Wet-suction versus slow-pull technique for endoscopic ultrasound-guided fine-needle biopsy: a multicenter, randomized, crossover trial.

BACKGROUND : It is unknown whether there is an advantage to using the wet-suction or slow-pull technique during endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) with new-generation needles. We aimed to compare the performance of each technique in EUS-FNB. METHODS: This was a multicenter, randomized, single-blind, crossover trial including patients with solid lesions of ≥ 1 cm. Four needle passes with 22 G fork-tip or Franseen-type needles were performed, alternating the wet-suction and slow-pull techniques in a randomized order. The primary outcome was the histological yield (samples containing an intact piece of tissue of at least 550 µm). Secondary end points were sample quality (tissue integrity and blood contamination), diagnostic accuracy, and adequate tumor fraction. RESULTS: Overall, 210 patients with 146 pancreatic and 64 nonpancreatic lesions were analyzed. A tissue core was retrieved in 150 (71.4 %) and 129 (61.4 %) cases using the wet-suction and the slow-pull techniques, respectively (P = 0.03). The mean tissue integrity score was higher using wet suction (P = 0.02), as was the blood contamination of samples (P < 0.001). In the two subgroups of pancreatic and nonpancreatic lesions, tissue core rate and tissue integrity score were not statistically different using the two techniques, but blood contamination was higher with wet suction. Diagnostic accuracy and tumor fraction did not differ between the two techniques. CONCLUSION: Overall, the wet-suction technique in EUS-FNB resulted in a higher tissue core procurement rate compared with the slow-pull method. Diagnostic accuracy and the rate of samples with adequate tumor fraction were similar between the two techniques.

Worldwide Techniques and Outcomes in Robot-assisted Minimally Invasive Esophagectomy (RAMIE): Results From the Multicenter International Registry.

OBJECTIVE: This international multicenter study by the Upper GI International Robotic Association aimed to gain insight in current techniques and outcomes of RAMIE worldwide. BACKGROUND: Current evidence for RAMIE originates from single-center studies, which may not be generalizable to the international multicenter experience. METHODS: Twenty centers from Europe, Asia, North-America, and South-America participated from 2016 to 2019. Main endpoints included the surgical techniques, clinical outcomes, and early oncological results of ramie. RESULTS: A total of 856 patients undergoing transthoracic RAMIE were included. Robotic surgery was applied for both the thoracic and abdominal phase (45%), only the thoracic phase (49%), or only the abdominal phase (6%). In most cases, the mediastinal lymphadenectomy included the low paraesophageal nodes (n=815, 95%), subcarinal nodes (n = 774, 90%), and paratracheal nodes (n = 537, 63%). When paratracheal lymphadenectomy was performed during an Ivor Lewis or a McKeown RAMIE procedure, recurrent laryngeal nerve injury occurred in 3% and 11% of patients, respectively. Circular stapled (52%), hand-sewn (30%), and linear stapled (18%) anastomotic techniques were used. In Ivor Lewis RAMIE, robot-assisted hand-sewing showed the highest anastomotic leakage rate (33%), while lower rates were observed with circular stapling (17%) and linear stapling (15%). In McKeown RAMIE, a hand-sewn anastomotic technique showed the highest leakage rate (27%), followed by linear stapling (18%) and circular stapling (6%). CONCLUSION: This study is the first to provide an overview of the current techniques and outcomes of transthoracic RAMIE worldwide. Although these results indicate high quality of the procedure, the optimal approach should be further defined.

An international survey on recognition and characterization of atrophic gastritis and intestinal metaplasia.

