Skilled Endoscopists Research Articles

Use of Snare Tip Endoscopic Submucosal Dissection in the Endoluminal Management of Complex Colon Lesions.

Endoscopic submucosal dissection for advanced colon lesions is typically performed with specialized and costly endoscopic knives, potentially limiting accessibility and increasing procedural cost. Alternatively, the tip of an endoscopic snare, which is inexpensive and universally available, has demonstrated safe and efficient use in gastric lesions but lacks sufficient data for use in colon lesions. This study aimed to assess patient outcomes following endoscopic submucosal dissection of advanced colon lesions using the endoscopic snare tip. A retrospective review of a prospectively maintained database at a single tertiary care center was conducted. This study was conducted at a single tertiary care center. Adult patients with colon lesions that were not amenable to snare polypectomy were evaluated for endoscopic submucosal dissection. Snare tip resection was performed in select patients with lesions that lifted adequately after submucosal injection. Patients who underwent hybrid resections with endoscopic mucosal dissection were excluded. En bloc resection rates, operative time, perioperative complications, and short-term outcomes such as length of stay and lesion recurrence on follow-up colonoscopy were evaluated. A total of 121 patients underwent snare tip endoscopic submucosal dissection, with a mean lesion size of 28.8 ± 9.84 mm. Most procedures were performed in the endoscopy suite (81.8%). The en bloc resection rate was 81.8% with an average procedure time of 37.1 ± 29.8 min. There were two perforations (1.70%), one of which was managed operatively. Recurrence occurred in 6 patients (7.89%) at the time of follow-up colonoscopy. This study was retrospective, conducted by two skilled endoscopists with experience in endoscopic resection, and had short-term follow up. Snare tip endoscopic submucosal dissection for advanced colon lesions demonstrates satisfactory short-term outcomes, suggesting its potential as a safe and accessible alternative to specialized knives, thereby possibly enhancing adoption of endoscopic resection and improving patient accessibility. See Video Abstract.

Differentiating Gastrointestinal Stromal Tumors From Leiomyomas of Upper Digestive Tract Using Convolutional Neural Network Model by Endoscopic Ultrasonography.

Gastrointestinal stromal tumors (GISTs) and leiomyomas are the most common submucosal tumors of the upper digestive tract, and the diagnosis of the tumors is essential for their treatment and prognosis. However, the ability of endoscopic ultrasonography (EUS) which could correctly identify the tumor types is limited and closely related to the knowledge, operational level, and experience of the endoscopists. Therefore, the convolutional neural network (CNN) is used to assist endoscopists in determining GISTs or leiomyomas with EUS. A model based on CNN was constructed according to GoogLeNet architecture to distinguish GISTs or leiomyomas. All EUS images collected from this study were randomly sampled and divided into training set (n=411) and testing set (n=103) in a ratio of 4:1. The CNN model was trained by EUS images from the training set, and the testing set was utilized to evaluate the performance of the CNN model. In addition, there were some comparisons between endoscopists and CNN models. It was shown that the sensitivity and specificity in identifying leiomyoma were 95.92%, 94.44%, sensitivity and specificity in identifying GIST were 94.44%, 95.92%, and accuracy in total was 95.15% of the CNN model. It indicates that the diagnostic accuracy of the CNN model is equivalent to skilled endoscopists, or even higher than them. While identifying GIST or leiomyoma, the performance of CNN model was robust, which is highlighting its promising role in supporting less-experienced endoscopists and reducing interobserver agreement.

Combination of Precut Techniques in Difficult Biliary Cannulation.

