Detachable string magnetically controlled capsule endoscopy for the noninvasive diagnosis of esophageal diseases: A prospective, blind clinical study.

BACKGROUND: Traditional esophagogastroduodenoscopy (EGD), an invasive examination method, can cause discomfort and pain in patients. In contrast, magnetically controlled capsule endoscopy (MCE), a noninvasive method, is being applied for the detection of stomach and small intestinal diseases, but its application in treating esophageal diseases is not widespread. AIM: To evaluate the safety and efficacy of detachable string MCE (ds-MCE) for the diagnosis of esophageal diseases. METHODS: Fifty patients who had been diagnosed with esophageal diseases were prospectively recruited for this clinical study and underwent ds-MCE and conventional EGD. The primary endpoints included the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of ds-MCE for patients with esophageal diseases. The secondary endpoints consisted of visualizing the esophageal and dentate lines, as well as the subjects' tolerance of the procedure. RESULTS: Using EGD as the gold standard, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of ds-MCE for esophageal disease detection were 85.71%, 86.21%, 81.82%, 89.29%, and 86%, respectively. ds-MCE was more comfortable and convenient than EGD was, with 80% of patients feeling that ds-MCE examination was very comfortable or comfortable and 50% of patients believing that detachable string v examination was very convenient. CONCLUSION: This study revealed that ds-MCE has the same diagnostic effects as traditional EGD for esophageal diseases and is more comfortable and convenient than EGD, providing a novel noninvasive method for treating esophageal diseases.

Usefulness of Direct Peroral Cholangioscopy Using a Multibending Ultraslim Endoscope for the Management of Intrahepatic Bile Duct Lesions (with Videos).

Background/Aims: : Peroral cholangioscopy (POC) has been used to assess intrahepatic duct (IHD) lesions but with a limited role. A new multibending (MB) ultraslim endoscope has been designed to improve POC performance. We evaluated the usefulness of POC using the MB ultraslim endoscope for the management of IHD lesions. Methods: : Between March 2017 and March 2020, 22 patients underwent direct POC using the MB ultraslim endoscope for IHD lesions documented by previous imaging or cholangiopancreatography. The primary outcome was technical success of POC, and secondary outcomes were technical success of POC-guided interventions, median procedure time, and POC-related adverse events. Results: : The technical success rate for POC using the MB ultraslim endoscope for IHD lesions was 95.5% (21/22). Free-hand insertion was successful in 95.2% (20/21). The overall technical success rate for POC-guided intervention was 100% (21/21), including nine diagnostic and 12 therapeutic procedures (eight direct stone removal and four intraductal lithotripsies). The median procedure time was 29 minutes (range, 9 to 79 minutes). There were no procedure-related adverse events. Conclusions: : Direct POC using the MB ultraslim endoscope allows direct visualization of IHD lesions and may be useful for diagnosis and therapeutic management in selected patients.

Transnasal endoscopy ease score "TNEase score" to evaluate patient tolerance of unsedated transnasal endoscopy.

Transnasal endoscopy (TNE) with virtual reality (VR) distraction allows for unsedated pediatric upper endoscopy. Understanding the pediatric population that is successful with TNE is imperative for patient selection and experience. We developed a "TNEase Score" to assess patient tolerance from the physician's assessment. The aim of this study was to identify factors that influence patient's acceptance and tolerability of sedation-free TNE in pediatric patients undergoing the procedure. From March 2020 to April 2021, 110 TNEs were performed on subjects 5-22 years of age. The overall completion rate was 98.1%. Of these subjects, 66 subjects (60%) were graded by the gastroenterologist as TNEase Score 1 (with ease); 27 subjects (25%) were graded as TNEase Score 2 (minimal complaints); nine subjects (8%) were graded as TNEase score 3 (moderate complaints, required frequent reassurance); six subjects were graded as TNEase Score 4 (significant complaints and resistance); two subjects (2%) were graded as TNEase Score 5 (procedure terminated). Feasibility of TNE was significantly related to age, height, and whether the patient had undergone previous TNE. Thus, young age, shorter height, and first time TNE were significant predictors of higher TNEase score or difficulty tolerating TNE. Factors examined that did not predict higher TNEase score included gender, junior versus senior endoscopist, past medical history of anxiety, autism, attention-deficit/hyperactivity disorder (ADHD), or history of using a nasal spray at home. "TNEase score" allowed grading of the subject's experience and the majority of patients tolerated TNE with minimal complaints.

