Diagnostic accuracy of magnetically guided capsule endoscopy with a detachable string for detecting oesophagogastric varices in adults with cirrhosis: prospective multicentre study.

OBJECTIVE: To evaluate the diagnostic accuracy and safety of using magnetically guided capsule endoscopy with a detachable string (ds-MCE) for detecting and grading oesophagogastric varices in adults with cirrhosis. DESIGN: Prospective multicentre diagnostic accuracy study. SETTING: 14 medical centres in China. PARTICIPANTS: 607 adults (>18 years) with cirrhosis recruited between 7 January 2021 and 25 August 2022. Participants underwent ds-MCE (index test), followed by oesophagogastroduodenoscopy (OGD, reference test) within 48 hours. The participants were divided into development and validation cohorts in a ratio of 2:1. MAIN OUTCOME MEASURES: The primary outcomes were the sensitivity and specificity of ds-MCE in detecting oesophagogastric varices compared with OGD. Secondary outcomes included the sensitivity and specificity of ds-MCE for detecting high risk oesophageal varices and the diagnostic accuracy of ds-MCE for detecting high risk oesophagogastric varices, oesophageal varices, and gastric varices. RESULTS: ds-MCE and OGD examinations were completed in 582 (95.9%) of the 607 participants. Using OGD as the reference standard, ds-MCE had a sensitivity of 97.5% (95% confidence interval 95.5% to 98.7%) and specificity of 97.8% (94.4% to 99.1%) for detecting oesophagogastric varices (both P<0.001 compared with a prespecified 85% threshold). When using the optimal 18% threshold for luminal circumference of the oesophagus derived from the development cohort (n=393), the sensitivity and specificity of ds-MCE for detecting high risk oesophageal varices in the validation cohort (n=189) were 95.8% (89.7% to 98.4%) and 94.7% (88.2% to 97.7%), respectively. The diagnostic accuracy of ds-MCE for detecting high risk oesophagogastric varices, oesophageal varices, and gastric varices was 96.3% (92.6% to 98.2%), 96.9% (95.2% to 98.0%), and 96.7% (95.0% to 97.9%), respectively. Two serious adverse events occurred with OGD but none with ds-MCE. CONCLUSION: The findings of this study suggest that ds-MCE is a highly accurate and safe diagnostic tool for detecting and grading oesophagogastric varices and is a promising alternative to OGD for screening and surveillance of oesophagogastric varices in patients with cirrhosis. TRIAL REGISTRATION: ClinicalTrials.gov NCT03748563.

Treatment of obstructive jaundice induced by non-hodgkin lymphoma with EUS-guided transgastric anterograde common bile duct stenting: Technical case report and literature review.

Background: Non-Hodgkin lymphoma (NHL) is a rare cause of biliary obstruction. The optimum treatment for these patients is unclear. Lymphoma-associated obstructive jaundice is generally managed with open surgery, Endoscopic retrograde cholangiopancreatography (ERCP), or Percutaneous transhepatic biliary drainage. Here, we present the first description of EUS-guided anterograde common bile duct stenting via the stomach for obstructive jaundice associated with NHL. Patient and methods: A 58-year-old male patient who had been undergoing chemotherapy for NHL was admitted to our institution for severe obstructive jaundice. The patient's hepatic function indicators were: alanine aminotransferase 211 U/L, aspartate aminotransferase 301 U/L, total bilirubin 485.6 µmol/L, and direct bilirubin 340.2 µmol/L. Abdominal magnetic resonance imaging showed massive lymphomatous lesions filling the peritoneal cavity. Magnetic resonance cholangiopancreatography revealed an external compressive stricture in the superior middle common bile duct and dilation of the intrahepatic and extrahepatic ducts. ERCP was performed unsuccessfully, due to the stricture at the descending junction of the duodenal bulb caused by lymphoma infiltration. So, EUS-guided anterograde common bile duct stenting via the stomach was performed. Results: The patient's bilirubin level decreased significantly in the postoperative period, and no adverse reaction was observed. Computed tomography showed marked shrinking of the abdominal mass after targeted therapy. Conclusions: Our report suggests that early relief of biliary obstruction may be more beneficial to subsequent chemotherapy when symptoms of lymphoma-associated jaundice are persistently aggravating. Endoscopic ultrasound-guided biliary drainage is a safe, effective and timely alternative approach to treat biliary obstruction when ERCP fails, especially in cases of malignancy caused by extrahepatic bile duct space-occupying lesions.

