RESUMO
BACKGROUND & AIMS: Endoscopic mucosal resection (EMR) is standard therapy for nonpedunculated colorectal polyps ≥20 mm. It has been suggested recently that polyp resection without current (cold resection) may be superior to the standard technique using cutting/coagulation current (hot resection) by reducing adverse events (AEs), but evidence from a randomized trial is missing. METHODS: In this randomized controlled multicentric trial involving 19 centers, nonpedunculated colorectal polyps ≥20 mm were randomly assigned to cold or hot EMR. The primary outcome was major AE (eg, perforation or postendoscopic bleeding). Among secondary outcomes, major AE subcategories, postpolypectomy syndrome, and residual adenoma were most relevant. RESULTS: Between 2021 and 2023, there were 396 polyps in 363 patients (48.2% were female) enrolled for the intention-to-treat analysis. Major AEs occurred in 1.0% of the cold group and in 7.9% of the hot group (P = .001; odds ratio [OR], 0.12; 95% CI, 0.03-0.54). Rates for perforation and postendoscopic bleeding were significantly lower in the cold group, with 0% vs 3.9% (P = .007) and 1.0% vs 4.4% (P = .040). Postpolypectomy syndrome occurred with similar frequency (3.1% vs 4.4%; P = .490). After cold resection, residual adenoma was found more frequently, with 23.7% vs 13.8% (P = .020; OR, 1.94; 95% CI, 1.12-3.38). In multivariable analysis, lesion diameter of ≥4 cm was an independent predictor both for major AEs (OR, 3.37) and residual adenoma (OR, 2.47) and high-grade dysplasia/cancer for residual adenoma (OR, 2.92). CONCLUSIONS: Cold resection of large, nonpedunculated colorectal polyps appears to be considerably safer than hot EMR; however, at the cost of a higher residual adenoma rate. Further studies have to confirm to what extent polyp size and histology can determine an individualized approach. German Clinical Trials Registry (Deutsches Register Klinischer Studien), Number DRKS00025170.
Assuntos
Pólipos do Colo , Colonoscopia , Ressecção Endoscópica de Mucosa , Hemorragia Pós-Operatória , Humanos , Feminino , Masculino , Pólipos do Colo/cirurgia , Pólipos do Colo/patologia , Ressecção Endoscópica de Mucosa/efeitos adversos , Ressecção Endoscópica de Mucosa/métodos , Pessoa de Meia-Idade , Idoso , Colonoscopia/métodos , Colonoscopia/efeitos adversos , Alemanha , Resultado do Tratamento , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/epidemiologia , Adenoma/cirurgia , Adenoma/patologia , Perfuração Intestinal/etiologia , Perfuração Intestinal/epidemiologia , Perfuração Intestinal/cirurgia , Neoplasia Residual , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologia , Carga Tumoral , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/patologia , Criocirurgia/efeitos adversos , Criocirurgia/métodosRESUMO
Obesity is a chronic, relapsing, degenerative, multifactorial disease that is associated with many co-morbidities. The global increasing burden of obesity has led to calls for an urgent need for additional treatment options. Given the rapid expansion of bariatric endoscopy and bariatric surgery across Europe, the European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. This curriculum is set out in terms of the prerequisites prior to training, minimum number of procedures, the steps for training and quality of training, and how competence should be defined and evidenced before independent practice. 1: ESGE recommends that every endoscopist should have achieved competence in upper gastrointestinal endoscopy before commencing training in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. 2: Trainees in bariatric endoscopy and the endoscopic treatment of the complications of bariatric surgery should have basic knowledge of the definition, classification, and social impact of obesity, its pathophysiology, and its related co-morbidities. The recognition and management of gastrointestinal diseases that are more common in patients with obesity, along with participation in multidisciplinary teams where obese patients are evaluated, are mandatory. 3 : ESGE recommends that competency in bariatric endoscopy and the endoscopic treatment of the complications of bariatric surgery can be learned by attending validated training courses on simulators initially, structured training courses, and then hands-on training in tertiary referral centers.