Relationship between observation time and detection rate of focal lesions in Esophagogastroduodenoscopy: a single-center, retrospective study.

BACKGROUND: Current studies have shown that longer observation time can improve neoplastic detection rate. This study aimed to clarify whether endoscopists with longer observation times can detect more focal lesions. METHODS: Based on the mean examination time for Esophagogastroduodenoscopy (EGD) without biopsy, endoscopists were divided into fast and slow groups, and the detection rate of focal lesions was compared between the two groups. Univariate analysis, multivariate analysis and restricted cubic spline were used to explore the factors of focal lesion detection rate. RESULTS: Mean examination time of EGD without biopsy was 4.5 min. The cut-off times used were 5 min. 17 endoscopists were classified into the fast (4.7 ± 3.6 min), and 16 into the slow (7.11 ± 4.6 min) groups. Compared with fast endoscopists, slow endoscopists had a higher detection rate of focal lesions (47.2% vs. 51.4%, P < 0.001), especially in the detection of gastric lesions (29.7% vs. 35.9%, P < 0.001). In univariate and multivariate analyses, observation time, patient age and gender, expert, biopsy rate, and number of images were factors in FDR. There is a nonlinear relationship between observation time and FDR. CONCLUSION: Longer examination time improves the detection rate of focal lesions. Observation time is an important quality indicator of the EGD examination.

Ultrathin endoscope equipped with ultrasonic miniprobe for upper GI US in a porcine model.

BACKGROUND AND AIMS: Ultrathin EGD (UT-EGD) is an ideal tool for unsedated upper GI examination and pediatric gastroenterology but is rarely competent for EUS miniprobe (EUS-MP). We developed a UT-EGD US method (UT-EUS) and verified its clinical application value through animal experiments. METHODS: Five Bama miniature pigs were selected. Using an acoustic medium, we performed US on the duodenum, stomach, and esophagus, respectively, with conventional 20-MHz EUS miniprobe (EUS-MP-20), 20-MHz UT-EUS (UT-EUS-20), and 30-MHz UT-EUS (UT-EUS-30). The times to acquire 5 consecutive stable US images, number of identifiable wall layers, and quality and penetration depth of the images were recorded. RESULTS: No significant differences were found in the time required to obtain images between EUS-MP-20 and UT-EUS-20 at each site (P > .05). UT-EUS-30 showed more wall levels than UT-EUS-20 (P < .05). No significant differences were noted between EUS-MP-20 and UT-EUS-20 in imaging quality and penetration depth (P > .05). CONCLUSIONS: The UT-EUS is easy to use with a satisfactory image quality and has potential clinical application value.

Developing an electronic health record measure of low-value esophagogastroduodenoscopy for GERD at a large academic health system.

OBJECTIVES: Low-value esophagogastroduodenoscopies (EGDs) for uncomplicated gastro-oesophageal reflux disease (GERD) can harm patients and raise patient and payer costs. We developed an electronic health record (EHR) 'eMeasure' to detect low-value EGDs. DESIGN: Retrospective cohort of 518 adult patients diagnosed with GERD who underwent initial EGD between 1 January 2019 and 31 December 2019. SETTING: Outpatient primary care and gastroenterology clinics at a large, urban, academic health centre. PARTICIPANTS: Adult primary care patients at the University of California Los Angeles who underwent initial EGD for GERD in 2019. MAIN OUTCOME MEASURES: EGD appropriateness criteria were based on the American College of Gastroenterology 2012 guidelines. An initial EGD was considered low-value if it lacked a documented guideline-based indication, including alarm symptoms (eg, iron-deficiency anaemia); failure of an 8-week proton pump inhibitor trial or elevated Barrett's oesophagus risk. We performed manual chart review on a random sample of 204 patients as a gold standard of the eMeasure's validity. We estimated EGD costs using Medicare physician and facility fee rates. RESULTS: Among 518 initial EGDs performed (mean age 53 years; 54% female), the eMeasure identified 81 (16%) as low-value. The eMeasure's sensitivity was 42% (95% CI 22 to 61) and specificity was 93% (95% CI 89 to 96). Stratifying across clinics, 62 (74.6%) low-value EGDs originated from 2 (12.5%) out of 16 clinics. Total cost for 81 low-value EGDs was approximately US$75 573, including US$14 985 in patients' out-of-pocket costs. CONCLUSIONS: We developed a highly specific eMeasure that showed that low-value EGDs occurred frequently in our healthcare system and were concentrated in a minority of clinics. These results can inform future QI efforts at our institution, such as best practice alerts for the ordering physician. Moreover, this open-source eMeasure has a much broader potential impact, as it can be integrated into any EHR and improve medical decision-making at the point of care.