Selective biliary cannulation (SBC) is a prerequisite for successful endoscopic retrograde cholangiopancreatography (ERCP). SBC has the potential to fail in as many as 20% of cases, even with skilled endoscopists. Precut incision techniques like needle-knife sphincterotomy (NKS) and transpancreatic septotomy (TPS) can be used in cases where standard cannulation techniques fail. However, these precut techniques may also fail in some cases. We aimed to evaluate the procedural success of the combined TPS + NKS technique in difficult biliary cannulation. The study included 289 patients who underwent ERCP with precut techniques from 2017 to 2022. Patients were classified into the following three groups and evaluated retrospectively in terms of cannulation success, and ERCP-related adverse effects: Transpancreatic septotomy, NKS, and TPS + NKS; statistical package for the social sciences (SPSS), version 29.0, software was used to analyze the data. The success rate of SBC was 69% in the TPS group, 75.3% in the NCS group, and 87% in the TPS + NCS group. There was no significant difference between the NKS and TPS + NKS groups. Cannulation success in both NKS group and NKS + TPS groups was significantly higher than in the TPS group (p < 0.001). Complication rates were similar. In cases where standard sphincterotomy and precut techniques fail, a second precut technique can be used. A previous TPS does not prevent NKS. Abiyev A, Tuzcu B, Bilican G, et al. Combination of Precut Techniques in Difficult Biliary Cannulation. Euroasian J Hepato-Gastroenterol 2024;14(1):56-59.

Modified submucosal tunneling endoscopic septum division for symptomatic esophageal diverticula: a prospective case series (with video)

Background and aimsSubmucosal tunneling endoscopic septum division (STESD) is a valid endoscopic modality for treating esophageal diverticula. However, it requires highly skilled endoscopists. Here we propose a modified STESD method. MethodsThis is a single center prospective case series. We consecutively enrolled 8 patients diagnosed with esophageal diverticula. All the patients underwent the modified STESD by one experienced endoscopist. ResultsOnly one patient had intraoperative bleeding and was successfully stopped endoscopically. The size of the diverticula were 3.16 ± 1.14 cm as mean ± SD. The operation time ranged from 27 to 68 min with the mean value of 40.88 min. The number of clips ranged from 4 to 8. The success rate was 100%. None of the patients had symptom recurrences during 2 - 25 months of follow-up. ConclusionsThe modified STESD method for esophageal diverticula is effective and safe, further large prospective controlled studies are needed.

Needs assessment of basic gastrointestinal endoscopy training: A qualitative study in Indonesia.

Gastointestinal endoscopy is a complex practical skill, and training and experience are required to ensure the accuracy and safety of the procedures. Therefore, proper endoscopy training is needed to provide highly skilled endoscopists. This study explores the learning experience and assesses the need for endoscopy training in Indonesia from an endoscopy trainee's point of view. Limitations from the current training model and the trainees' suggestions hopefully will become a foundation for the future endoscopy training model in Indonesia. A total of 132 current endoscopy trainees and graduates of endoscopy training from various centers in Indonesia completed an online qualitative survey regarding their endoscopy training experience, their satisfaction with the current training method, barriers to achieving competency, and their suggestions for future training. Data were subjected to descriptive and qualitative analysis using content analysis. We found variations in the trainee's learning experience regarding the training supervision, feedback, and assessment methods. The most common endoscopy training methods were observation and direct practice with supervision. There was only a low proportion of simulator use (25%). The most found concept in barriers to achieving competency was "insufficient number of patients." Meanwhile, the most found concept in suggestions for future training methods was "increasing the variety of cases and procedures." Our findings suggest that there are still variations in endoscopy training methods in Indonesia. Therefore, we propose to design a standardized endoscopy training program to ensure the competence of endoscopy trainees and better care for endoscopic patients. Simulators might be used to increase the trainees' competence in settings with low numbers of patients or cases.

Artificial intelligence-based diagnosis of the depth of laryngopharyngeal cancer

ObjectiveTransoral surgery (TOS) is a widely used treatment for laryngopharyngeal cancer. There are some difficult cases of setting the extent of resection in TOS, particularly in setting the vertical margins. However, positive vertical margins require additional treatment. Further, excessive resection should be avoided as it increases the risk of bleeding as a postoperative complication and may lead to decreased quality of life, such as dysphagia. Considering these issues, determining the extent of resection in TOS is an important consideration. In this study, we investigated the possibility of accurately diagnosing the depth of laryngopharyngeal cancer using radiomics, an image analysis method based on artificial intelligence (AI). MethodsWe included esophagogastroduodenoscopic images of 95 lesions that were pathologically diagnosed as squamous cell carcinoma (SCC) and treated with transoral surgery at our institution between August 2009 and April 2020. Of the 95 lesions, 54 were SCC in situ, and 41 were SCC. Radiomics analysis was performed on 95 upper gastrointestinal endoscopic NBI images of these lesions to evaluate their diagnostic performance for the presence of subepithelial invasion. The lesions in the endoscopic images were manually delineated, and the accuracy, sensitivity, specificity, and area under the curve (AUC) were evaluated from the features obtained using least absolute shrinkage and selection operator analysis. In addition, the results were compared with the depth predictions made by skilled endoscopists. ResultsIn the Radiomics study, the average cross-validation was 0.833. The mean AUC for cross-validation calculated from the receiver operating characteristic curve was 0.868. These results were equivalent to those of the diagnosis made by a skilled endoscopist. ConclusionThe diagnosis of laryngopharyngeal cancer depth using radiomics analysis has potential clinical applications. We plan to use it in actual surgery in the future and prospectively study whether it can be used for diagnosis.

