Colonoscopic perforation:A report from World Gastroenterology Organization endoscopy training center in Thailand

AIM： To determine the incidence of colonoscopic perforation （CP）, and evaluate clinical findings, management and outcomes of patients with CP from the World Gastroenterology Organization （WGO） Endoscopy Training Center in Thailand. METHODS： All colonoscopies and sigmoidoscopies performed between 1999 and 2007 in the Endoscopic unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok were reviewed. Incidence of CP, patients＇ characteristics, endoscopic information, intraoperative findings, management and outcomes were analyzed. RESULTS： A total of 17357 endoscopic procedures of the colon （13 699 colonoscopies and 3658 flexible sigmoidoscopies） were performed in Siriraj hospital over a 9-year period. Fifteen patients （0.09%） had CP： 14 from colonoscopy and 1 from sigmoidoscopy. The most common site of perforation was in the sigmoid colon （80%）, followed by the transverse colon （13%）. Perforations were caused by direct trauma from either the shaft or the tip of the endoscope （n = 12,80%） and endoscopic polypectomy （n = 3, 20%）. All patients with CP underwent surgical management： primary repair （27%） and bowel resection （73%）. The mortality rate was 13% and postoperative complication rate was 53%. CONCLUSION： CP is a rare but serious complication following colonoscopy and sigmoidoscopy, with high rates of morbidity and mortality. Incidence of CP was 0.09%. Surgery is still the mainstay of CP management.

Prevention program for the COVID-19 in a children’s digestive endoscopy center

The pneumonia caused by the coronavirus disease-2019(COVID-19)outbreak in Wuhan,China constitutes a public health emergency of international concern.The gastrointestinal symptoms of vomiting,diarrhea and abdominal pain and the detection of COVID-19 nucleic acid from fecal specimens in a small number of patients suggest the possibility of transmission via the gastrointestinal tract.People of all ages are vulnerable to this virus,including children.Digestive endoscopy is an invasive procedure during which children cannot wear masks;therefore,they have higher risks of exposure to COVID-19,and the digestive endoscopy center is a relatively high-risk area for COVID-19 infection.Based on these factors and in combination with related policies and regulations,a prevention and control program for the COVID-19 pneumonia in a children's digestive endoscopy center was established to prevent the COVID-19 nosocomial infection.

Establishing a model to measure and predict the quality of gastrointestinal endoscopy

BACKGROUND Tens of millions of gastrointestinal endoscopic procedures are performed every year in China,but the quality varies significantly and related factors are complex.Individual endoscopist-and endoscopy division-related factors may be useful to establish a model to measure and predict the quality of endoscopy.AIM To establish a model to measure and predict the quality of gastrointestinal endoscopic procedures in China's Mainland.METHODS Selected data on endoscopy experience,equipment,facility,qualification of endoscopists,and other relevant variables were collected from the National Database of Digestive Endoscopy of China.The multivariable logistic regression analysis was used to identify the potential predictive variables for occurrence of medical malpractice and patient disturbance.Linear and nonlinear regressions were used to establish models to predict incidence of endoscopic complications.RESULTS In 2012,gastroscopy/colonoscopy-related complications in China's Mainland included bleeding in 4,359 cases(0.02%)and perforation in 914(0.003%).Endoscopic-retrograde-cholangiopancreatography-related complications included severe acute pancreatitis in 593 cases(0.3%),bleeding in 2,151(1.10%),perforation in 257(0.13%)and biliary infection in 4,125(2.11%).Moreover,1,313(5.0%)endoscopists encountered with medical malpractice,and 5,243(20.0%)encountered with the disturbance from patients.The length of endoscopy experience,weekly working hours,weekly night shifts,annual vacation days and job satisfaction were predictors for the occurrence of medical malpractice and patient disturbance.However,the length of endoscopy experience and the ratio of endoscopists to nurses were not adequate to establish an effective predictive model for endoscopy complications.CONCLUSION The workload and job satisfaction of endoscopists are valuable predictors for medical malpractice or patient disturbance.More comprehensive data are needed to establish quality-predictive models for endoscopic complications.