Establishment of a system for control of cross-infection and workflow in endoscopy center during the pandemic of coronavirus disease 2019. / 2019å† çŠ¶ç— æ¯’ç— ç–«æƒ æœŸé—´æ¶ˆåŒ–å† é•œä¸­å¿ƒè¯Šç–—æµç¨‹å’Œé˜²æŽ§ä½“ç³»çš„å»ºç«‹åŠåº”ç”¨.

OBJECTIVES: To establish a system for control of cross-infection and workflow for preventing severe acute respiratory syndrome coronavirus 2 spread and ensuring the safety of medical staffs and patients in endoscopy center during the pandemic of the coronavirus disease 2019 (COVID-19). METHODS: Based on the national publication of relevant documents and relevant guidance of Digestive Endoscopy Branch of Chinese Medical Association, we explored and optimized the workflow, staff protection and sterilization of endoscope in digestive endoscopy center during the pandemic of the COVID-19. RESULTS: The prevention system of cross-infection and workflow in endoscopy during the pandemic of the COVID-19 were developed. The optimized workflow in endoscopy was conducted in 106 patients with necessary endoscopy from the Department of Gastroenterology, Third Xiangya Hospital, Central South University between January 24, 2020 and February 26, 2020, and no case of cross-infection was presented among the medical staffs, patients and family members. CONCLUSIONS: Measures on control of cross-infection and workflow in digestive endoscopy center during the pandemic of the COVID-19 are effective, which are beneficial to preventing cross-infection in hospital and provide a scientific guidance for the general work in the digestive endoscopy centers during the pandemic of the COVID-19.

[Clinical application of stent insertion before surgical operation for malignant colorectal obstruction].

OBJECTIVE: To evaluate the feasibility and safety of colon stenting as bridge surgery for colorectal cancer obstruction.
 Methods: A total of 30 patients (stent group), who underwent colonic stenting for colorectal obstruction at the Third Xiangya Hospital, Central South University from September 2015 to June 2017, were selected to receive the preoperative bridge surgery. Technical success rates, clinical success rates, and stent-related complications were observed. A total of 38 patients (emergency surgery group), who underwent surgical operation for colorectal obstruction, served as a control. The tumor resection rate at Stage I, ostomy rate, hospitalization time, and hospitalization cost were compared between the 2 groups.
 Results: The technical success and clinical success rates were 100.0% and 90.0% in the stent group, respectively. The stent-related complications included bleeding in 2 cases (6.7%), micro-perforation in 1 case (3.3%), stent displacement in 1 case (3.3%), and stent occlusion in 3 cases (10.0%) in the stent group. The Stage I tumor resection rate in the stent group was significantly higher than that in the emergency surgery group (90.0% vs 68.4%, P<0.01). The incidence of anastomotic leakage in the stent group was lower than that in the emergency surgery group (3.3% vs 10.5%, P<0.05); the stoma rate in the stent group was lower than that in the emergency surgery group (13.3% vs 44.7%, P<0.01). The surgical complications occurred in the stent group were significantly lower than those in the emergency surgery group (20.0% vs 47.3%, P<0.01). The average hospital stay in the stent group was lower than that in the emergency surgery group (20.0 vs 24.5 days, P<0.05). There was no significant difference in hospitalization costs between the 2 groups (P>0.05).
 Conclusion: Preoperative colonic stenting for colorectal obstruction surgery as a bridge is feasible in terms of methods, and which can significantly increase the Stage I tumor resection rate, reduce the ostomy rate, decrease surgical complications, shorten the average length of hospital stay, and reduce patient suffering.

[Use of esophageal small balloon or papillary sphincter knife in the treatment of stent implantation for colorectal malignant obstruction].

