Gastric cystica profunda: Another indication for minimally invasive endoscopic resection techniques?

Gastric cancer presents a significant global health burden, as it is the fifth most common malignancy and fourth leading cause of cancer mortality worldwide. Variations in incidence rates across regions underscores the multifactorial etiology of this disease. The overall 5-year survival rate remains low despite advances in its diagnosis and treatment. Although surgical gastrectomy was previously standard-of-care, endoscopic resection techniques, including endoscopic mucosal resection and endoscopic submucosal dissection (ESD) have emerged as effective alternatives for early lesions. Compared to surgical resection, endoscopic resection techniques have comparable 5-year survival rates, reduced treatment-related adverse events, shorter hospital stays and lower costs. ESD also enables en bloc resection, thus affording organ-sparing curative endoscopic resection for early cancers. In this editorial, we comment on the recent publication by Geng et al regarding gastric cystica profunda (GCP). GCP is a rare gastric pseudotumour with the potential for malignant progression. GCP presents a diagnostic challenge due to its nonspecific clinical manifestations and varied endoscopic appearance. There are several gaps in the literature regarding the diagnosis and management of GCP which warrants further research to standardize patient management. Advances in endoscopic resection techniques offer promising avenues for GCP and early gastric cancers.

Endoscopic submucosal dissection (ESD) outcomes in T1B esophageal cancer: a retrospective study.

BACKGROUND AND AIMS: The role of submucosal endoscopic dissection (ESD) in management of invasive esophageal cancer (EC) remains unclear. In this case series, we evaluate the clinical and technical outcomes of patients who underwent ESD with pathologically staged T1b EC. METHODS: This retrospective study included patients who underwent ESD between December 2016 and April 2023 with pathologically staged T1b EC. Patient demographics, tumor characteristics, and ESD technical outcomes were analyzed. Patients were followed to determine disease-free survival and tumor recurrence rates. RESULTS: Sixteen patients with a total of 17 pathologically staged T1b ECs were included in this case series with a median follow-up time of 28 months [range 3-75]. ESD had high en-bloc (100%) and R0 (82.3%) resection rates. 16/17 patients (94.1%) were discharged the same day, and there were no immediate perioperative complications. 4/17 patients (23.5%) had curative ESD resections with no tumor recurrence. Among those with non-curative resections (n = 13), 5 patients had ESD only, 6 had ESD + surgery, and 2 underwent ESD + chemoradiation. In the ESD only group, 2/5 patients (40%) had tumor recurrence. In the ESD + surgery group, one patient died from a surgical complication, and 1/5 (20%) had tumor recurrence at follow-up. There was no tumor recurrence among patients who had ESD + chemoradiation. CONCLUSION: ESD is safe with high en-bloc and R0 resection rates in T1b EC. Recurrence rates are low but patients need close monitoring. Larger-scale studies are needed to determine the long-term clinical efficacy of ESD in T1b EC.

Endoscopic double-layered suturing: an updated technique for clip closure of large mucosal defects after endoscopic submucosal dissection.

Video 1Endoscopic submucosal dissection of a large, laterally spreading-type granular mixed polyp in the ascending colon followed by closure of the ulcer bed using modified double-layered endoscopic suturing with endoscopic clips.

Usefulness of three-dimensional imaging in a flexible endoscopic surgery platform with multi-degrees-of-freedom articulating devices.

BACKGROUND AND AIMS: Recent studies on endoscopic submucosal dissection have aimed to reduce the difficulty of the procedure by using multi-degrees-of-freedom articulating devices. In this study, we evaluated the usefulness of adding three-dimensional (3D) video imaging into simulated endoscopic submucosal dissection tasks using multi-degrees-of-freedom devices. METHODS: We designed an endoscopic platform with a 3D camera and two multi-degrees-of-freedom devices. Four ex vivo bench tasks were created, and a crossover study comparing 2D and 3D conditions was conducted on 15 volunteers. In each task, performance such as procedure time and accuracy were objectively evaluated. Additionally, a comprehensive visual analogue scale questionnaire was conducted. RESULTS: In the tasks simulating submucosal flap grasping, marking, and full-area incision, the use of 3D imaging significantly improved the speed and accuracy of the multi-degrees-of-freedom device manipulation (p < .01). No significant differences were observed in the task that simulated the dissection procedure. Furthermore, it appears that the accuracy of recognizing curved surfaces may be reduced in the 3D environment. Operators reported subjective increases in recognizability and operability with the 3D camera, along with an increase in asthenopia (p < .01). CONCLUSIONS: 3D vision improves the technical accuracy of certain simulated multi-degrees-of-freedom endoscopic submucosal dissection tasks and subjectively improved operating conditions, at the cost of increased eye strain.