The Therapeutic Effect of Biling Weitong Granules Combined with Oryz-Aspergillus Enzyme and Pancreatin Tablet on Reflux Esophagitis with Functional Dyspepsia

Objective:To investigate the therapeutic effect of Biling Weitong Granules combined with oryz-aspergillus enzyme and pancreatin tablets on patients with reflux esophagitis with functional dyspepsia.Methods:Sixty patients diagnosed with reflux esophagitis with functional dyspepsia who were admitted to the Affiliated Hospital of Hebei University between June 2020 and June 2023 were selected and divided into two groups:the control group and the observation group,each consisting of 30 cases.The control group received oryz-aspergillus enzyme and pancreatin tablets only,while the observation group received Biling Weitong Granules in addition to the tablets.The clinical efficacy,Chinese medicine syndrome points,esophageal kinetic indexes,gastrointestinal hormone levels,and therapeutic safety of both groups were evaluated.Results:The total efficiency of the observation group reached 93.33%,significantly higher than the 73.33%of the control group(P<0.05).After treatment,patients in the observation group exhibited significantly lower scores for Chinese medicine symptoms such as early satiety,belching,abdominal distension,abdominal pain,and loss of appetite compared to the control group(P<0.05).Furthermore,the observation group showed significantly higher upper esophageal sphincter pressure,lower esophageal sphincter pressure,and distal esophageal contraction scores compared to the control group(P<0.05).Additionally,levels of gastric motility hormone,vasoactive intestinal peptide,and gastrin were significantly higher in the observation group compared to the control group(P<0.05).Throughout the treatment period,there was no significant difference in the incidence of adverse reactions between the two groups,indicating comparable safety of the two treatment modalities(P>0.05).Conclusion:The combination of Biling Weitong Granules with oryz-aspergillus enzyme and pancreatin tablets demonstrates significant efficacy in the treatment of reflux esophagitis with functional dyspepsia,with a better safety profile.This finding warrants further clinical promotion.

Comparison of efficacy and safety of transpancreatic septotomy, needle-knife fistulotomy or both based on biliary cannulation unintentional pancreatic access and papillary morphology

Background: Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography(ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy(TPS), needle-knife fistulotomy(NKF) or both based on the presence of unintentional pancreatic access and papillary morphology. Methods: Between March 2008 and December 2016, 157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified. Precut techniques were chosen depending on repetitive inadvertent pancreatic cannulation and the papillary morphology. We retrospectively assessed the rates of cannulation success and procedure-related complications among three groups, namely TPS, NKF, and TPS followed by NKF. Results: The baseline characteristics of the three groups were comparable. The overall success rate of biliary cannulation reached 98.1%, including 111 of 113(98.2%) with TPS, 35 of 36(97.2%) with NKF and 8 of 8(100%) with NKF following TPS, without significant difference among groups. The incidences of total complications and post-ERCP pancreatitis were 9.6% and 7.6%, respectively. There was a trend towards less frequent post-ERCP pancreatitis after NKF(0%) compared with 11 cases(9.7%) after TPS and one case(12.5%) after NKF following TPS, but not significantly different( P = 0.07). No severe adverse event occurred during this study period. Conclusions: The choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.

Antimicrobial prophylaxis in patients with colorectal lesions undergoing endoscopic resection

AIM: To investigate the effect of prophylaxis withantibiotics on clinical adverse events in patients who underwent endoscopic submucosal dissection(ESD) or endoscopic mucosal resection(EMR) for colorectal lesions.METHODS: From June 2011 to December 2013, a total of 428 patients were enrolled into the study, of which 214 patients admitted to hospital underwent EMR or ESD procedures. These patients were randomized to an antibiotic group, in which patients were given cefuroxime 1.5 g iv half an hour before and 6 h after surgery respectively, and a control group, in which patients were not given any antibiotic. A further 214 outpatients with small polyps treated by polypectomy were compared with controls that were matched by age and gender, and operations were performed as outpatient surgery. Recorded patient parameters were demographics, characteristics of lesions and treatment modality, and the size of the wound area. The primary outcome measures were clinical adverse events, including abdominal pain, diarrhea, hemotachezia, and fever. Secondary outcome measures were white blood cell count, C-reactive protein and blood culture. Additionlly, the relationship between the size of the wound area and clinical adverse events was analyzed. RESULTS: A total of 409 patients were enrolled in this study, with 107 patients in the control group, 107 patients in the antibiotic group, and another 195 cases in the follow-up outpatient group. The patients' demographic characteristics, including age, gender, characteristics of lesions, treatment modality, and the size of the wound area were similar between the 2 groups. The rates of adverse events in the antibiotic group were significantly lower than in the control group: abdominal pain(2.8% vs 14.9%, P < 0.01), diarrhea(2.0% vs 9.3%, P < 0.05), and fever(0.9% vs 8.4%, P < 0.05) respectively. The levels of inflammatory markers also decreased significantly in the antibiotic group compared with the control group: leukocytosis(2.0% vs 11.2%, P < 0.01), and C-reactiveprotein(2.0% vs 10.7%, P < 0.05). Additionally, clinica adverse events were related to the size of the surgica wound area. When the surgical wound area was larger than 10 mm × 10 mm, there were more clinica adverse events.CONCLUSION: Clinical adverse events are not uncommon after EMR or ESD procedures. Prophylactic antibiotics can reduce the incidence of clinical adverse events. This should be further explored.

