Endoscopic trans-anal tube placement is a safe and helpful tool for colonic decompression: final results of a standardized single-centre retrospective assessment of 125 patients.

OBJECTIVES: Endoscopic trans-anal colonic decompression (ECD) may be requested in the case of massive colon distension, but evidence regarding success and safety issues remains scarce. The aim of this analysis is to examine the technical success, complications and clinical outcome in a large series of patients undergoing an ECD in various clinical scenarios. A standardized evaluation system was used to identify the pre-interventional risk parameters that might be helpful to guide clinical decision making. METHODS: In this single-centre retrospective study, the modified Clavien-Dindo classification (CDC) was applied to assess technical success, complications and clinical outcome of 125 consecutive patients who underwent ECD between 2007 and 2020. PRIMARY ENDPOINT: post interventional 90-day mortality. Secondary endpoints: periprocedural complications (CDC event IV-V) and technical success rate. All Martin criteria for standardized reporting of complications were met. Uni- and multivariable analyses for prediction of complications were carried out. RESULTS: The overall technical success rate was 90%. The periprocedural complication rate was low with 3%. Overall 90-day mortality was 31%. Univariable analyses showed a significant correlation between 90-day mortality and ASA≥4 (p<0.001, odds ratio [OR] 15.33), general anaesthesia (p=0.05, OR 21.42) and elevated serological infection parameters (p 0.028, OR 1.004). The pre-interventional multivariable model identified ASA ≥4 (p <0.001; OR 10.94) as the only independent risk factor. CONCLUSIONS: ECD is a safe, easily available, technical feasible, inexpensive and successful tool for colonic decompression in various colonic obstruction scenarios, even in critically ill patients. ASA Score ≥IV can be helpful to identify patients at risk for complications/mortality after ECD.

High prevalence of incidental endoscopic findings at routine endoscopy after atrial fibrillation ablation: Do we need a screening endoscopy for the upper gastrointestinal tract in the general population?

INTRODUCTION: High-power short-duration ablation (HPSD) is an effective therapy for atrial fibrillation with thermal esophageal injury as a rare but relevant side effect. AIM AND METHODS: In this retrospective single-center analysis we evaluated the incidence and relevance of ablation-induced findings and the prevalence of ablation-independent incidental gastrointestinal findings. For 15 months all patients undergoing ablation were screened by postablation esophagogastroduodenoscopy. Pathological findings were followed up and treated if necessary. RESULTS: 286 consecutive patients (66±10 years; 54.9% male) were included. 19.6% of patients showed ablation-associated alterations (10.8% esophageal lesions, 10.8% gastroparesis, 1.7% both findings). Logistic multivariable regression analysis confirmed an influence of lower BMI on the occurrence of RFA-associated endoscopic findings (OR 0.936, 95% CI 0.878-0.997, p<0.05). 48.3% of patients demonstrated incidental gastrointestinal findings. In 1.0% neoplastic lesions were present, 9.4% showed precancerous lesions and in 4.2% neoplastic lesions of unknown dignity were found requiring further diagnostics or therapy. 18.1% of patients demonstrated findings associated with a potentially increased risk of bleeding under anticoagulation. Patients with clinically relevant incidental findings were significantly more often male, 68.8% vs. 49.5% (p<0.01). CONCLUSION: HPSD ablation is safe, no devasting complication occurred in any patient. It resulted in 19.6% ablation-induced thermal injury whereas incidental findings of the upper GI tract were found in 48.3% of patients. Due to the high prevalence of 14.7% of findings requiring further diagnostics, therapy, or surveillance in a cohort that is mimicking the general population, screening endoscopy of the upper GI tract seems to be reasonable in the general population.

Intraductal biliopancreatic imaging: European Society of Gastrointestinal Endoscopy (ESGE) technology review.

This technology review expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) on the available techniques for intraductal biliopancreatic imaging. The three cholangioscopy techniques are described: the "dual-operator" and " single-operator" mother-baby approaches using dedicated instruments, and the "direct" technique using currently available ultrathin gastroscopes. The mother-baby method is standardized and reproducible, while direct cholangioscopy is technically demanding and its safety requires further evaluation. As well as direct visualization of the bile ducts, cholangioscopy has the further advantage of allowing targeted biopsy. Image quality is still suboptimal for single-operator cholangioscopy, while the other techniques have achieved adequately detailed imaging. The costs of mother-baby cholangioscopy are high and its application in clinical practice should be restricted to selected cases (i.e. indeterminate biliary strictures/intraluminal lesions, difficult biliary stones) and to the setting of tertiary care centers. Peroral pancreatoscopy may find an indication in situations where other imaging modalities (mainly EUS) are inconclusive (i.e. delineation of main duct intraductal papillary mucinous neoplasia extension, sampling of indeterminate main pancreatic duct strictures). Intraductal ultrasonography (IDUS) has a poorer performance than EUS in the staging of pancreatic malignancies and can increase the risk of pancreatitis. A promising indication for IDUS could be the evaluation of indeterminate biliary strictures and ampullary tumors. Probe-based confocal laser endomicroscopy (pCLE) of the bile ducts is a difficult and expensive technique. Appropriate training needs to be established, since interpretation of images is challenging. pCLE can be an important diagnostic tool in the setting of indeterminate biliary strictures.

