌患者都会出现腹痛。胰管减压虽然未被广泛采纳,但有报道该方法能缓解腹痛症状。本研究旨在评估内镜下胰管减压对于缓解胰腺癌患者餐后梗阻型腹痛的作用、效果及安全性。方法:该系统综述的文献检索时间截至2020年10月7日。由两位研究者独立地筛选文献、提取数据,并对文献质量进行评估。结果:12篇文献共计192例有腹痛症状且尝试胰管减压的胰腺癌患者纳入研究。其中,167例患者成功完成胰管减压(平均年龄62.5岁,58.7%为男性)。159(95.2%)例患者采用塑料支架。所有被纳入的研究均报道了胰管支架置入术后患者疼痛部分或完全缓解,缓解率为93%(95%CI:79%-100%)。平均的疼痛缓解期为94˘16天。内镜逆行性胰胆管造影(ERCP)相关的不良反应包括括约肌切开术后出血(1.8%)、ERCP后胰腺炎(0.6%)和胰管出血(0.6%)。2例行内镜超声引导的胰管减压患者未报道任何不良反应。在成功置入支架的167例患者中,支架移位和支架阻塞的发生率分别为3.6%和3.0%。未报道不良反应相关的死亡病例。文献质量评估提示,绝大部分文献质量较低或难以评价。结论:初步分析结果表明,对于部分经选择的胰腺癌病例,内镜下胰管引流可能是缓解梗阻型疼痛一种安全有效的方法。但该侵入性方法的作用尚需随机对照研究来进一步明确。

Endo-anesthesia:a primer

Gastrointestinal(GI)endoscopy has witnessed a Cambrian explosion of techniques,indications,and expanding target populations.GI endoscopy encompasses traditional domains that include preventive measures,palliation,as alternative therapies in patients with prohibitive risks of more invasive procedures,and indicated primary treatments.But,it has expanded to include therapeutic and diagnostic interventional endosonography,luminal endoscopic resection,third space endotherapy,endohepatology,and endobariatrics.The lines between surgery and endoscopy are blurred on many occasions within this paradigm.Moreover,patients with high degrees of co-morbidity and complex physiology require more nuanced peri-endoscopic management.The rising demand for endoscopy services has resulted in the development of endoscopy referral centers that offer these invasive procedures as directly booked referrals for regional and rural patients.This further necessitates specialized programs to ensure appropriate evaluation,risk stratification,and optimization for safe sedation and general anesthesia if needed.This landscape is conducive to the organic evolution of endo-anesthesia to meet the needs of these focused and evolving practices.In this primer,we delineate important aspects of endo-anesthesia care and provide relevant clinical and logistical considerations pertaining to the breadth of procedures.

建立一个窄带成像分型以减少胃息肉的常规活检

背景:上消化道内镜检查时意外发现的胃息肉大多都是低风险的,但目前的指南推荐对所有的胃息肉都进行活检以进行组织病理学分析。我们设计了一个简单的窄带成像(NBI)分型,旨在减少对低危胃息肉的常规活检。方法:筛选出具有组织病理学诊断的73枚息肉,提取其NBI影像和白光影像,进行诊断性队列研究。两名并不清楚息肉性质的内镜医生对每枚息肉的NBI特征进行独立评估,包括颜色、血管模式和表面结构,并将这些特征进行各种组合,从而建立一个分型标准,以鉴别低危息肉(基底腺性或增生性息肉)与高危息肉(腺瘤或腺癌)以及基底腺性息肉(FGP)和非FGP。结果:孤立网状的血管模式和均质或缺失的表面结构可有效鉴别低危与高危胃息肉。将这两个特征相结合来诊断高危息肉,可获得100%的阴性预测值(95%CI:100%-100%),阳性预测值为13.7%(95%CI:2.6%-24.8%),灵敏度和特异度分别为100%(95%CI:100%-100%)和53.7%(95%CI:45.3%-62.0%);可将需要活检的息肉数量减少50%的同时,不会漏掉一例高危息肉。采用孤立网状的血管模式来判断无需活检的FGP,其阴性预测值高达94.9%(95%CI:89.2%-100%),阳性预测值为63.2%(95%CI:47.2%-79.2%),灵敏度和特异度分别为94.8%(95%CI:89.5%-100%)和63.6%(95%CI:51.3%-76.0%)。结论:这项推导性队列研究发现,NBI有助于高危与低危胃息肉的鉴别,从而对减少低危息肉的常规活检。这些结果需要在不同的研究人群中进行验证。