Meta-analysis reveals an association between acute pancreatitis and the risk of pancreatic cancer

BACKGROUND Chronic pancreatitis is associated with pancreatic cancer(PC),although the relationship between acute pancreatitis(AP)and the risk of PC remains unclear due to inconsistent and contradictory results.AIM To conduct a meta-analysis of retrospective and prospective studies to explore the association between AP and PC risk.METHODS We first searched original articles on the association of AP with PC using PubMed,Web of Science,Cochrane,and EMBASE databases.Then we calculated the combined overall effect estimates(EEs)between AP and PC risk at a 95%confidence interval(CI)deploying a random-effects model,and assessed heterogeneity using the I2 test.The combined relative risk with 95%CI was performed to examine the relationship between AP and PC.Publication bias and subgroup analyses were also conducted.Furthermore,we performed sensitivity analysis to explain this heterogeneity.RESULTS Eleven studies were eligible for inclusion standards in this meta-analysis,resulting in pooled EEs of 2.07(95%CI:1.36-2.78)for AP and PC risk.Additionally,five prospective cohort studies reported 103961 patients in the AP group,relative to 1442158 subjects in the control group,with a pooled relative risk of 7.81(95%CI:5.00-12.19).We also performed subgroup analyses using different follow-up times and type of research methods(case-control or cohort).Results from analyses of different follow-up times revealed the following pooled effect values:1-year lag period(EEs=23.47,95%CI:3.26-43.68),2-year lag period(EEs=9.82,95%CI:3.01-16.64),5-year lag period(EEs=2.47,95%CI:1.93-3.02),10-year lag period(EEs=1.69,95%CI:1.26-2.11),and>10-year lag period(EEs=1.17,95%CI:0.78-1.57).With regards to the methods,the case-control studies recorded EEs=3.03(95%CI:-1.02 to 7.08),whereas cohort studies had EEs=2.09(95%CI:1.22-2.97)pooled effect values.CONCLUSION Overall,our findings indicated an association between AP and PC risk.Based on subgroup analyses,AP is unlikely to be a causal factor for PC.

Acute pancreatitis and small bowel obstruction caused by a migratory gastric bezoar after dissolution therapy: A case report

BACKGROUND Bezoars are conglomerates of indigestible foreign material that can be found in the gastrointestinal tract.Gastric ulcer,gastrointestinal perforation,and intestinal obstruction are the main complications.Acute pancreatitis secondary to bezoar is rare.Here,we present a rare case of a migratory gastric bezoar complicated by acute pancreatitis and small bowel obstruction after dissolution therapy.CASE SUMMARY A-65-year-old woman underwent gastroscopy because of epigastric pain,which revealed a huge bezoar and a gastric ulcer 10 d prior.The patient was discharged with a prescription of drinking 1 L Coca-Cola daily for 6 d,without repeat gastroscopy.However,she suddenly developed epigastric pain,nausea and vomiting for 3 d.Abdominal computed tomography(CT)revealed mild inflammation of the pancreas.Magnetic resonance cholangiopancreatography showed no abnormalities in the pancreatic duct or common bile duct.The nasogastric tube still showed drainage of more than 1.6 L of dark fluid each day after symptomatic treatment.Abdominal CT re-examination suggested intestinal obstruction.Esophagogastroduodenoscopy revealed a huge yellowish hard mass in the jejunal lumen,and we used the basket and net to fragment the bezoar.She was discharged with a good outcome.CONCLUSION Endoscopic therapy is the first choice for gastric bezoars.When mechanical disintegration cannot be achieved,timing of repeat endoscopy is important during Coca-Cola dissolution therapy.