Impact and assessment of training models in interventional endoscopic ultrasound.

Interventional endoscopic ultrasound (IEUS) has gained significant popularity in recent years because of its diagnostic and therapeutic capabilities. The proper training of endoscopists is critical to ensure safe and effective procedures. This review study aims to assess the impact of different training models on the competence of trainees performing IEUS. Eight studies that evaluated simulators for IEUS were identified in the medical literature. Various training models have been used, including the EASIE-R, Mumbai EUS, EUS Magic Box, EndoSim, Thai Association for Gastrointestinal Endoscopy model, and an exvivo porcine model (HiFi SAM). The trainees underwent traditional didactic lectures, hands-on training using simulators, and direct supervision by experienced endoscopists. The effectiveness of these models has been evaluated based on objective and subjective parameters such as technical proficiency, operative time, diagnostic success, and participant feedback. As expected, the majority of skills were improved after the training sessions concluded, although the risk of bias is high in the absence of external validation. It is difficult to determine the ideal simulator among the existing ones because of the wide variation between them in terms of costs, reusability, design, fidelity of anatomical structures and feedback, and types of procedures performed. There is a need for a standardized approach for the evaluation of IEUS simulators and the ways skills are acquired by trainees, as well as a clearer definition of the key personal attributes necessary for developing a physician into a skilled endoscopist capable of performing basic and advanced therapeutic EUS interventions.

APPLICATION OF ENDOSCOPIC ULTRASOUND GUIDED FNAC(EUS-FNAC) IN DIAGNOSING PANCREATIC MASS LESIONS

Introduction: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNAC) has become an important modality for identification of pancreatic masses. It is a minimally invasive procedure that provides excellent cell yield even in deep seated lesions. The preoperative diagnosis of pancreatic mass by EUS-FNAC can help the surgeons in early detection and confirmation of neoplasm as pancreatic mass lesions are highly concerning for pancreatic carcinoma. This study was aimed at application of EUS-FNAC in diagnosing pancreatic mass lesions. Methods: A study was conducted for 20 cases who underwent EUS guided FNAC for pancreatic mass lesions. EUS-FNAC was performed by using a curvilinear array echo endoscope. The technique was carried out by a skilled endoscopist, and the glass slides were used to make smears from fluid that was aspirated containing corpuscular fractions. The slides were air dried before being examined cytopathologically. Results: Out of 20 cases,10 were of pancreatic Ductal adenocarcinoma, 3 of Neuroendocrine tumor of pancreas, 2 of Acinar cell carcinoma, 1 of Solid pseudopapillary tumor, 2 of Serous cystadenoma and 2 of Mucinous cystadenoma. This was confirmed later, on further Immunocytochemical stains. Conclusions:Out of 20 cases, 16 were malignant and 4 were benign. EUS-FNAC can help in early diagnosis and can improve the patient outcome. It is safe, cost-effective and reliable. It not only gives precise cytological diagnosis, but it also allows for the exact site of tiny lesions.

Endoscopic Transcecal Appendectomy (ETA): A Literature Review on Risks and Benefits.