OBJECTIVE: To explore the function of esophageal small balloon or papillary sphincter knife in the treatment of stent implantation for colorectal malignant obstruction, and to improve the success rate of colonic stent placement in such patients.
 Methods: A total of 49 patients with colorectal cancer complicated with almost complete obstruction or colorectal cancer were enrolled for this study. The esophageal small balloon or papillary sphincter knife was used in the guide wires. The guide wires gradually crossed the tumor gap and they were placed in the contralateral intestinal cavity with balloon progression. X-ray was then used to confirm whether the guide wire was inserted in the lesion intestinal cavity, and then the metal bare stent was inserted.
 Results: The guide wires was successfully inserted with conventional methods in these 49 cases, while they were also successfully placed the guide wire and the stent in the new way.
 Conclusion: For the patients with colorectal cancer complicated with complete obstruction or colorectal cancer located in obviously angled location, the use of esophageal small balloon or papillary sphincter knife can help the guide wire insert. They greatly improve the success rate of stent implantation.

[Application of endoscopic full-thickness resection in the treatment of gastric tumors originated fromthe muscularis propria].

OBJECTIVE: To evaluate the curative effect and safety of endoscopic full-thickness resection (EFR) in the treatment of gastric tumor originated from the muscularis propria.
 METHODS: Clinical data were collected from 34 patients, who underwent EFR of gastric tumor originated from muscularis propria, to observe the resection rate and complications from November 2012 to August 2014.
 RESULTS: Of the 34 patients, 15 were male, 19 were female, with the age of 38.3-70.6 (52.3±4.3) years old. The lesions of 25 patients located in the fundus of stomach and the rest was in the gastric body. EFR was successfully performed in the 34 patients with no need for surgery. The complete resection rate was 100%. Lesion diameter ranged from 1.0 to 5.0 (2.8±1.2) centimeters. The operation time was 50-100 (76.5±18.2) min. Patients with pneumoperitoneum were relieved after abdominal puncture exhaust, without post-operation bleeding and perforation. The hospitalization duration was 3-5 (3.6±0.8) days. Except 1 case, the remaining 33 cases were spindle cell tumors, consistent with the results of immunohistochemistry. The risk for two lesions with 4.5 cm and 5.0 cm was moderate. The risk of invasion was low or very low in the remaining 31 cases. Among them, 2 stromal tumors near the cardia showed a differentiation tendency toward smooth muscle. No lesion residual or recurrence happened during the follow-up period (range 5-23 months) in 34 cases. 
 CONCLUSION: EFR is a safe and effective method for gastric tumor originated from muscularis propria.

Application of clips assisted with foreign body forceps in defect closure after endoscopic full-thickness resection.

BACKGROUND: This study was designed to evaluate the feasibility and efficacy of metallic clips assisted with foreign body forceps closing the gastric wall defect after endoscopic full-thickness resection (EFR) for gastric submucosal tumors (SMTs). METHODS: Eighteen patients with gastric SMTs originated from the muscularis propria were treated by EFR between September 2012 and June 2014. Twelve patients underwent endoscopic closure of the gastric wall defects after EFR with endoloop and metallic clips (endoloop string suture method, ESSM), and six patients with clips and foreign body forceps (clips assisted with foreign body forceps clip method, CFCM). RESULTS: No significant differences existed between the two groups in terms of demographics, clinical characteristics, and the size of the gastric wall defects. The average time spent in closing the gastric wall defects (14.83 ± 1.94 min for the CFCM group and 22.42 ± 5.73 min for the ESSM group) and hospitalization fees of the CFCM group were significantly lower than those of the ESSM group. The average hospitalization time of the two groups had no statistical significance. No single case had surgical intervention or complications, such as gastric bleeding, perforation, peritonitis, or abdominal abscess. CONCLUSION: The CFCM and the ESSM are safe and effective techniques for gastric defect closure after EFR for gastric SMTs. Because of the "chopsticks effect," the CFCM more suitable for the lesions located at the gastric fundus, the greater curvature or anterior wall of the gastric body and gastric antrum.