Background and study aims Atrophic gastritis (AG) and intestinal metaplasia (IM) are premalignant conditions of gastric cancer and endoscopic recognition and characterization may help in stratifying the gastric cancer risk for screening and surveillance. However, there is currently lack of consensus in defining the severity of AG and IM. We aimed to conduct an international survey to understand the current practice of endoscopists worldwide. Methods An online survey was designed to collect data regarding participants' practice in endoscopic assessment of AG & IM. A test using images was conducted to evaluate the difference in accuracy of characterization of AG & IM. Results From July to October 2017, 249 endoscopists responded to the survey. Around 70 % of participants received some form of training on recognition of AG & IM. There was significant variety in the training received across different continents. One hundred seventy-six participants (70 %) would document the presence of both AG and IM, but the classification systems used were inconsistent between endoscopists. Overall accuracy in diagnosis of AG & IM in the image test was 84.5 % and 80.7 % respectively. The diagnostic accuracy was significantly higher among Japanese and Korean endoscopists compared to the rest of the world. Conclusion Training regarding endoscopic recognition of AG & IM differs significantly in different parts of the world. The difference in diagnostic accuracy for these premalignant gastric conditions may also explain the discrepancy in the early cancer detection rates among different countries. A simple unified classification system may be beneficial for better stratification of cancer risks.

Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding.

BACKGROUND: It is recommended that patients with acute upper gastrointestinal bleeding undergo endoscopy within 24 hours after gastroenterologic consultation. The role of endoscopy performed within time frames shorter than 24 hours has not been adequately defined. METHODS: To evaluate whether urgent endoscopy improves outcomes in patients predicted to be at high risk for further bleeding or death, we randomly assigned patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death) to undergo endoscopy within 6 hours (urgent-endoscopy group) or between 6 and 24 hours (early-endoscopy group) after gastroenterologic consultation. The primary end point was death from any cause within 30 days after randomization. RESULTS: A total of 516 patients were enrolled. The 30-day mortality was 8.9% (23 of 258 patients) in the urgent-endoscopy group and 6.6% (17 of 258) in the early-endoscopy group (difference, 2.3 percentage points; 95% confidence interval [CI], -2.3 to 6.9). Further bleeding within 30 days occurred in 28 patients (10.9%) in the urgent-endoscopy group and in 20 (7.8%) in the early-endoscopy group (difference, 3.1 percentage points; 95% CI, -1.9 to 8.1). Ulcers with active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) with peptic ulcers in the urgent-endoscopy group and in 76 of 159 (47.8%) in the early-endoscopy group. Endoscopic hemostatic treatment was administered at initial endoscopy for 155 patients (60.1%) in the urgent-endoscopy group and for 125 (48.4%) in the early-endoscopy group. CONCLUSIONS: In patients with acute upper gastrointestinal bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after gastroenterologic consultation was not associated with lower 30-day mortality than endoscopy performed between 6 and 24 hours after consultation. (Funded by the Health and Medical Fund of the Food and Health Bureau, Government of Hong Kong Special Administrative Region; ClinicalTrials.gov number, NCT01675856.).

How I do it: Flexible 3-D endoscope for endoscopic submucosal dissection.

Endoscopic submucosal dissection (ESD) is technically challenging as a result of a lack of depth perception. The present article investigated the 3-D endoscope for carrying out ESD and translated the technique from bench to clinical use. In a preclinical porcine experiment, ESD using a 3-D endoscope was compared between an experienced and a novice endoscopist. All ESD were completed without perforation. Median operative time per surface area was significantly lower for the experienced endoscopist than for the novice (197.9 s/cm2 vs 434.7 s/cm2 ; P = 0.05). The second part was a prospective clinical experience to evaluate use of the 3-D endoscope for carrying out ESD. Ten patients received ESD using the 3-D endoscope. Four patients had gastric ESD, two had duodenal ESD and four had sigmoid and rectal ESD. There were no complications, whereas ESD failed in one patient who had gastric neoplasia at anastomosis. Mean operative time was 99.4 min, and operative time per surface area resection was 391 s/cm2 . The operating endoscopist did not complain of motion sickness, whereas the assistants had some dizziness upon prolonged ESD procedure. This study showed that carrying out ESD was safe and effective using a 3-D endoscope with an excellent 3-D view enhancing depth perception. Future study should be conducted to compare 3-D against 2-D endoscopes for ESD.