Different colorectal lesions have attracted different procedures in their management. One of the novel approaches that have been documented in recent times is endoscopic transcecal appendectomy (ETA). ETA is an endoscopic and less invasive approach to the excision of lesions within the appendix. The appendix is also completely resected in the process. The main aim of this paper is to establish some of the benefits and risks that come with ETA. The study was conducted from a systematic review perspective using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, which governs the implementation of systematic reviews. Key considerations in the PRISMA framework used in this article include identifying the articles, screening them, and determining their eligibility and their final inclusion or exclusion based on the specified criteria. To arrive at relevant articles, some keywords were used in the various search engines of the databases that were consulted. Some of the keywords that were used included ETA, endoscopic mucosal resection (EMR), endoscopic full-thickness resection (EFTR), endoscopic submucosal dissection (ESD), adverse events, risks, safety, efficacy, and the appendiceal orifice. It was established that the key benefits of the ETA include the ability to avoid postoperative appendicitis and residual lesions in tissue. On the other hand, some risks that could come with ETA were found to include potential tumor seeding and postoperative bleeding. However, the key study limitation is that most of the referenced studies in this literature review are retrospective case series and case reports that are prone to selection bias. Furthermore, most ETA procedures in this literature review were performed by a few experienced and highly skilled endoscopists, making the ability to make such results generalizable to all endoscopists and patient populations a debatable issue. In the future, there is a need for more multicenter and large studies to be conducted with longer follow-up periods to ascertain the results obtained in this review. This will ensure a more informed decision-making process for or against ETA implementation in real-world clinical environments.

Flexible robotic endoscopy for treating gastrointestinal neoplasms.

Therapeutic flexible endoscopic robotic systems have been developed primarily as a platform for endoscopic submucosal dissection (ESD) in the treatment of early-stage gastrointestinal cancer. Since ESD can only be performed by highly skilled endoscopists, the goal is to lower the technical hurdles to ESD by introducing a robot. In some cases, such robots have already been used clinically, but they are still in the research and development stage. This paper outlined the current status of development, including a system by the author's group, and discussed future challenges.

Difficult colorectal polypectomy: Technical tips and recent advances.

Colonoscopy has been shown to be an effective modality to prevent colorectal cancer (CRC) development. CRC reduction is achieved by detecting and removing adenomas, which are precursors of CRC. Most colorectal polyps are small and do not pose a significant challenge for trained and skilled endoscopists. However, up to 15% of polyps are considered "difficult", potentially causing life-threatening complications. A difficult polyp is defined as any polyp that is challenging for the endoscopist to remove owing to its size, shape, or location. Advanced polypectomy techniques and skills are required to resect difficult colorectal polyps. There were various polypectomy techniques for difficult polyps such as endoscopic mucosal resection (EMR), underwater EMR, Tip-in EMR, endoscopic submucosal dissection (ESD), or endoscopic full-thickness resection. The selection of the appropriate modality depends on the morphology and endoscopic diagnosis. Several technologies have been developed to aid endoscopists in performing safe and effective polypectomies, especially complex procedures such as ESD. These advances include video endoscopy system, equipment assisting in advanced polypectomy, and closure devices/techniques for complication management. Endoscopists should know how to use these devices and their availability in practice to enhance polypectomy performance. This review describes several useful strategies and tips for managing difficult colorectal polyps. We also propose the stepwise approach for difficult colorectal polyps.

Factors of easy and difficult cecal intubation during unsedated colonoscopy.

difficulty of cecal intubation should be a main indicator for the need of sedated colonoscopy and skilled endoscopists. The present study aimed to explore the factors associated with easy and difficult cecal intubation in unsedated colonoscopy. all consecutive patients who underwent unsedated colonoscopy at our department by the same endoscopist from December 3, 2020 to August 30, 2022 were retrospectively collected. Age, gender, body mass index (BMI), reasons for colonoscopy, position change, Boston Bowel Preparation Scale score, cecal intubation time (CIT) and major colonoscopic findings were analyzed. CIT < 5 min, CIT 5-10 min and CIT > 10 min or failed cecal intubation were defined as easy, moderate and difficult cecal intubation, respectively. Logistic regression analyses were performed to identify independent factors associated with easy and difficult cecal intubation. overall, 1,281 patients were included. The proportions of easy and difficult cecal intubation were 29.2 % (374/1,281) and 27.2 % (349/1,281), respectively. Multivariate logistic regression analysis found that age ≤ 50 years, male, BMI > 23.0 kg/m2 and the absence of position change were independently associated with easy cecal intubation, and that age > 50 years, female, BMI ≤ 23.0 kg/m2, position change, and insufficient bowel preparation were independently associated with difficult cecal intubation. some convenient factors independently associated with easy and difficult cecal intubation have been identified, which will be potentially helpful to determine whether a colonoscopy should be sedated and a skilled endoscopist should be selected. The current findings should be further validated in large-scale prospective studies.