Upper Gastrointestinal Endoscopy Quality in Italy: A Nationwide Study.

BACKGROUND AND AIMS: International guidelines advise improving esophagogastroduodenoscopy (EGD) quality in Western countries, where gastric cancer is still diagnosed in advanced stages. This nationwide study investigated some indicators for the quality of EGD performed in endoscopic centers in Italy. METHODS: Clinical, endoscopic, and procedural data of consecutive EGDs performed in one month in the participating centers were reviewed and collected in a specific database. Some quality indicators before and during endoscopic procedures were evaluated. RESULTS: A total of 3,219 EGDs performed by 172 endoscopists in 28 centers were reviewed. Data found that some relevant information (family history for GI cancer, smoking habit, use of proton pump inhibitors) were not collected before endoscopy in 58.5-80.7% of patients. Pre-endoscopic preparation for gastric cleaning was routinely performed in only 2 (7.1%) centers. Regarding the procedure, sedation was not performed in 17.6% of patients, and virtual chromoendoscopy was frequently (>75%) used in only one (3.6%) center. An adequate sampling of the gastric mucosa (i.e., antral and gastric body specimens) was heterogeneously performed, and it was routinely performed only by 23% of endoscopists, and in 14.3% centers. CONCLUSIONS: Our analysis showed that the quality of EGD performed in clinical practice in Italy deserves to be urgently improved in different aspects.

Impact of COVID-19 Pandemic on Performance of Gastrointestinal Endoscopy.

Background/Aims: Non-time-sensitive gastrointestinal endoscopy was deferred because of the risk of exposure to coronavirus disease 2019 (COVID-19), but no population-based studies have quantified the adverse impact on gastrointestinal procedures. This study examined the impact of the COVID-19 pandemic on the performance of esophagogastroduodenoscopy (EGD), colonoscopy, ERCP, and abdominal ultrasonography (US) in South Korea. Methods: This nationwide, population-based study compared the claim data of EGD, colonoscopy, ERCP, and abdominal US in 2020 and 2021 (COVID-19 era) with those in 2019 (before the COVID-19 era). Results: During the first year (2020) of the COVID-19 pandemic, the annual claim data of EGD and colonoscopy were reduced by 6.3% and 6.9%, respectively, but those of ERCP and abdominal US were increased by 1.0% and 2.9%, compared to those in 2019. During the first surge (March and April 2020) of COVID-19, the monthly claim data of EGD, colonoscopy, ERCP, and abdominal US were reduced by 28.8%, 43.8%, 5.1%, and 21.6%, respectively, in March 2020, and also reduced by 17.2%, 32.8%, 4.4%, and 9.5%, respectively, in April 2020, compared to those in March and April 2019. During March and April 2020, the monthly claims of ERCP, compared with those in 2019, declined less significantly than those of EGD and colonoscopy (both p<0.001). Conclusions: The claims of EGD and colonoscopy were reduced more significantly than those of ERCP and abdominal US during the COVID-19 pandemic because ERCPs are time-sensitive procedures and abdominal USs are non-aerosolized procedures.

A 2-week intensive gastrointestinal endoscopy training program for pediatricians.