Robotic-assisted minimally invasive esophagectomy for treatment of esophageal carcinoma.

Minimally invasive esophagectomy (MIE) is technically challenging. Da Vinci Robotic system could improve surgical dissection with additional degree of freedom from robotic arms. This study aimed to assess the feasibility and safety of performing MIE using Da Vinci Robotic system among patients with esophageal cancers. From 2009 to 2013, consecutive patients with esophageal cancers who received robotic-assisted MIE were recruited. We excluded tumors with suspected invasion to adjacent organs. Preoperative staging included EUS, CT thorax and abdomen and bronchoscopy. We perform mobilization of thoracic esophagus with two-field lymphadenectomy using robotic system, followed by laparoscopic gastric mobilization and hand-sewn cervical esophagogastric anastomosis. A total of 20 patients were recruited (16 male and 4 female) with mean age of 64.2 ± 8.8 years. All patients were successfully treated with robotic-assisted MIE with mean operative time of 499.5 ± 70 min and blood loss of 355.7 ± 329.6 mls. There was no pulmonary complication, while three patients sustained anastomotic leakage and managed conservatively. The mean hospital stay was 13 ± 6 days. Five patients had stage I tumors, five had stage II, and nine had stage III disease. One patient had complete response after neoadjuvant chemoradiotherapy. The number of lymph node dissection was 18.2 ± 13.2, and 2.8 ± 5.7 nodes involved. The follow-up period was 21 ± 9 months, and the overall survival was 75 %. Robotic-assisted MIE is feasible and safe for treatment of esophageal cancers. The surgical dissection can be enhanced by improved ergonomics from robotic arms and sense of depth from 3D images.

Use of the Over-The-Scope Clip for treatment of refractory upper gastrointestinal bleeding: a case series.

The Over-The-Scope Clip (OTSC; Ovesco, Tübingen, Germany) is a novel endoscopic clipping device designed for tissue approximation. The device has been used in the closure of fistulas and perforations. We hereby report on a series of patients in whom OTSCs were used for endoscopic control of refractory or major upper gastrointestinal bleeding from lesions in the gastroduodenal tract between 1 July and 31 December 2012. Nine patients were included (median age 72.5 years, range 39 - 91) with bleeding gastric ulcers (n = 2), bleeding duodenal ulcers (n = 5), bleeding gastrointestinal stromal tumor in the stomach (n = 1), and bleeding from ulcerative carcinoma of the pancreas (n = 1). The median size of the ulcers was 2.5 cm (range 1 - 4). Six of the nine patients had undergone previous endoscopic hemostasis. Technical success was achieved in all patients and the clinical effectiveness was 77.8 %. The OTSC is a safe and effective method of endoscopic hemostasis for major bleeding from miscellaneous upper gastrointestinal causes and should be considered in patients with refractory bleeding after failure of conventional methods of endoscopic hemostasis.

Hypertrophic pyloric stenosis in a newborn: a diagnostic dilemma.

Infants with hypertrophic pyloric stenosis typically present at 2 to 4 weeks of age with nonbilious projectile vomiting. Hypertrophic pyloric stenosis is exceedingly rare in newborn infants and is scarcely reported in literature. Also, the diagnostic criteria for ultrasonographic measurements in newborn infants have yet to be determined. This report is of a newborn infant with hypertrophic pyloric stenosis. The patient presented with high-volume non-bile-stained output from a nasogastric tube and a dilated gastric bubble on abdominal radiograph. Contrast study ruled out intestinal malrotation. Two ultrasound tests showed that the pyloric muscle thickness and pyloric canal length were within normal limits. Subsequent laparotomy showed a thickened pylorus and pyloromyotomy was performed. The patient showed marked improvement in feeding postoperatively. A high index of suspicion is required for newborn infants presenting with gastric outlet obstruction. Ultrasound and contrast studies provide additional information, but definitive diagnosis may only be available intra-operatively.