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Cirurgia Bariátrica , Endoscopia Gastrointestinal , Humanos , Endoscopia Gastrointestinal/métodos , Currículo , Cirurgia Bariátrica/efeitos adversos , Obesidade/cirurgia , Europa (Continente)RESUMO
BACKGROUND AND STUDY AIM: Relief from dysphagia and regurgitation are the main goals of therapy in symptomatic Zenker's diverticulum. Flexible endoscopic treatment has proved to be an effective and safe method in control of these symptoms. The aim of our study was to further improve the resection of the cricopharyngeal muscle using a new technique, the double incision and snare resection (DISR) procedure, to reduce the recurrence rate. PATIENTS AND METHODS: From February 2016 to April 2017, 16 patients were treated with 18 DISR procedures at our institution. The symptoms of the patients were recorded by a seven-item questionnaire prior to treatment, and re-evaluation was scheduled at 1 and 6 months after treatment. RESULTS: The median age was 70 years (range 55â-â85), and 10 patients were men (62â%). The median size of the diverticulum was 20âmm (range 5â-â40âmm), and the DISR procedure was performed in 28 minutes (range 20â-â47 minutes), with no major postinterventional complications. All patients re-started oral nutrition on the day after the intervention; a gastric tube was not required. The median follow-up was 3 months (range 1â-â15 months). Two patients received a planned second-step procedure, one because of a very large cricopharyngeal muscle and one because of a cyst inside the Zenker's bridge. Although one patient suffered from mild recurrence of symptoms, she refused a second treatment. All other patients were free of symptoms after treatment. CONCLUSIONS: The DISR procedure is a new endoscopic treatment technique that safely and reproducibly offers relief from symptomatic Zenker's diverticulum.
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Transtornos de Deglutição/cirurgia , Esofagoscopia/métodos , Microcirurgia/métodos , Divertículo de Zenker/cirurgia , Idoso , Idoso de 80 Anos ou mais , Transtornos de Deglutição/etiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Divertículo de Zenker/complicaçõesRESUMO
Background In the German hospital reimbursement system (G-DRG) endoscopic procedures are listed in cost center 8. For reimbursement between hospital departments and external providers outdated or incomplete catalogues (e.âg. DKG-NT, GOÄ) have remained in use. We have assessed the cost for endoscopic procedures in the G-DRG-system. Methods To assess the cost of endoscopic procedures 74 hospitals, annual providers of cost-data to the Institute for the Hospital Remuneration System (InEK) made their data (2011â-â2015; §â21 KHEntgG) available to the German-Society-of-Gastroenterology (DGVS) in anonymized form (4873â809 case-data-sets). Using cases with exactly one endoscopic procedure (nâ=â274â186) average costs over 5 years were calculated for 46 endoscopic procedure-tiers. Results Robust mean endoscopy costs ranged from 230.56â for gastroscopy (144â666 cases), 276.23â (nâ=â32â294) for a simple colonoscopy, to 844.07â (nâ=â10â150) for ERCP with papillotomy and plastic stent insertion and 1602.37â (nâ=â967) for ERCP with a self-expanding metal stent. Higher costs, specifically for complex procedures, were identified for University Hospitals. Discussion For the first time this catalogue for endoscopic procedure-tiers, based on §â21 KHEntgG data-sets from 74 InEK-calculating hospitals, permits a realistic assessment of endoscopy costs in German hospitals. The higher costs in university hospitals are likely due to referral bias for complex cases and emergency interventions. For 46 endoscopic procedure-tiers an objective cost-allocation within the G-DRG system is now possible. By international comparison the costs of endoscopic procedures in Germany are low, due to either greater efficiency, lower personnel allocation or incomplete documentation of the real expenses.