BACKGROUND: In Japan there are limited opportunities for pediatricians to learn gastrointestinal (GI) endoscopy. This study investigated whether a short-term intensive training for 2 weeks in an adult GI setting enabled pediatricians to acquire basic technical competence for pediatric GI endoscopic procedures. METHODS: This was a retrospective case series of pediatricians who underwent 2 weeks of intensive endoscopy training at an adult endoscopy unit in a community hospital. The numbers of esophagogastroduodenoscopy (EGD) and ileocolonoscopy procedures each pediatrician performed were evaluated. All enrolled pediatricians were asked to answer questionnaires regarding the 2 week intensive GI endoscopy training program. RESULTS: There were 17 enrolled pediatricians, of whom 13 were men; average age 32 years (range 27-54). The median (range) numbers of EGDs and ileocolonoscopies performed by each pediatrician during the 2-week training period were 102 (66-144) and 14 (1-48), respectively. Fifteen out of 17 pediatricians experienced more than 100 GI endoscopies during the 2 weeks. All pediatricians performed biopsies as part of some EGD procedures. All 17 pediatricians found this program satisfactory. All pediatricians became cable of performing pediatric EGD (i.e., for children ≤15 years) after this training program. Sixteen pediatricians have continued to perform pediatric GI endoscopy since this training program. CONCLUSIONS: A short-term intensive training program for 2 weeks in an adult GI setting enabled pediatricians to acquire basic technical competence for pediatric endoscopic procedures.

Cholangioscopy under direct visualization: skill progress during a dedicated Image-Guided Surgery Course.

AIMS: Training programs are essential to introduce new methods for bile duct clearance. Visual examination via cholangioscopy is ideal to diagnose and treat biliary tract diseases such as cancer and choledocholithiasis. However, surgeons rarely use cholangioscopes. Specific training is required to master laparoscopic and percutaneous cholangioscopy. This study aims to assess skill acquisition and retention during cholangioscopy training in the Image-Guided Therapies Masterclass. METHODS: This prospective study enrolled 17 physicians undergoing training in interventional treatments of biliary diseases. A novel disposable cholangioscope and access kit were used with a biliary tract model including two simulated common bile duct (CBD) stones. The curriculum required visualization of all critical structures before removal of one stone with a Dormia basket. After informed consent, demographic data and time to exercise completion were recorded on each of two subsequent training days. Task-specific questions were measured at the completion of training using a Likert scale (strongly disagree to strongly agree, 1-5 points). RESULTS: All participants successfully completed the task (6F/11 M, age 36 ± 5 years; 13 surgeons, 4 interventional radiologists; median experience with percutaneous procedures 2 years, range 0-20). Significant improvement in mean task completion time was observed (day 1: 172 ± 59 s, day 2: 89 ± 45 s; P < 0.0001). All task-specific questions were answered with a median rating of 5/5: "The platform facilitates cholangioscopy" and "This training method accelerates gain in proficiency and is useful for residents/fellows" (IQR 5-5), "This platform is useful to measure the proficiency level" and "There is an application for simulation in percutaneous surgery training" (IQR 4.5-5), "The platform is user-friendly" and "The model quality recreates realistic scenarios" (IQR 4-5). CONCLUSION: Cholangioscopic bile duct exploration and stone retrieval were achieved by all participants using a dedicated training program and physical simulator. Significant skill progress was observed during 2 days of dedicated training.

Percutaneous transhepatic cholangioscopy for benign and malignant biliary disease using a novel short single-operator cholangioscope.