Stepwise sedation for elderly patients with mild/moderate COPD during upper gastrointestinal endoscopy.

AIM: To investigate stepwise sedation for elderly patients with mild/moderate chronic obstructive pulmonary disease (COPD) during upper gastrointestinal (GI) endoscopy. METHODS: Eighty-six elderly patients with mild/moderate COPD and 82 elderly patients without COPD scheduled for upper GI endoscopy were randomly assigned to receive one of the following two sedation methods: stepwise sedation involving three-stage administration of propofol combined with midazolam [COPD with stepwise sedation (group Cs), and non-COPD with stepwise sedation (group Ns)] or continuous sedation involving continuous administration of propofol combined with midazolam [COPD with continuous sedation (group Cc), and non-COPD with continuous sedation (group Nc)]. Saturation of peripheral oxygen (SpO2), blood pressure, and pulse rate were monitored, and patient discomfort, adverse events, drugs dosage, and recovery time were recorded. RESULTS: All endoscopies were completed successfully. The occurrences of hypoxemia in groups Cs, Cc, Ns, and Nc were 4 (9.3%), 12 (27.9%), 3 (7.3%), and 5 (12.2%), respectively. The occurrence of hypoxemia in group Cs was significantly lower than that in group Cc (P < 0.05). The average decreases in value of SpO2, systolic blood pressure, and diastolic blood pressure in group Cs were significantly lower than those in group Cc. Additionally, propofol dosage and overall rate of adverse events in group Cs were lower than those in group Cc. Finally, the recovery time in group Cs was significantly shorter than that in group Cc, and that in group Ns was significantly shorter than that in group Nc (P < 0.001). CONCLUSION: The stepwise sedation method is effective and safer than the continuous sedation method for elderly patients with mild/moderate COPD during upper GI endoscopy.

[Influence of age on sedation for colonoscopy in adults].

OBJECTIVE: To investigate the efficacy and risk of midazolam and propofol for sedation during colonoscopy procedures in adults of different age groups. METHODS: A total of 180 patients undergoing colonoscopy were allocated to 3 groups: a young adult group (n=45, 18-44 years), a mid-aged group (n=78,45-64 years) and an elderly group (n=57, 65-80 years). All patients were premedicated with midazolam 0.02-0.03 mg/kg and propofol 0.5-2.5 mg/kg. The pulse rate, arterial pressure, and oxygen saturation for each patient were monitored continuously before, during and after the procedure. RESULTS: The doses of midazolam and propofol for the young adults were significantly higher than that for the mid-aged and the elderly (P<0.01). Based on the view of gastroenterologists, the satisfied rate of sedation quality was significantly higher in the elderly group than that in the young or the mid-aged group (P<0.01). There were significant changes in the arterial pressure in all groups compared with the baseline level (P<0.01), but there was no significant difference among the 3 groups. Other parameters such as heart rate, saturation of O2, and the rate of severe adverse reaction among the 3 groups were not significantly different (P>0.05). CONCLUSION: Higher dose of midazolam and propofol is needed to obtain the sedation quality in young adults. Whereas for the elderly, properly reducing the dose of midazolam and propofol may still keep the sedation quality during colonoscopy procedures.

Sedation, analgesia, and cardiorespiratory function in colonoscopy using midazolam combined with fentanyl or propofol.

BACKGROUND AND AIMS: The use of sedatives during colonoscopy remains controversial because of its safety concerns. We compared cardiorespiratory function and sedative and analgesic effects in sedative colonoscopy, using combinations of midazolam with either fentanyl or propofol. METHODS: Eligible patients (n = 480) received 1.0-2.0 mg midazolam alone (n = 160), midazolam combined with either 50-100 mg fentanyl intramuscularly (n = 160), or 0.5-2.5 mg/kg propofol intravenously, as premedication for sedative colonoscopy. Pulse rate, blood pressure, and saturation of peripheral oxygen (SpO(2)) were monitored. Levels of sedation and analgesia were semi-quantitatively scored using visual analog scales, and amnesia profiles were qualitatively evaluated. RESULTS: Combining midazolam with either fentanyl or propofol resulted in acceptable sedative and analgesic effects compared to treatment with midazolam alone (P < 0.001), with the combination with propofol giving more favorable results. More patients receiving the propofol combination became amnestic to the procedure than patients receiving the fentanyl combination. However, midazolam combined with propofol disturbed the pulse rate (P < 0.05) and blood pressure (P < 0.001) more significantly than a combination with fentanyl, or midazolam alone. CONCLUSION: The combination of midazolam with either fentanyl or propofol allowed patients to undergo colonoscopy under comparable sedative and analgesic conditions. The combination with fentanyl had a significantly lower effect on pulse rate and blood pressure. The combination with propofol produced superior amnestic effects.