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Endoscopia/economia , Gastroenterologia , Custos de Cuidados de Saúde/estatística & dados numéricos , Análise de Dados , Grupos Diagnósticos Relacionados , Alemanha , HumanosRESUMO
Background and study aims There are no data showing the outcome of ESD during live endoscopy events (LEE). ESD performed during the Augsburg Endo-Update LEE were compared with matched routine procedures with the aim of demonstrating non-inferiority of LEE ESD. Patients and methods ESD performed during the Endo-Update between 2006 and 2018 were reviewed. The controls were routine procedures matched according to age, location and lesion size. Resection, recurrence, survival and complication rates, procedure time and propofol sedation were assessed. Clinically relevant margins were assumed for resection and complication rates, procedure time and propofol sedation quantity. Results Thirty-eight ESD were performed in the given time period, and were compared with 38 matched routine ESD. En bloc and curative resection rates in the LEE group and in the control group were 100â% and 87â% as well as 84â% and 71â% respectively, while procedure times were 135 and 125 minutes, respectively. Non-inferiority was demonstrated for resection rates and procedure time. The complication rate was lower in the LEE group as compared with the control group (5â% vs 13â%) while propofol sedation was similar in both groups (863âmg vs 872âmg). Recurrence and 5-year survival rates for both groups were 4â% vs 0â% and 70â% vs 65% respectively. Conclusions The resection rate and procedure time of ESD during LEE was non-inferior to those of routine ESD procedures. Comparison of the complication rates, however, was inconclusive owing to the low patient number and complication risk in both groups.
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BACKGROUND AND AIMS: Small bowel MR enteroclysis and wireless capsule endoscopy (WCE) are new diagnostic tools for the investigation of the small bowel. The aim of this study was to compare the diagnostic yield of WCE with MR enteroclysis in the detection of small bowel pathologies. METHODS: A total of 36 patients were included in the study. Indications for imaging of the small bowel were proven or suspected small bowel Crohn's disease (CD; n=18), obscure gastrointestinal (GI) bleeding (n=14) and tumour surveillance (n=4). RESULTS: In patients with Crohn's disease WCE detected significantly more inflammatory lesions in the first two segments of the small bowel compared with MR enteroclysis (12 patients vs. 1 patient, p=0.016). In 5 out of 14 (36%) patients with GI bleeding, angiodysplasia was detected as a possible bleeding source. Three of these patients had active bleeding sites detected by WCE. One patient had scattered inflammation of the mucosa. MR enteroclysis did not reveal any intestinal abnormalities in this patient group. MR enteroclysis provided extraintestinal pathologies in 10 out of 36 (28%) patients. CONCLUSION: In patients with Crohn's disease WCE revealed significantly more inflammatory lesions in the proximal and middle part of the small bowel in comparison to MR enteroclysis, whereas in patients with obscure GI bleeding WCE was superior to MR enteroclysis.
Assuntos
Endoscopia por Cápsula/métodos , Doença de Crohn/diagnóstico , Ileíte/diagnóstico , Imageamento por Ressonância Magnética/métodos , Adolescente , Adulto , Idoso , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Fluorescence endoscopy is a promising new method for detection and treatment of premalignant and malignant lesions. The aim of this pilot study was to investigate the feasibility of hexaminolevulinate-based photodetection of rectal adenoma and cancer, including safety, dose finding, and efficacy. METHODS: Ten patients with known rectal adenoma or cancer were sensitized by instillation of 3.2 mM of hexaminolevulinate as an enema. Fluorescence endoscopy was performed after retention of the enema for 30 to 60 minutes, followed by a rest time of up to 30 minutes before endoscopy. Biopsy specimens were taken from fluorescent and non-fluorescent areas and fluorescence microscopy studies were performed to assess the distribution of protoporphyrin IX fluorescence in different tissue layers. Adverse events were reported by direct questioning of all patients; skin photosensitivity, changes in biochemical tests of liver function, blood pressure and heart rate, and the occurrence of GI symptoms (nausea, vomiting) were recorded for 5 patients. OBSERVATIONS: Hexaminolevulinate-induced fluorescence endoscopy produced selective fluorescence of all rectal adenomas with intraepithelial neoplasia. For rectal cancer, there was only weak fluorescence or none at all. No hexaminolevulinate-induced side effect was observed. In two patients, fluorescence differentiated adenomas and hyperplastic polyps. CONCLUSIONS: Hexaminolevulinate-based fluorescence endoscopy (3.2 mM administered as an enema) in patients with rectal cancer and adenoma was well tolerated and produced no significant skin sensitivity or other side effects. The optimal duration of application is 30 to 45 minutes, with a rest time of 30 minutes. Selective fluorescence of adenoma with intraepithelial neoplasia suggests that hexaminolevulinate-based fluorescence endoscopy may be useful for detection of premalignant lesions.