Endoscopic diagnosis and treatment of an appendiceal mucocele:A case report

BACKGROUND Appendiceal mucocele is a rare disease that causes obstructive dilatation of the appendix due to the intraluminal accumulation of mucin.We report a case of endoscopic diagnosis and treatment of an appendiceal mucocele.CASE SUMMARY A 47-year-old man presented with a protrusion around the orifice of the appendix discovered by colonoscopy incidentally.He was admitted to our hospital for a routine checkup without any symptoms.Abdominal computed tomography showed a cystic mass approximately 3 cm in diameter with fat stranding.The preoperative diagnosis was non-neoplastic appendiceal mucocele,and endoscopic treatment was performed.The endoscopic findings and pathological results supported our preoperative diagnosis.The endoscopic treatment of appendiceal mucocele was feasible and effective,which was confirmed by repeated endoscopy and post-operative computed tomography after 7 mo.CONCLUSION Endoscopic therapy provides a new method for the treatment of appendiceal mucocele.

Predictors of difficult endoscopic resection of submucosal tumors originating from the muscularis propria layer at the esophagogastric junction

BACKGROUND Endoscopic resection approaches,including endoscopic submucosal dissection(ESD),submucosal tunneling endoscopic resection(STER)and endoscopic fullthickness resection(EFTR),have been widely used for the treatment of submucosal tumors(SMTs)located in the upper gastrointestinal tract.However,compared to SMTs located in the esophagus or stomach,endoscopic resection of SMTs from the esophagogastric junction(EGJ)is much more difficult because of the sharp angle and narrow lumen of the EGJ.SMTs originating from the muscularis propria(MP)in the EGJ,especially those that grow extraluminally and adhere closely to the serosa,make endoscopic resection even more difficult.AIM To investigate the predictors of difficult endoscopic resection for SMTs from the MP layer at the EGJ.METHODS A total of 90 patients with SMTs from the MP layer at the EGJ were included in the present study.The difficulty of endoscopic resection was defined as a long procedure time,failure of en bloc resection and intraoperative bleeding.Clinicopathological,endoscopic and follow-up data were collected and analyzed.Statistical analysis of independent risks for piecemeal resection,long operative time,and intraoperative bleeding were assessed using univariate and multivariate analyses.RESULTS According to the location and growth pattern of the tumor,44 patients underwent STER,14 patients underwent EFTR,and the remaining 32 patients received a standard ESD procedure.The tumor size was 20.0 mm(range 5.0–100.0 mm).Fourty-seven out of 90 lesions(52.2%)were regularly shaped.The overall en bloc resection rate was 84.4%.The operation time was 43 min(range 16–126 min).The intraoperative bleeding rate was 18.9%.There were no adverse events that required therapeutic intervention during or after the procedures.The surgical approach had no significant correlation with en bloc resection,long operative time or intraoperative bleeding.Large tumor size(≥30 mm)and irregular tumor shape were independent predictors for piecemeal resection(OR:7.346,P=0.032 and OR:18.004,P=0.029,respectively),long operative time(≥60 min)(OR:47.330,P=0.000 and OR:6.863,P=0.034,respectively)and intraoperative bleeding(OR:20.631,P=0.002 and OR:19.020,P=0.021,respectively).CONCLUSION Endoscopic resection is an effective treatment for SMTs in the MP layer at the EGJ.Tumors with large size and irregular shape were independent predictors for difficult endoscopic resection.