Diagnosis of Depth of Submucosal Invasion in Colorectal Cancer with AI Using Deep Learning.

The submucosal invasion depth predicts prognosis in early colorectal cancer. Although colorectal cancer with shallow submucosal invasion can be treated via endoscopic resection, colorectal cancer with deep submucosal invasion requires surgical colectomy. However, accurately diagnosing the depth of submucosal invasion via endoscopy is difficult. We developed a tool to diagnose the depth of submucosal invasion in early colorectal cancer using artificial intelligence. We reviewed data from 196 patients who had undergone a preoperative colonoscopy at the Osaka University Hospital and Osaka International Cancer Institute between 2011 and 2018 and were diagnosed pathologically as having shallow submucosal invasion or deep submucosal invasion colorectal cancer. A convolutional neural network for predicting invasion depth was constructed using 706 images from 91 patients between 2011 and 2015 as the training dataset. The diagnostic accuracy of the constructed convolutional neural network was evaluated using 394 images from 49 patients between 2016 and 2017 as the validation dataset. We also prospectively tested the tool from 56 patients in 2018 with suspected early-stage colorectal cancer. The sensitivity, specificity, accuracy, and area under the curve of the convolutional neural network for diagnosing deep submucosal invasion colorectal cancer were 87.2% (258/296), 35.7% (35/98), 74.4% (293/394), and 0.758, respectively. The positive predictive value was 84.4% (356/422) and the sensitivity was 75.7% (356/470) in the test set. The diagnostic accuracy of the constructed convolutional neural network seemed to be as high as that of a skilled endoscopist. Thus, endoscopic image recognition by deep learning may be able to predict the submucosal invasion depth in early-stage colorectal cancer in clinical practice.

Laparoscopic-Assisted Endoscopic Retrograde Cholangiopancreatography (ERCP) Versus Endoscopic Ultrasound-Directed Transgastric ERCP in Patients With Roux-en-Y Gastric Bypass: A Systematic Review and Meta-Analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure for skilled endoscopists that can be even more challenging in some situations, including patients' post-Roux-en-y Gastric Bypass (RYGB) surgery. There is still no consensus on whether laparoscopic-assisted ERCP (LA-ERCP) or endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) is the most appropriate, safe, and feasible approach in patients with this type of post-surgical anatomy. This systematic review and meta-analysis aimed to examine both approaches' feasibility, efficacy, and safety in this situation. We searched for electronic databases (MEDLINE, EMBASE, Lilacs, Google Scholar, and Central Cochrane) to identify studies comparing LA-ERCP versus EDGE. Outcomes measured included technical success, adverse events (AEs) and serious AEs, length of stay (LOS), and procedural time. Descriptive data related to the EDGE procedure was also extracted. The risk of bias and the quality of evidence of the enrolled studies were assessed. Five studies, totalizing 268 patients (176 LA-ERCP and 92 EDGE), were included. There was no statistical difference in technical success and AEs between groups; however, the LOS and procedural times were shorter for the EDGE group. High rates of fistula closure and no weight regain were observed in EDGE.Both methods are feasible and safe techniques to perform ERCP in patients with RYGB anatomy, with comparable technical success and adverse events rate. However, EDGE is associated with shorter LOS and procedural time.

S2857 Post-ERCP Greater Curvature Hematoma Complicated by Polymicrobial Infection: Case Report and Literature Review