Diagnostics and Early Diagnosis of Esophageal Cancer.

In the esophagus two different kinds of primary neoplasias may arise: squamocellular carcinomas (SCC) and esophageal adenocarcinomas (EAC). Although both types of carcinoma are rare diseases, especially the incidence of EAC rose in the last years. The management of esophageal cancer is challenging. There are no specific symptoms of early esophageal cancers. Due to this fact, most of the esophageal cancers are found incidentally, and only 12.5% of esophageal tumors are endoscopically resectable. Gastroscopy is the gold standard for the diagnosis of esophageal cancer. The sensitivity of detecting early-stage carcinoma may be improved by adjunct techniques such as chromoendoscopy, virtual chromoendoscopy, magnification endoscopy, and other advanced endoscopic imaging techniques. The diagnosis of esophageal cancer can be verified with targeted biopsies. Accurate staging information is crucial for establishing appropriate treatment choices for esophageal cancer, while the depth of the tumor determines the feasibility of therapy. In terms of staging, endosonography, abdominal ultrasound, and computed tomography scan of the thorax and abdomen should thus be performed before initiation of therapy.

Efficacy and safety of direct transnasal cholangioscopy with standard ultraslim endoscopes: results of a large cohort study.

BACKGROUND: Direct cholangioscopy (DC) with ultraslim endoscopes and free-hand cannulation of the common bile duct (CBD) is a promising technique for evaluating and treating cholangiopathy. However, its safety and success rates are as yet unclear. OBJECTIVE: To evaluate the overall success rates and adverse events with the procedure. DESIGN: Single-center, prospective cohort study; 12 patients retrospectively enrolled. SETTING: Academic tertiary referral center. PATIENTS: A total of 100 DC procedures in 84 patients with biliary disease were evaluated prospectively. INTERVENTIONS: DC performed with the patient under conscious sedation. MAIN OUTCOME MEASUREMENTS: Overall success rates and adverse events with the procedure. RESULTS: In 34 cases with small- or medium-sized sphincterotomies, sphincteroplasty was performed with a 10-mm dilating balloon before DC. The intraductal area of interest was successfully accessed in 87% of the procedures. The intended interventions were successfully carried out in 81 patients (93.1%), but failed in 6 (6.9%). In patients without significant strictures, intrahepatic exploration of the bile ducts beyond the level of the bifurcation was feasible in only 10.8%. The mean total procedure time was 38.6 ± 12.2 minutes. Adverse events occurred in 12 procedures (12%) and were managed conservatively. LIMITATIONS: All procedures were performed by 1 endoscopist. CONCLUSION: DC is safe and allows direct, high-resolution examination and a wide range of therapeutic options in the bile ducts in the majority of patients with biliary disease. However, the range of access is limited to the main bile duct. Suspected pathology restricted to the proximal intrahepatic ducts beyond the bifurcation is therefore not a good indication for DC.

Prospective randomized comparison of short-access mother-baby cholangioscopy versus direct cholangioscopy with ultraslim gastroscopes.

BACKGROUND: Mother-baby technologies, the criterion standard for cholangioscopy, have several limitations. A novel, short-access, mother-baby (SAMBA) system may improve this technique. Direct cholangioscopy (DC) was recently developed as an alternative to mother-baby cholangioscopy. OBJECTIVE: Comparison of success rates with SAMBA and DC. DESIGN: Single-center, randomized, controlled trial. SETTING: Academic tertiary-care referral center. PATIENTS: Sixty patients with suspected cholangiopathies randomized to either SAMBA (n = 30) or DC (n = 30). INTERVENTION: Cholangioscopy under deep sedation. MAIN OUTCOME MEASUREMENTS: Technical success rate of diagnostic or therapeutic procedure. RESULTS: A total of 24 and 21 diagnostic procedures were performed in the SAMBA and DC groups, respectively. There were no significant differences in the overall technical success rates between SAMBA (90.0%) and DC (86.7%) (P = 1.0). There was better correlation between the endoscopic prediction and histologic findings in DC (P = .013). Procedure times were shorter in DC (P < .03). In patients without significant stenoses, SAMBA allowed intrahepatic bile duct exploration in all cases, compared with 10.5% of cases in DC (P < .01). No differences regarding adverse event rates between the groups occurred (10.0% both groups). LIMITATIONS: Small sample size. Heterogeneous indications for cholangioscopy. DC requires advanced skills of the endoscopist. The study is not replicable. CONCLUSION: SAMBA and DC offer high technical success rates for diagnostic and therapeutic interventions. The advantages of DC consist of superior imaging, shorter total procedure time, and a wider working channel for adequate tissue sampling. SAMBA is better than DC with regard to intraductal stability and accessibility of the intrahepatic bile ducts.