Interventional Endoscopic Ultrasound: Current Status and Future Frontiers.

Interventional endoscopic ultrasound has fueled remarkable advancements in the field of therapeutic procedures, revolutionizing minimally invasive interventions for a diverse range of conditions. This review highlights the latest breakthroughs and advancements in therapeutic endoscopic ultrasound, showcasing its potential to transform patient care.

Endoscopic approaches to small intestinal strictures.

PURPOSE OF REVIEW: Gastric outlet obstruction (GOO) occurs from benign or malignant causes. Historically, the treatment of benign strictures revolved around endoscopic balloon dilation, whereas, in the case of malignant strictures, the placement of self-expandable metallic stents was the focus. The advent of lumen-apposing metal stent has opened new horizons in addressing shortcomings of enteral stenting and surgical gastroenterostomies. The purpose of the review is to discuss the endoscopic approaches to small bowel strictures and to examine the supporting data behind each practice. RECENT FINDINGS: Given the risk and futility of balloon dilation for malignant strictures, enteral stenting is pursued in patients who are poor surgical candidates and with life expectancy less than 6 months. For patients with longer survival, surgical gastroenterostomy (S-GE) should be considered. Recent data have shown comparable technical and clinical success rates between EUS-gastroenterostomy and S-GE but with lower adverse event rate and hospital length of stay. SUMMARY: In recurrent benign strictures and malignant GOO, EUS-GE has recently gained momentum in providing an effective and a well tolerated alternative. Individualized therapy centered around the patient's prognosis and preference while factoring in the local expertise for the specific indication is vital.

Randomized controlled trial comparing the Franseen needle with the Fork-tip needle for EUS-guided fine-needle biopsy.

BACKGROUND AND AIMS: EUS-guided FNA primarily provides cytologic samples. EUS-guided fine-needle biopsy (FNB) with needles that provide histologic specimens may enhance diagnostic yield and facilitate accessory tissue staining. Several different needle designs are currently available and design superiority is unknown. We designed a randomized controlled trial to compare 2 commonly used EUS-FNB needles in their ability to provide histologic tissue samples (primary endpoint) and to reach an accurate diagnosis (secondary endpoint). METHODS: A total of 150 lesions from 134 patients (November 2018 to June 2019) were randomized 1:1 between biopsy with a Franseen needle and a Fork-tip needle. The groups were compared regarding the quality of the tissue samples and diagnostic accuracy. RESULTS: Of 150 lesions, 75 were pancreatic and 75 were other solid lesions in and around the GI tract. There was no statistically significant difference between the Franseen needle and the Fork-tip needle in the yield of adequate histologic samples, 71 of 75 (94.7%) versus 72 of 75 (96%), (P = 1.00), an absolute difference of -1.3% (95% confidence interval [CI], -8.1% to 5.4%). The 2 groups were similar in the diagnostic accuracy of histologic analysis, 64 of 75 (85.3%) versus 68 of 75 (90.7%) (P = .45), absolute difference -5.4% (95% CI, -15.7% to 5%); and in the diagnostic accuracy of combined cytologic and histologic analysis, 65 of 75 (86.7%) versus 69 of 75 (92%) (P = .43), absolute difference -5.3% (95% CI, -15.2% to 4.5%). CONCLUSIONS: There was no significant difference in the performance of the Franseen needle versus the Fork-tip needle. Both needles achieved a high yield of histologic tissue samples and high diagnostic accuracy. (Clinical trial registration number: NCT03672032.).

[Acrometastasis revealing a pulmonary adenocarcinoma: Report of a case with unusual histopathological findings]. / Acrométastase révélatrice d'un adénocarcinome pulmonaire : à propos d'un cas de présentation histopathologique inhabituelle.

Acrometastasis are rare and can be exceptionally indicative of an occult carcinoma. The prognosis is generally poor. The radiological and immunohistochemical findings can be of great value to determine the primary and to guide treatment. We report a case of a 56-years-old man with acrometastasis at the fourth finger of the left hand revealing a pulmonary adenocarcinoma. Histopathological analysis showed a cribriform adenocarcinoma with an unusual cytoplasmic co-expression of TTF1 and Hepar-1 upon immunohistochemical analysis. There was no nuclear TTF1 immunostaining. Imaging explorations showed a 6-cm mass of the left superior pulmonary lobe. The patient received immunochemotherapy. Upon follow-up, there was evidence of disease progression on chest computed tomography scan.