Introduction: ERCP has become critical in diagnosing and treating biliary and pancreatic diseases. ERCP-related complications occur in 2.5 - 8% of procedures and include pancreatitis, biliary hemorrhage, and cholangitis. Rarely, subcapsular hepatic, splenic, and duodenal hematomas have been reported in case reports. Here we present a rare case of an intramural post-ERCP hematoma at the greater curvature of the stomach, complicated by polymicrobial infection. Case Description/Methods: A 67-year-old male with a past medical history of choledocholithiasis status-post ERCP with plastic stent placement three months prior presented as a transfer from an outside hospital in septic shock on vasopressors. Upon arrival ultrasound revealed a 13mm common bile duct (CBD) and gallstones measuring up to 1 cm. Emergent ERCP was performed and showed a proximally migrated CBD plastic stent with distal flap not visible and pus extruding from the major papilla (Image A). Multiple maneuvers were required to extract the stent including balloon, rat-tooth forceps, and flower basket. The patient was too unstable for further maneuvers such as Spyglass. The CBD was swept with a balloon and a fully-covered metal stent was placed. Liver function tests after the ERCP improved; however, the patient had a hemoglobin drop of 2 g/dL and continued to require pressors so a computed tomography of abdomen and pelvis was performed. It demonstrated an 11.3 cm fluid collection centered around the greater curvature of the stomach with hyperattenuating foci concerning for blood of varying chronicity (Image 1B). The collection was drained by radiology the next day and appeared grossly bloody. Upon culture the fluid grew Pseudomonas aeruginosa, Enterococcus faecalis, and Candida albicans. Patient was subsequently given multiple different antibiotic regimens due to resistance and the hematoma has nearly resolved since. (Figure) Discussion: ERCP-related complications can occur even when done by skilled endoscopists. Complex interventions are more likely to cause such complications. In particular, scope placement in the "long scope position" could have sheared the short gastric veins and resulted in our patient’s hematoma. While it is a rare complication, hematoma formation can cause ischemia and infection and lead to significant morbidity or mortality. Our case highlights a rare complication of ERCP that requires early recognition and response.Figure 1.: Image 1A: Pus near major papilla concerning for cholangitis Image 1B: 11.3 cm collection/hematoma in the left upper abdomen, centered at the greater curvature of the stomach. Scattered hyperattenuating foci within the stomach and within this collection, which likely represent blood products of varying ages.

S1107 Duodenal Endoscopic Submucosal Dissection in the United States: A Single Center Case Series

Introduction: Endoscopic Submucosal Dissection (ESD) is a well-established effective endoscopic technique which facilitates en bloc removal of gastrointestinal epithelial lesions. Duodenal ESD is a relatively novel and rare procedure in the United States (US). Here we report a single-center case series of duodenal ESD in the US. Methods: Patients who received ESD at Memorial Sloan Kettering Cancer Center from June 2018 to May 2022 were reviewed (n=477) and a total of 29 patients who had duodenal ESD were included in this study. Gender, age, American Society of Anesthesiology (ASA) score, type of sedation, type of solution for submucosal lifting agents, procedure time, location of the lesion, en bloc resection rate, R0 (complete) resection rate, presence of scar, adverse events, final pathology, and the length of hospital stay were reviewed. Results: A total of 29 patients had duodenal ESD (6.0%). 13 were female (44.8%), 16 were male (55.2%) and the median age was 68 (range 40 – 79). 25 cases (86.2%) had adenoma, 3 cases (10.3%) had neuroendocrine tumor and 1 had no tumor in the final pathology report. 23 were performed under general anesthesia (79.3%) and 6 with propofol sedation (20.7%). 10 patients (34.5%) were classified ASA Ⅱ and 19 patients (65.5%) were ASA Ⅲ. The location of lesions was 2nd part (15/29, 51.7%), followed by 3rd part (10/29, 34.5%), 1st part and bulb (3/29, 10.3%). En bloc resection was achieved in 14 cases (48.3%) and 3 had post-endoscopic mucosal resection (EMR)/ polypectomy scars (3/14, 21.4%). R0 resection rate was 44.8% (13 cases). Of 15 of piecemeal resections (51.7%), 4 had post-EMR/ polypectomy scars (4/15, 26.7%). En bloc and piecemeal resection rate were not affected by the presence of scars (p=0.35). ORISE was used in 16 cases (55.2%) and Eleview was used in 13 cases (44.8%) as the lifting solution and en bloc resection rate was 50% (8/16) with ORISE cases and 46.2% (6/13) in Eleview cases. Mean procedure time was 119 minutes (range 24 -240). As a complication, no perforations were noted. 1 patient developed post-ESD pancreatitis after the removal of large adenoma involving ampulla. The median length of hospital stay was 2 days (range 0 - 20). (Table) Conclusion: This study demonstrated that the duodenal ESD is safe and feasible in the US. The current task is to increase more skilled endoscopists for ESD procedures. Further studies with a larger population are necessary to investigate safety and efficacy in the US. Table 1. - The Data of Duodenal Endoscopic Submucosal Dissection (ESD), Single-Center Case Series Rate of en bloc or piecemeal resection were not affected by the presence of scars (p=0.35) n % Duodenal ESD cases total 29 Gender Female 13 44.8 Male 16 55.2 Age Median age 68 Sedation type General anesthesia 23 79.3 Propofol sedation 6 20.7 ASA score ASA II 10 34.5 ASA III 19 65.5 Location of the lesions 1st part, bulb 3 10.3 2nd part 15 51.7 2nd and 3rd part 1 3.4 3rd part 10 34.5 En bloc (n) % Lifting solution Eleview 13 44.8 6 46.2 ORISE 16 55.2 8 50 Post-EMR/polypectomy scars Scar positive (n) % Resection type En bloc 14 48.3 3 21.4 Piecemeal 15 51.7 4 26.7 Procedure time Mean time 119min Median time 110min Adverse events after ESD Post-ESD pancreatitis 1 3.4 Final pathology Adenoma 25 86.2 NET 3 10.3 No tumor 1 3.4 R0 resection 13 44.8 Maximum size of resected area Mean of maximum size 28.2mm Length of hospital stay Mean length 2.48days Median length 2days ESD: Endoscopic submucosal dissection ASA: American Society of Anesthesiology EMR: Endoscopic mucosal resection NET: Neuroendocrine tumor