Complete circumferential endoscopic submucosal dissection for early Barrett's neoplasia.

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is carving out an increasing role in the treatment of esophageal neoplasia in the Western world. Contrary to Asia, most esophageal cancers in North America are associated with Barrett's esophagus. Patients with circumferential advanced neoplasia were previously managed by esophagectomy, but an increased experience with ESD has allowed for an endoscopic alternative. We present our experience with complete circumferential esophageal ESD at a North American referral center. METHODS: All patients undergoing 100% circumferential esophageal ESD between October 2016 and January 2023 at a single tertiary care center in Canada were included in the cohort. Demographics, procedural data, and lesion characteristics are presented in this series. RESULTS: Eleven patients underwent 100% circumferential esophageal ESD during this period for Barrett's neoplasia. All patients had technically successful procedures with en-bloc resection. Nine patients (82%) had R0 resections, defined as clear lateral and deep margins on histologic examination. Two patients had positive deep margins on histologic examination and proceeded to esophagectomy. Seven patients (64%) had adenocarcinoma on the final pathology, of which 6 (86%) had upstaging from their initial biopsy sampling results. The median area of resected specimen was 48 cm2 (interquartile range [IQR], 26-80), and the median procedure time was 231 minutes (IQR, 180-246). Procedural efficiency was 4.0 min/cm2 (IQR, 2.7-5). Two patients (18%) developed refractory strictures after the procedure, which were endoscopically managed to resolution. CONCLUSIONS: Multifocal dysplastic Barrett's esophagus remains a challenging entity to treat. Circumferential ESD is a possible therapeutic option, with high procedural success and a low rate of adverse outcomes. This should be balanced against the risk of stricture development, as the optimal postprocedural prophylaxis regimen is investigated.

Peroral endoscopic myotomy for a pediatric case of suspected congenital esophageal stenosis.

Video 1Peroral endoscopic myotomy for a pediatric case of suspected congenital esophageal stenosis.

Multicenter retrospective cohort of EUS-guided anterograde pancreatic duct access.

Background and study aims Pancreatic duct (PD) cannulation may be difficult during conventional endoscopic retrograde cholangiopancreatography (ERCP) due to underlying pathology, anatomical variants or surgically altered anatomy. Pancreatic access in these cases previously necessitated percutaneous or surgical approaches. Endoscopic ultrasound (EUS) allows for an alternative and can be combined with ERCP for rendezvous during the same procedure, or for other salvage options. Patients and methods Patients with attempted EUS access of the PD from tertiary referral centers between 2009 and 2022 were included in the cohort. Demographic data, technical data, procedural outcomes and adverse events were collected. The primary outcome was rendezvous success. Secondary outcomes included rates of successful PD decompression and change in procedural success over time. Results The PD was accessed in 105 of 111 procedures (95 %), with successful subsequent ERCP in 45 of 95 attempts (47 %). Salvage direct PD stenting was performed in 5 of 14 attempts (36 %). Sixteen patients were scheduled for direct PD stenting (without rendezvous) with 100 % success rate. Thus 66 patients (59 %) had successful decompression. Success rates improved from 41 % in the first third of cases to 76 % in the final third. There were 13 complications (12 %), including post-procedure pancreatitis in seven patients (6 %). Conclusions EUS-guided anterograde pancreas access is a feasible salvage method if retrograde access fails. The duct can be cannulated, and drainage can be achieved in the majority of cases. Success rates improve over time. Future research may involve investigation into technical, patient and procedural factors contributing to rendezvous success.

Clinicopathological Features and the Prevalence of Oxyntic Gland Neoplasm: A Single-center Retrospective Study.

Objective We explored the clinicopathological characteristics and disease frequency of oxyntic gland neoplasms (OGNs). Methods We retrospectively evaluated the data of patients pathologically diagnosed with OGN at an internal medicine clinic. Patients A total of 13,240 upper gastrointestinal endoscopies were performed on 7,488 patients between December 1, 2017, and March 31, 2021. Results We identified 27 patients with 30 histopathologically confirmed OGNs, yielding a disease frequency of 0.36% (27/7,488). Furthermore, multiple simultaneous lesions were found in 3 of 27 patients (11%). One (3.3%) of the 30 lesions was present in the antrum, whereas the remaining lesions occurred in the body of the stomach. Nine (33%) of the 27 patients had no history of Helicobacter pylori infection, whereas the remaining 18 (67%) were either currently or had been previously infected. Nevertheless, 27/30 lesions (90%) still occurred in non-atrophied regions. After endoscopic treatment, a histopathological examination of the resected specimens revealed submucosal infiltration in 8 (44%) of the 18 lesions; however, none of the lesions showed submucosal desmoplasia. For all patients with submucosal involvement, only observation was performed. There were no recurrent lesions found on follow-up. Conclusion The period prevalence of OGN was 0.36%, which is much higher than previously reported. The discovery of a small submucosal appearing lesion with a faded yellow or white color and dilated microvasculature, especially in a non-atrophic area of the stomach, should raise suspicion for an OGN, which can be endoscopically managed.