[Efficacy and security of sedation in upper gastrointestinal endoscopy in snoring patients].

OBJECTIVE: To investigate the efficacy and security of different administrations of propofol on the sedation in upper gastrointestinal endoscopic procedures in snoring patients. METHODS: A total of 1,117 patients with snoring in ASA I-II level, who underwent gastroscopy and received propofol as sedation, were assigned to Group A, Group B, and Group C.These groups had different administration methods of propofol. The dose of propofol, response to endoscopic procedures, changes of oxygen saturation of arterial blood (SPO2), incidence of severe respiratory depression and sedation quality assessed by operators were observed. RESULTS: The incidence of transient decline in SPO2 in Group A, B, and C were 50.4%, 3.1%, and 18.5%, respectively. The doses of propofol of Group A, B, and C were (108.50±18.02) mg, (57.50±7.50) mg, and (79.80±10.02) mg, respectively, with significant difference (P<0.05). The incidence of severe respiratory depression in Group A was 1.2%, but Group B and C were 0%. Compared with Group A(100%) and C(100%), the satisfaction rate of sedation quality in Group B was 74%, with significant difference (P<0.05). CONCLUSION: During the upper gastrointestinal endoscopic procedures, snoring patients are premedicated with propofol in various uses by steps or one slow administration. Both methods are safe and effective to reduce the incidence of severe respiratory depression, and patients have no memory of the procedure.

[Capsule endoscopy in the diagnosis of intestinal diseases].

OBJECTIVE: To determine the efficiency and safety of capsule endoscopy for patients with intestinal diseases. METHODS: Given M2A capsule endoscopy (CE) was performed on 81 patients with obscure gastrointestinal bleeding and obscure abdominal pain, and the clinical data were analyzed. RESULTS: In the 81 patients, 9 showed negative finding, CE didn't reach the small intestine in 1 patient. In the other 71 patients, 132 intestinal lesions were detected, and the total positive rate of CE for intestinal diseases was 88.75%. The findings consisted of 36 intestinal inflammation, 24 angiopathy, 16 protuberant lesions, 15 mutipolypi in the intestine, 12 blood in the intestine, 11 single or multiple ulcers, 6 ascarid in the intestine, 5 diverticula, 1 ankylostomiasis, 1 intestinal dysplasia with internal fistula, and the 5 intestinal Crohn's disease. Ten patients with protuberant lesion were verified by surgical operation and pathology, and the 5 stromal tumors diagnosed by CE were confirmed by pathological examination, while no one of Crohn's disease, lymphoma and angioma was diagnosed correctly by CE. All images of CE were good. All the patients had no complications. CONCLUSION: Capsule endoscopy is a safe and effective procedure, with a high positive rate, but the diagnostic yield is limited, which can be used for intestinal diseases.

[Propofol combined with midazolam intravenous sedation anesthesia in pediatric upper gastrointestinal endoscopy].