BACKGROUND: The length of conventional single-use cholangioscopes poses a challenge for percutaneous or laparoscopic approaches for direct visualization of the biliary tract. The aim of this retrospective observational clinical study was to assess the use of a dedicated percutaneous short single-operator cholangioscope (PSSOC) for diagnosis and treatment of benign or malignant biliary diseases. METHODS: Retrospective analysis of a prospectively maintained database including all consecutive patients undergoing percutaneous transhepatic cholangioscopy with the PSSOC between 06/2021 and 01/2023. RESULTS: Forty patients were included (22F/18 M, age 58.7 ± 16.7 years). The diagnostic and therapeutic management plan was based on procedural findings. Indications were bile duct obstruction associated with complex anatomy (n = 13), choledocholithiasis (n = 11), suspected malignant stenosis of the biliary tract (n = 11), biliary stent placement (n = 2) and removal (n = 1), and failed endoscopic retrograde cholangiopancreatography (n = 2). The cholangioscopies were diagnostic (n = 5), therapeutic (n = 20) or both simultaneously (n = 15). The most frequent procedures were electrohydraulic lithotripsy (n = 25) and biopsy sampling (n = 12). Complications occurred in 7 cases (17.5%), including cholangitis (n = 4, B2), pleural perforation (n = 1, B2), portal bleeding (n = 1, B3), and Tako-Tsubo syndrome (n = 1, B3), classified according to the Society of Interventional Radiology classification. Intraprocedural visual diagnosis was confirmed by the histopathologic result in 11/12 patients in which biopsies were performed (91.7%). PSSOC was relevant to avoid surgery in 2 patients (5%) with indeterminate strictures, allowing to rule out malignancy and treat the lithiasis. CONCLUSIONS: Direct visualization of the biliary tract enabled targeted biopsies for histopathological diagnosis. The visual and histopathological diagnoses were concordant in all but one case. Percutaneous cholangioscopy with a dedicated PSSOC allows to optimize identification and treatment of complex biliary disease including biliary lithiasis while assessing bile duct patency. The clinical use of the novel PSSOC system was safe and effective and could prevent surgical exploration in select patients.

Percutaneous Transhepatic Cholangioscopy Interventions-Updates.

Percutaneous transhepatic cholangioscopy (PTCS) was initially described around the same time that peroral cholangioscopy (POSC) was developed. The cited utility attributed to PTCS is the ability to be utilized in the subset of patients with surgical proximal bowel anatomy, often precluding the use of traditional POSC. However, since first described, PTCS use has been limited due to a lack of physician awareness and a lack of procedure-specific equipment and supplies. With recent developments of PTSC-specific equipment, there has been an expansion in the possible interventions able to be performed during PTCS, resulting in a rapid increase in clinical use. This short review will serve as a comprehensive update of the previous and more recent novel interventions now able to be performed during PTCS.

Pediatric Unsedated Transnasal Endoscopy.

Unsedated transnasal endoscopy (TNE) is a feasible, safe, and cost-effective procedure for pediatric patients. TNE provides direct visualization of the esophagus and enables acquisition of biopsy samples while eliminating the risks associated with sedation and anesthesia. TNE should be considered in the evaluation and monitoring of disorders of the upper gastrointestinal tract, particularly in diseases such as eosinophilic esophagitis that often require repeated endoscopy. Setting up a TNE program requires a thorough business plan as well as training of staff and endoscopists.

Evaluation of a novel disposable esophagogastroduodenoscopy system in emergency, bedside, and intraoperative settings: Pilot study (with videos).

OBJECTIVES: The disposable esophagogastroduodenoscopy (EGD) system is a novel endoscopic device which is highly portable and is designed to eliminate the risk of cross-infection caused by reusable EGD. This study aimed to investigate the feasibility and safety of disposable EGD in emergency, bedside, and intraoperative settings. METHODS: This was a prospective, single-center, noncomparative study. Disposable EGD was used for emergency, bedside, and intraoperative endoscopies in 30 patients. The primary end-point was the technical success rate of the disposable EGD. Secondary end-points included technical performance indicators including clinical operability, image quality score, procedure time, the incidence of device malfunction and/or failure, and the incidence of adverse events. RESULTS: A total of 30 patients underwent diagnosis and/or treatment with disposable EGD. Therapeutic EGD was performed on 13/30 patients, including hemostasis (n = 3), foreign body retrieval (n = 6), nasoenteric tube placement (n = 3), and percutaneous endoscopic gastrostomy (n = 1). The technical success rate was 100%: all procedures and indicated interventions were completed without changing to a conventional upper endoscope. The mean image quality score obtained immediately after procedure completion was 3.72 ± 0.56. The mean (± SD) procedure time was 7.4 (± 7.6) min. There were no device malfunctions or failures, device-related adverse events, or overall adverse events. CONCLUSION: The disposable EGD may be a feasible alternative to the traditional EGD in emergency, bedside, and intraoperative settings. Preliminary data show that it is a safe and effective tool for diagnosis and treatment in emergency and bedside upper gastrointestinal cases. TRIAL REGISTRATION: Chinese Clinical Trial Registry (Trial ID: ChiCTR2100051452, https://www.chictr.org.cn/showprojen.aspx?proj=134284).