Single operator experience of endoscopic submucosal dissection for Barrett's neoplasia in a North American academic center.

Objectives: Endoscopic submucosal dissection (ESD) is carving out an increasing role in the treatment of Barrett's associated neoplasia. ESD provides the advantage of en-bloc resections and greater R0 resection rates. We aim to present outcomes from one of the largest single-center cohorts of esophageal ESD in North America. Methods: All patients undergoing esophageal ESD for Barrett's neoplasia between Oct 2016 and June 2020 at a Canadian tertiary care center were included. Demographic, procedural data, and lesion characteristics are presented. Subgroup analysis was performed on patients who underwent extensive resection (≥75% of esophageal circumference) and the patients who developed strictures. Results: Thirty-four patients were included in the series. The median lesion diameter was 5.7 cm and the median procedure time was 129 min. The en-bloc resection rate was 97%, and the R0 resection rate was 91%. Curative resection was achieved in 82% of patients. Upstaging in histology occurred in 59% of cases. Two adverse events occurred, and there were no perforations. Procedural outcomes were similar in patients with extensive resections, but those with ≥75% circumferential resection developed more strictures (65% vs. 6.3%, p < 0.01). Stricture formation was associated with extensive resection (odds ratio [OR]: 27.5, p < 0.01) and longer lesion diameter (OR: 1.7, p = 0.02). Conclusion: Our experience with ESD for Barrett's related neoplasia shows excellent en-bloc and R0 resection rate, and provides more accurate histological specimens. Curative resection is possible in the majority of cases, including those with extensive resections. Further investigation into stricture prophylaxis will be useful as near circumferential resections are attempted.

The utility of image-enhanced endoscopy and Lugol's for the assessment of esophageal squamous carcinoma.

Video 1This is a case of a patient with esophageal squamous cell carcinoma who underwent endoscopic submucosal dissection and subsequent esophagectomy. The endoscopic findings using imaged endoscopy, magnification, and Lugol's are demonstrated. There is a demonstration of endoscopic and pathological correlation in addition to the emphasis on a patient-centered multidisciplinary approach to esophageal neoplasia and the diagnostic utility of endoscopic submucosal dissection.

Novel triangle tip-jet knife increases efficiency in peroral endoscopic myotomy for achalasia.

BACKGROUND AND AIM: Peroral endoscopic myotomy (POEM) is performed globally for the treatment of achalasia. A newly available endoscopic knife, the triangle tip-jet (TTJ) (Olympus Triangle TipKnife-J, KD-645L), has the capability of knife dissection along with submucosal injection. We aim to present our experience with the TTJ knife in comparison to the conventional TT knife in POEM, with a focus on procedural characteristics including time, efficiency, and the number of instrument exchanges. METHODS: All patients with achalasia who underwent POEM between March 2016 and March 2020 at a single tertiary academic center were included in the retrospective cohort. Demographic, procedural, and outcomes data were compared. RESULTS: Ninety-two procedures, 48 using the TT knife, and 44 with the TTJ knife were analyzed. Demographic data were similar. Procedure time was reduced using the TTJ knife (87 vs 61 min, P = <0.001) despite similar myotomy lengths (16.5 vs 15.2 cm, P = 0.09). Efficiency was increased in the TTJ group (5.5 vs 4.3 min/cm of procedure, P = 0.005). The number of instrument exchanges (16.7-1.7, P = <0.001) and usage of coagulation forceps decreased (1.7-0.5, P = <0.001). There was no difference in the procedural difficulty (POEM difficulty score [PDS] 2.2 vs 2.4, P = 0.4). Patients with higher procedural difficulty saw a greater improvement in procedural outcomes. Procedural success was high in both groups (96% vs 100%, P = 0.2). No serious adverse events were reported. CONCLUSIONS: The use of the TTJ knife increases efficiency during POEM for Achalasia. The total procedure time is decreased by 28-41%, and procedural efficiency is increased by 22-34%.

Changes in weight following peroral endoscopic myotomy: results from a North American center.