Gastroduodenal endoscopic findings and Seroprevalence of Helicobacter pylori among suspected individuals

The peptic ulcer was developed at appeared recently as a contagious disease, distributed all over the world and the most common cause of this disease is H.pylori. Laboratory diagnosis was used to detect this bacterium by several methods which include invasive and non-invasive methods. . ELISA technique was used to identify IgG, IgM, and IgA antibodies against H. Pylori. All participants underwent endoscopic procedures at the Duhok City/Azadi Hospital/Endoscopy Center, and a highly skilled endoscopist carried out the procedures, As well questionnaire form has been filled out through the interview with the participants to enroll the socio-demographic factors which include occupation, history of treatment, and endoscopic findings. Among the 90 participants, the serological prevalence is 72%, 7%, and 30% of positive antibodies IgG, IgM, and IgA respectively. The housewife group recorded a high percentage of positive IgG whereas low percentages were recorded for the military group. A significant immune reaction of IgG in the student group has been noted. In addition to the housewife group to the positive IgM. The effect of those who had treatment previously has been revealed by positive IgG. Moreover, antral gastritis had a significant relationship with positive IgG by using ELISA. in the conclusion, the Housewives group was more infected with this bacterium, and a significant association was found between antral gastritis and seropositive IgG .

Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) surgical staging for endometrial carcinoma: The feasibility of an innovative approach

ObjectiveThis study aims to describe the feasibility of treating early-stage endometrial cancer with hysterectomy, bilateral salpingo-oophorectomy, sentinel lymph node biopsy, and bilateral pelvic lymphadenectomy by vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES). Materials and methodsA longitudinal study of prospectively registered patients was conducted at an academic tertiary care center. 15 patients who underwent vNOTES surgical staging of early endometrial carcinoma between January 2014 and December 2020 were included in the study. Results15 patients between 20 and 80yrs of age with histologically proven Stage1 Gr1-2 endometrial cancer underwent vNOTES surgical staging. The mean age of the study population was 52.8 years (Standard Deviation [SD] 6.8) and the mean BMI was 27.8 kg/m2 (SD 6.4). The average operative time was 231.4 min (SD 41.0) with the mean estimated blood loss of 122.0 mL (SD 104.4). A total of 12 (80%) patients underwent SNL biopsy with ICG guided system, whereas 3 (20%) had pelvic lymph node dissection. There was one case with the surgical complication of bladder injury requiring conversion to conventional laparoscopy. ConclusionWith this study, we studied the feasibility of vNOTES surgery for early-stage endometrial cancer with minimal complications and the best long-term surgical outcome. The surgeries were performed by a single skilled endoscopist surgeon with previous experience with vNOTES surgery for adnexal tumors and hysterectomy. Our results showed the practicality of vNOTES in staging surgery for early-stage endometrial cancer. However, application to a larger cohort is required for more extensive surgical outcome studies.