STAT6 and Furin Are Successive Triggers for the Production of TGF-ß by T Cells.

Production of TGF-ß by T cells is key to various aspects of immune homeostasis, with defects in this process causing or aggravating immune-mediated disorders. The molecular mechanisms that lead to TGF-ß generation by T cells remain largely unknown. To address this issue, we take advantage of the fact that intestinal helminths stimulate Th2 cells besides triggering TGF-ß generation by T lymphocytes and regulate immune-mediated disorders. We show that the Th2 cell-inducing transcription factor STAT6 is necessary and sufficient for the expression of TGF-ß propeptide in T cells. STAT6 is also necessary for several helminth-triggered events in mice, such as TGF-ß-dependent suppression of alloreactive inflammation in graft-versus-host disease. Besides STAT6, helminth-induced secretion of active TGF-ß requires cleavage of propeptide by the endopeptidase furin. Thus, for the immune regulatory pathway necessary for TGF-ß production by T cells, our results support a two-step model, composed of STAT6 and furin.

[Pancreatic Mass or Cyst? Diagnostic Dilemma].

A santorinicele is a rare anomaly defined as focal cystic dilation of the terminal portion of the dorsal pancreatic duct at the minor papilla. Importantly this anomaly has been suggested as a possible cause of relative stenosis of the minor papilla. This anomaly has been associated with pancreatic divisum and recurrent acute pancreatitis. Magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic ultrasound (EUS) are the main diagnostic modalities. Endoscopic minor papilla sphincterotomy has been shown to improve pain and quality of life in patients with this anomaly presenting with recurrent pancreatitis. We present a case of a single episode of pancreatitis who underwent EUS for evaluation of possible pancreatic mass leading to a diagnosis of santorinicele and complete pancreatic divisum. We attempt to describe this anomaly, diagnostic approach, and management options.

Per oral endoscopic myotomy: early experience and safety of a multispecialty approach.

BACKGROUND: Per oral endoscopic myotomy (POEM) has gained increasing popularity for treating achalasia. A multidisciplinary approach may allow safe and early adoption of POEM into clinical practice. MATERIALS AND METHODS: We performed a retrospective review of our initial POEM cases. All procedures were performed by a team of interventional gastroenterologist and thoracic surgeon. We analyzed demographics, comorbidities, achalasia subtypes, length of hospital stay, duration of surgery, morbidity, mortality, length of myotomy, preoperative and postoperative Eckardt scores. RESULTS: Thirty-one consecutive patients underwent POEM during the 24-month period from January 2014 to December 2015. Eighteen patients (58%) had prior non-operative interventions. Average duration of follow-up was 9.6 months. Seventeen patients (66.8%) had follow-up of 12 months and longer. Average preoperative Eckardt score was 6.3 (3-10), median 6. Average postoperative Eckardt score was 1.4 (0-8), median 1, in 1 month and an average 2.2, median 1, in 1 year. Patients with type III achalasia were most refractory to treatment, while patients with type II had the best results. Average LOS was 1.3 days (1-5), median 1 day. Average DOS was 106 min (60-148), median 106. Average LOM was 13 cm (10-15), with median of 13 cm. We had one 30-day mortality secondary to coronary artery disease. Four patients had prior Heller myotomies and underwent a posterior myotomy during POEM, with outcomes similar to patients with no prior myotomy. CONCLUSIONS: We demonstrated safety and efficiency of a multispecialty approach for achalasia with POEM with a low rate of complications.

The Use of Linear Formulas to Estimate Glenoid Bone Loss in the Lebanese Population: A 3-Dimensional Computed Tomography Study.