完全子宫纵隔、双宫颈、阴道纵隔的宫腔镜下子宫成形术

Objective: To determine if sectioning of the cervical septum in hysteroscopic metroplasty of the complete uterine septum is associated with intraoperative bleeding, cervical incompetence, and secondary infertility. Design: Multicenter, randomized, controlled clinical trial. Setting: University hospitals. Patient(s): Twenty-eight women with a diagnosis of complete uterine septum who had a history of pregnancy wastage or infertility. They were randomized into two groups: group A underwent metroplasty including section of the cervical septum; group B underwent the same procedure with preservation of the cervical septum. Intervention(s): Hysteroscopic metroplasty was performed for all patients in the two groups. Main Outcome Measure(s): Operating time, distending media deficit, total distending media used, intraoperative bleeding, complications, and reproductive outcome. Result(s): Operating times were 36.40 ± 10.67 minutes and 73 ± 14.40 minutes in group A and group B, respectively. Distending media deficit was 456.66 ± 165.68m Lin group A,while in groupB it was 673.84± 220.36. Two cases of pulmonary edema and three cases of significant bleeding ( > 150 mL)were seen in group B. The cesarean section rate was significantly higher in group B. There were no signifi cant differences in the reproductive outcome in the two groups. Conclusion(s): Resection of the cervical septum during hysteroscopic metroplasty of complete uterine septum makes the procedure safer, easier, and less complicated than the procedure with preservation of the cervical septum. This procedure is recommended for all cases of complete uterine septum.

Failure of sequential biliary stenting for unsuccessful common bile duct stone removal

AIM: To determine the factors associated with the failure of stone removal by a biliary stenting strategy. METHODS: We retrospectively reviewed 645 patients with common bile duct (CBD) stones who underwent endoscopic retrograde cholangiography for stone removal in Siriraj GI Endoscopy center, Siriraj Hospital from June 2009 to June 2012. A total of 42 patients with unsuccessful initial removal of large CBD stones that underwent sequential biliary stenting were enrolled in the present study. The demographic data, laboratory results, stone characteristics, procedure details, and clinical outcomes were recorded and analyzed. In addition, the patients were classified into two groups based on outcome, successful or failed sequential biliary stenting, and the above factors were compared. RESULTS: Among the initial 42 patients with unsuccessful initial removal of large CBD stones, there were 37 successful biliary stenting cases and five failed cases. Complete CBD clearance was achieved in 88.0% of cases. The average number of sessions needed beforecomplete stone removal was achieved was 2.43 at an average of 25 wk after the first procedure. Complications during the follow-up period occurred in 19.1% of cases, comprising ascending cholangitis (14.3%) and pancreatitis (4.8%). The factors associated with failure of complete CBD stone clearance in the biliary stenting group were unchanged CBD stone size after the first biliary stenting attempt (10.2 wk) and a greater number of endoscopic retrograde cholangio-pancreatography sessions performed (4.2 sessions). CONCLUSION: The sequential biliary stenting is an effective management strategy for the failure of initial large CBD stone removal.

Burden of digestive system diseases in China and its provinces during 1990-2019:Results of the 2019 Global Disease Burden Study

Background:Evaluating the impact of digestive system diseases is vital for devising effective prevention strategies.However,comprehensive reports on the burden of digestive system diseases in China are lacking.Our study aimed to provide an overview of the burden and trends of digestive system diseases from 1990 to 2019 in China and its provinces.Methods:This cross-sectional study utilized the Global Disease Burden Study 2019 to estimate the incidence,mortality rate,disability-adjusted life years(DALYs),years of life disability,years of life lost,and changes in the burden of digestive diseases across Chinese provinces from 1990 to 2019.The analysis of disease burden primarily examines the characteristics of sub-disease distribution,time trends,age distribution,and sex distribution.Additionally,we compared provincial age-standardized DALYs for digestive diseases with the expected rates based on the socio-demographic index(SDI).Results:In 2019,there were 499.2 million cases of digestive system diseases in China,resulting in 1,557,310 deaths.Stomach cancer,colon and rectal cancer,and esophageal cancer are the top three diseases associated with mortality and DALY related to digestive system diseases.Meanwhile,cirrhosis and other chronic liver diseases,gastroesophageal reflux disease,and gallbladder and biliary diseases are the top three kinds of diseases with the highest prevalence among digestive system diseases.The risk of gastric cancer sharply increases among men after the age of 40 years,leading to a significant disparity in burden between men and women.As the SDI increased,the DALYs associated with digestive system diseases in China and its provinces showed a downward trend.Conclusion:Our study highlights the inverse correlation between DALYs associated with digestive system diseases and the SDI.