OBJECTIVE: To explore the application of propofol combined with midazolam intravenous anesthesia in pediatric upper gastrointestinal endoscopy. METHODS: A total of 497 ASA I~II patients who received sedative upper gastrointestinal endoscopy were assigned to a children group (2-14 years) and an adults group (18-65 years).The 2 groups were treated with midazolam (0.02-0.03 mg/kg, iv) and propofol(0.6-0.7 mg/s,iv) with an interval of 3-5 minutes. Enterscopy was inserted at light sleep, relaxing muscles, and disappearance of eyelash relaxation. Combining of pro-endoscopy, reaction to intravenous administration, dose of propofol, reaction to endoscopy, time of returning to consciousness, changes of SpO2, R, HR, and BP, and sedative quality were evaluated. RESULTS: Good sedation of the 2 groups after intravenous administration was observed. Rate of combining of pro-endoscopy in children was lower (42%) than that in adults(100%). The incidence of restlessness, hyperphasia, temporary decreasing of SpO2, dose of propofol of per kilogram weight, time of returning to consciousness in the children were 82.7%, 17%, 2.4 mg/kg, and (17.5+/-3.2) min, respectively, which were all higher in the adults [9%, 4%, 1.4 mg/kg, and (9.5+/-1.3) min, P<0.01]. HR and BP decreased in the 2 groups, and recovered rapidly after the endoscopy. There was no significant difference between the 2 groups(P>0.05). CONCLUSION: It is safe and effective to use propofol combined with midazolam intravenous sedation anesthesia in pediatric upper gastrointestinal endoscopy.

[Effect of various uses of propofol on the upper gastrointestinal endoscopy].

OBJECTIVE: To investigate the efficacy and security of different uses of propofol on the sedation during the upper gastrointestinal endoscopic procedures. METHODS: Four hundred patients who underwent gastroscopy received midazolam and propofol as sedation. Patients were divided to 4 groups with different intervals between midazolam and propofol: Group A and D with the interval of 30 seconds to 1 minute, Group B and C with 3 to 5 minute interval. All patients were premedicated with midazolam and propofol at 16 approximately 25 mg/10s (Group A and B) and 6 approximately 7 mg/10s (Group C and D). RESULTS: The doses of propofol of Group A,B,C, and D were (111.90+/-22.43),(102.20+/-15.99),(73.05+/-13.08) and (80.90+/-17.36)mg respectively, with significant difference(P<0.01). The time of return to consciousness decreased markedly in Group C and D [(9+/-1), (10+/-2)min ], and that of Group A and B was [(14+/-5), (13+/-3)min ]. There was significant difference between Group C, D and Group A, B(P<0.01). CONCLUSION: The dose of propofol and the time of return to consciousness depend on the rate of administration and the interval between midazolam and propofol. Appropriate rate and interval can produce safer and more effective sedation for the upper gastrointestinal endoscopic procedure.

[Two-stage administration sedation method for gastroscopy in hypoxia predisposed patients].

OBJECTIVE: To explore the safety and the efficacy of two-stage administration sedation method (with propofol plus midazolam) in the analgesia gastroscopy for hypoxia predisposed patients. METHODS: Sixty-four hypoxia predisposed patients (with snore or expectoration) were divided into two groups and received sedation respectively with two-stage administration method and routine continuum administration method before gastroscopy. We analyzed the alteration of SBP, DBP, SpO2, sedation level, the degree of pharyngeal malaise, recovery time, dose of propofol,the lethe degree of upset, and procedure of gastroscopy to evaluate the safety and the efficacy of the two methods in the analgesia gastroscopy for hypoxia predisposed patients. RESULTS: Compared with routine continuum administration sedation method, two-stage administration sedation method had little influence on SpO2, so it reduced the accident of respiratory arrest (P < 0.01). The gastroscopy could be achieved at the lower sedation level with two stage administration method (P <0.01), so that the recovery time was shortened (P < 0.01). The degree of pharyngeal malaise in the patients with two-stage administration sedation method was higher than that of patients with routine continuum administrationsedation method (P < 0.01), and the dose of propofol used for sedation decreased (P < 0.01). While the lethe degree of gastroscopy upset and alteration of SBP, DBP were rated similarly in both groups (P > 0.05), and the lethe degree of gastroscopy procedure in two-stage administration method group was significantly lower than that of routine continuum adminis- tration method group (P <0.01). CONCLUSION: The two-stage administration sedation method is a new effective and safe sedation method for gastroscopy in the hypoxia predisposed patients.