Identification of Patient-Related and Procedure-Related Factors Contributing to Hypoxemia in Adult Outpatients Undergoing Esophagogastroduodenoscopy (EGD).

PURPOSE: To assess which patient factors and procedure-related factors contribute to hypoxemia during esophagogastroduodenoscopy (EGD) and determine whether prophylactic oropharyngeal suctioning reduces the rate of hypoxemia when compared to oropharyngeal suctioning when clinically indicated by patient's coughing or secretions. DESIGN: This was a single-site study taking place at a private practice, outpatient facility with no anesthesia trainees present. Patients were randomized to one of two groups based on birth month. After the administration of sedating medications but before the insertion of the endoscope, Group A was oropharyngeal suctioned by either the anesthesia provider or the proceduralist. Group B was oropharyngeal suctioned only when clinically indicated by coughing or visible copious secretions. METHODS: Data were collected on a variety of patient and procedure-related factors. Associations between these factors and hypoxemia during esophagogastroduodenoscopy were analyzed using the statistical analysis system application JMP. After analysis and literature review, a protocol for prevention and treatment of hypoxemia during EGD was proposed. FINDINGS: This study found that chronic obstructive pulmonary disease increases the risk for hypoxemia during esophagogastroduodenoscopy. There were no other statistically significant associations between other factors and hypoxemia. CONCLUSIONS: This study highlights factors that should be evaluated in the future when considering the risk of hypoxemia during EGD. Although not statistically significant, this study's results indicated that prophylactic oropharyngeal suctioning may reduce rates of hypoxemia, as only 1 of 4 cases of hypoxemia occurred in Group A. Additionally, future studies on hypoxemia during monitored anesthesia care for EGD should include an evaluation of the impact of American Society of Anesthesiologists class, history of chronic obstructive pulmonary disease or asthma, body mass index, obstructive sleep apnea, and opioid administration on hypoxemia risk.

Usefulness of texture and color enhancement imaging in peroral pancreatoscopy.

Tanisaka and colleagues report the usefulness of texture and color enhancement imaging provided by a new-generation image-enhanced endoscopy system in a patient with intraductal papillary mucinous neoplasm who had undergone peroral pancreatoscopy. Texture and color enhancement imaging clearly showed structural changes of the lesion and improved the diagnostic quality of peroral pancreatoscopy.

Cholangioscopy for biliary diseases.

PURPOSE OF REVIEW: Cholangioscopy is a mini-invasive endoscopic procedure, which consists in a direct intraductal visualization of the biliary tract. The purpose of this review is to summarize the technique, the clinical applications, as well as future perspectives of cholangioscopy. RECENT FINDINGS: Numerous technologic advances during the last decades have allowed for an improved utility and functionality, leading to a broader use of this procedure, for diagnostic or therapeutic purposes, in the setting of biliary diseases. Novel tools and emerging indications have been developed and more are yet to come. SUMMARY: Cholangioscopy can be performed by peroral, percutaneous transhepatic or intra-operative transcystic or transcholedochal access. Clinical applications of cholangioscopy are multiple, ranging from visual impression and optical guided biopsies of indeterminate biliary strictures to the management of difficult stones , guidance before biliary stenting and retrieval of migrated ductal stents. Multiple devices such as lithotripsy probes, biopsy forceps, snares and baskets have been developed to help achieve these procedures successfully.Cholangioscopy has improved the way biliary diseases can be visualized and treated. New technology, accessories, and applications are expected in the future.