Background and study aims Weight loss is a feature of untreated achalasia. While weight gain after achalasia treatment is expected, little data exist about the extent of it, particularly after peroral endoscopic myotomy (POEM). We aimed to describe the changes in weight after POEM. Patients and methods A retrospective analysis was performed of patients from March 2016 to March 2020 undergoing POEM by an experienced operator at an academic referral center in Kingston, Ontario, Canada. Data examined included pre- and post-POEM body mass index (BMI), procedural characteristics, and Eckardt scores. Results Ninety-two patients underwent POEM during the study period, for 77 of whom follow-up data were available including BMI. Prior to POEM, the median BMI was 26. Six patients (7.8 %) were considered to be underweight, 24 (31.2 %) were normal, 26 (33.8 %) were pre-obese, and 21 (27.2 %) were obese. At a median follow-up of 15 months, the clinical success rate was 95 %. Patients in the normal weight and pre-obesity categories had a significant increase in weight post-POEM. Of the underweight patients, two (33.3 %) moved up to a normal weight category and two (33.3 %) became pre-obese. In the normal BMI category, eight (37.5 %) became pre-obese and one patient (4.2 %) became obese. Ten of the 26 pre-obese patients (38.4 %) were obese post-POEM. Seven of the obese patients (33.3 %) reached Class III (morbid) obesity at follow-up.  Conclusions Patients may experience a marked increase in BMI following POEM, with over one-third of patients becoming pre-obese, obese or morbidly obese at follow-up in our study in a North American population. Further study is required to analyze weight gain patterns post-POEM.

The who, what, where, how, and why of endoscopic submucosal dissection in Canada: A survey among Canadian endoscopists.

BACKGROUND AND AIM: Endoscopic submucosal dissection (ESD) is an internationally accepted technique for the resection of superficial gastrointestinal neoplasia. ESD allows for en-bloc removal when endoscopic mucosal resection (EMR) is unsuitable due to the size or depth of the lesion. The aim of this survey was to examine Canadian clinicians' experience and perceptions of ESD as its prevalence increases across the country. METHODS: An electronic survey consisting of 24 multiple-choice questions was distributed via the Canadian Association of Gastroenterology email database and directly to those known to be performing or interested in ESD. The survey covered training, practice, obstacles in implementation, and perceptions of the future of ESD in Canada. RESULTS: A total of 21 participants completed the survey. ESD was performed primarily in the endoscopy suite exclusively (71%), and most operators (64%) performed it on an outpatient basis. Procedure time was selected as the greatest technical challenge in the performance of ESD by 86% of the participants. Both lack of formalized training and long procedure times were the highest ranked barriers to the adoption of ESD. Over the next 5 years, 95% believed there would be an increase in ESD volume in Canada, and 43% believed ESD was ready for adoption by more therapeutic endoscopists. INTERPRETATION: In this survey, we explored the current practice, attitude, and challenges of ESD in the Canadian landscape. As the performance of ESD increases and gains more acceptance across Canada, there are opportunities to address technical challenges and barriers through the formalization of training, education, and practice guidelines.

Are psychological interventions effective in treating functional dyspepsia? A systematic review and meta-analysis.

BACKGROUND AND AIM: Functional dyspepsia (FD) is a common gastrointestinal disorder, characterized primarily by postprandial fullness or early satiety and/or pain in the epigastrium with no endoscopic evidence of disease. Psychological therapies have been adapted to the treatment of disordered gut-brain interaction such as FD. We sought to determine if psychological interventions were efficacious in providing symptom management and improving health-related quality of life in patients suffering from FD. METHODS: Data were sorted that belonged to Embase (1947 to January 2020), PsychINFO (1806 to January 2020), and Ovid MEDLINE (1946 to January 2020). Randomized controlled trials using a psychological intervention in adults meeting relevant diagnostic criteria for FD were included. Data including symptom scores and quality of life measures were extracted. A random-effect model meta-analysis with standardized mean differences was used. RESULTS: Nine randomized controlled trials were identified that met our inclusion criteria. These were small, single-centered studies and used varying psychological therapies. Three studies had a sham treatment arm, leading to a high risk of bias in the remaining studies. All the studies reported beneficial effects of psychological treatment on patient's symptoms, some of which persisted up to 1 year. Psychological intervention was associated with an improvement in global FD symptom scores (standardized differences in means -1.33, 95% confidence interval -1.97 to -0.68). CONCLUSIONS: Despite the limited data, the available evidence suggests that psychological therapy is beneficial in treating patients with FD and should be considered by treating physicians if available and patients are willing. Large well-designed, sham controlled trials are needed for this extremely common disorder.