Background: Glenoid bone loss (GBL) is common in patients with shoulder instability and plays a major role in surgical decision-making. While a plethora of GBL estimation methods exist, all of which present specific challenges, recent studies have developed simple linear formulas estimating GBL based on glenoid height. Purpose: To assess the correlation between glenoid height and width, and to develop specific formulas based on age and sex to calculate the native glenoid width in the Lebanese population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Computed tomography scans for 202 normal shoulders were extracted from our database. The glenoids were reconstructed in 3 dimensions and their width and height were measured. Glenoid width and height were compared between male and female groups. Correlation analysis was also performed on the width, height, age, and body mass index. Formulas estimating glenoid width were developed using regression analysis including all variables significantly influencing the model. Results were then compared with the values calculated using previously published formulas to determine the external validity when using linear formulas to estimate GBL. Results: Significant differences were found between men and women. Regression analysis found that glenoid height and width strongly influenced the model, and that age showed a weak but significant correlation; therefore, the following 2 sex-specific formulas were developed: width (mm) = 6.1 + 0.51 ×height+ 0.03 ×age, and width (mm) = 4.55 + 0.51 ×height+ 0.03 ×age, in men and women, respectively. The values yielded from the formulas developed in this study and the true width significantly differed from those calculated from previous reports. Conclusion: A strong correlation was found between glenoid height and width in a the Lebanese population and demonstrated that glenoid width can be accurately calculated based on the glenoid height and patient's age and sex using the following simplified formulas: width (mm) = 6 + 0.5 ×height+ 0.03 ×age, and width (mm) = 4.5 + 0.5 ×height+ 0.03 ×age, in men and women, respectively.

Peroral endoscopic myotomy and septotomy for Zenker diverticulum.

Zenker diverticulum (ZD) is the most common hypopharyngeal diverticulum seen often in septuagenarian and octogenarian males. Oropharyngeal dysphagia is the most common presenting symptom. Treatment of ZD has been advancing with the introduction of a wide variety of accessory devices, primarily focusing on obliteration of the septum by complete transection of the cricopharyngeus muscle to recreate the common cavity and restore normal pharyngo-esophageal bolus outflow. This review aimed to provide an overview of the various surgical and endoscopic treatment options for ZD, while focusing specifically on Zenker peroral endoscopic myotomy.

Augmented reality and shoulder replacement: a state-of-the-art review article.

Since its implementation, the rates of failure of total shoulder arthroplasty which may be due to malpositioning pushed to improve this surgery by creating new techniques and tools to help perioperatively. Augmented reality, a newly used tool in orthopedic surgery can help bypass this problem and reduce the rates of failure faced in shoulder replacement surgeries. Although this technology has revolutionized orthopedic surgery and helped improve the accuracy in shoulder prosthesis components positioning, it still has some limitations such as inaccurate over-imposition that should be addressed before it becomes of standard usage.

A novel technique for the treatment of radiation-induced acquired esophageal atresia in patients with head and neck cancer.

Background and Aims: Dysphagia is a common complaint for patients after radiation therapy for head and neck cancer. Chronic dysphagia ensues when the radiation-induced injury matures into a fibrotic stricture, with the severity of symptoms paralleling the degree of stenosis. Most patients experience progressive dysphagia that prompts medical attention before complete esophageal obliteration. Rarely, patients present late with inability to clear their secretions because of complete obstruction, also termed acquired atresia. These patients represent a challenge and require aggressive and unconventional interventions to reestablish lumenal patency. Using a case series, we hereby describe a novel yet simple technique to treat patients with acquired esophageal atresia. Methods: Five patients with head and neck cancer in various stages who all underwent nonsurgical treatment with definitive chemotherapy and radiation along with enteral feeding tube placement prior to/during treatment presented with acquired esophageal atresia. All patients underwent an EGD to reestablish lumenal patency. This was accomplished with gentle pressure that was applied in a to-and-fro semi-circular rotational manner as if pushing a corkscrew and twisting it in alternating clockwise and counterclockwise manner. Results: In all cases we were able to reestablish esophageal lumenal patency with a single procedure. There were no adverse events. Four of the 5 patients required additional dilations for symptomatic management. However, all patients' esophageal lumens remained patent. Conclusions: We describe a novel yet simple technique to treat acquired esophageal atresia after radiation for head and neck cancer. This technique allows for generous dilation yielding complete resolution of the stenosis in a single session. When our approach is used, the patient can be discharged home the same day and resume immediate oral intake.