Broad learning system stacking with multi-scale attention for the diagnosis of gastric intestinal metaplasia

Gastric intestinal metaplasia (GIM) is a pre-malignant lesion of gastric cancer, which is the fourth leading cause of cancer-related mortalities. The accurate diagnosis and effective treatment of GIM can decrease the incidence of gastric cancer. Traditionally, GIM diagnosis is conducted through upper endoscopy imaging, which is highly dependent on endoscopists’ experience, and the diagnostic results may fluctuate with their discrepant skills or potential fatigue. Thus, computer-aided diagnosis (CAD) of GIM with high accuracy is urgently needed, while currently there is no such computer system in commercial market. In this paper, a novel broad learning system stacking framework with multi-scale attention (BLS2-MSA) is proposed, which contains Level-0 for preliminary diagnosis and Level-1 for final decision. In Level-0 of the BLS2-MSA, there are five classifiers, four of which are constructed using multi-scale features from the backbone neural network with the proposed parallel attention module, and the other classifier adopts a standard TL method only. In Level-1 of the BLS2-MSA, a broad learning system-based incremental updating approach is first proposed to boost the performance of classifiers in Level-0. Experimental results show that the True Positive Rate (TPR), the True Negative Rate (TNR), the Positive Predictive Value (PPV), the Accuracy (ACC), the F1and the Area Under ROC Curve (AUC) of the BLS2-MSA are 93.6%, 91.2%, 93.6%, 93.2%, 93.6 and 0.931 respectively, and the diagnostic results demonstrate that the BLS2-MSA could perform competitively compared with skilled endoscopists. All of these indicate that the proposed method enables an accurate and reliable GIM diagnosis.

EUS-guided biliary drainage with LAMS for distal malignant biliary obstruction when ERCP fails: single-center retrospective study and maldeployment management.

EUS-guided biliary drainage (EUS-BD) with Lumen Apposing Metal Stent (LAMS) is a mini-invasive approach for jaundice palliation in distal malignant biliary obstruction (D-MBO) not amenable to ERCP, with good efficacy and not exiguous adverse events. From January 2015 to December 2019, we retrospectively enrolled all the EUS-BD with electrocautery-enhanced LAMS for biliary decompression in unresectable D-MBO and failed ERCP. Primary study aims were to evaluate technical/clinical success and AEs rate. In case of maldeployment, we estimated the efficacy of an intra-operative rescue therapy. Secondary aims were to assess the jaundice recurrence and gastric outlet obstruction symptoms. Thirty-six EUS-BD were enrolled over a cohort of 738 patients (ERCP cannulation failure rate was 2.6%): 31 choledocho-duodenostomy and 5 cholecystogastrostomy. A pre-loaded guidewire through the LAMS was systematically used in case of common bile duct ≤ 15mm or scope instability for a safe/preventive biliary entryway in case of intra-procedural complications. Technical success was 80.6% (29/36 patients). Seven cases of LAMS maldeployment during EUS-guided choledocho-duodenostomy were successfully treated with RT by an over-the-wire fully-covered Self-Expandable Metal Stent (FC-SEMS). The FC-SEMS was released through the novel fistula tract in endoscopic fashion in 5/7 cases and transpapillary in percutaneous-transhepatic-endoscopic rendezvous (1/7) and laparoscopic-endoscopic rendezvous (1/7) in the two remaining cases. The total efficacy of rescue therapy was 100%. Same-session duodenal SEMS was placed in 17 patients with optimal gastric outlet obstruction management. Final clinical success was 100% and no other late adverse events or FC-SEMS migration were observed. EUS-BD with LAMS is effective for jaundice palliation after ERCP failure but with considerable adverse events. Maldeployment remains a serious complication with fatal evolution if not correctly recognized/managed. Rescue therapy must be promptly applied especially in tertiary-care centers with highly skilled endoscopists, interventional radiologist and dedicated surgeon.