Insights into the endoscopic management of esophageal achalasia.

Achalasia is a primary esophageal motility disorder characterized by the loss of inhibitory neurons in the myenteric plexus, resulting in impaired relaxation of the esophagogastric junction. Achalasia is an incurable disease, and the treatment modalities are aimed at disruption of the esophagogastric junction and vary widely from pharmacological to endoscopic to surgical. Traditional endoscopic therapy includes pneumatic dilation, botulinum toxin injection, and peroral endoscopic myotomy. This review aims to provide an overview of the endoscopic management of achalasia, while focusing on the utilization of peroral endoscopic myotomy and other novel approaches.

Modified Endoscopic Ultrasound Needle to Obtain Histological Core Tissue Samples: A Retrospective Analysis.

BACKGROUND/AIMS: Endoscopic ultrasound (EUS)-guided fine-needle aspiration is very effective for providing specimens for cytological evaluation. However, the ability to provide sufficient tissue for histological evaluation has been challenging due to the technical limitations of dedicated core biopsy needles. Recently, a modified EUS needle has been introduced to obtain tissue core samples for histological analysis. We aimed to determine (1) its ability to obtain specimens for histological assessment and (2) the diagnostic accuracy of EUS-guided fine-needle biopsy (EUS-FNB) using this needle. METHODS: We retrospectively analyzed consecutive cases of FNB using modified EUS needles for 342 lesions in 303 patients. The cytology and histological specimens were analyzed. Diagnostic accuracy was calculated. RESULTS: Adequate cytological and histological assessment was possible in 293/342 (86%) and 264/342 (77%) lesions, respectively. Diagnostic accuracy of the cytological specimen was 294/342 (86%) versus 254/342 (74%) for the histological specimen (p<0.01). Diagnostic accuracy of the combined cytological and histological assessment was 323/342 (94.4%), which was significantly higher than that of both histology alone (p<0.001) and cytology alone (p=0.001). CONCLUSION: EUS-FNB with the modified EUS needle provided histologic tissue cores in the majority of cases and achieved excellent diagnostic accuracy with few needle passes.

Lunate Excision with Partial Bicolumnar Wrist Fusion: A New Alternative for Isolated Radiolunate Arthritis?: A Report of 2 Cases.

CASE: We report the case of 2 patients presenting with advanced isolated radiolunate arthritis with limited wrist strength and range of motion (ROM). After failure of conservative therapy, both patients underwent lunate excision and scaphocapitate and triquetrohamate joints fusion using compression headless screws. Improved functional outcomes are reported at 4 years of follow-up with painless wrists and increased grip strength and ROM. CONCLUSIONS: Lunate excision and partial bicolumnar wrist fusion lead to increased grip strength and wrist ROM. This is a unique alternative for people suffering isolated radiolunate osteoarthritis, for which no standard surgical care exists.

Peroral Endoscopic Myotomy Is Feasible and Safe in a Gastric Bypass Population.

BACKGROUND: Obesity is public health problem of epidemic proportions. Esophageal dysmotility including achalasia is more commonly seen in an obese population. Standard therapy for achalasia can be complicated by hepatomegaly and a post-surgical anatomy in a pre- and post-bariatric population. Peroral endoscopic myotomy (POEM) has not been adequately studied in this population. METHODS: A retrospective review of a prospectively collected database was completed. Patients who had undergone a Roux-en-y gastric bypass (RYGB) prior to or following a POEM were enrolled. Patient demographics, operative information and post-operative course data was collected. RESULTS: Six patients underwent POEM prior to or after RYGB. There were no peri-operative complications with an average length of stay of 1.2 days. Five patients experienced a clinical success with excellent symptom resolution. The one failure was in the setting of type III achalasia, but did have objective evidence of lower esophageal sphincter (LES) relaxation post-operatively. CONCLUSION: POEM in the setting of bariatric surgery is safe and feasible. The potential increase in GERD following POEM is obviated by RYGB anatomy. In an obese individual, a staged POEM prior to or following a RYGB is an appropriate treatment algorithm for obese and achalasia.