Therapeutic Gastrointestinal Endoscopy Research Articles

Electrosurgery in Gastrointestinal Endoscopy: Bench to Bedside

AbstractElectrosurgical generator units (ESUs) are instrumental in modern therapeutic gastrointestinal (GI) endoscopy, converting household alternating current into high-frequency current to generate thermal energy within tissues. This review elucidates the essentials of electrosurgery, exploring the thermal effects on tissue, current resistance, voltage, current density, duty cycle, crest factor, and the distinctions between monopolar and bipolar circuitry. The concept of duty cycle, the proportion of time electrical current is delivered, and crest factor, the ratio of peak to root mean square voltage, are essential while comparing differently named modes across various commercially available ESUs. This article discusses the practical applications of electrosurgery in therapeutic GI endoscopy procedures, including endoscopic sphincterotomy, polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, and peroral endoscopic myotomy. It outlines recommended modes and settings for ESUs across various procedures, emphasizing the balance between cutting and coagulation to achieve optimal outcomes while minimizing adverse effects. The review further addresses special considerations for the use of grounding pads and the management of patients with implanted cardiac devices during electrosurgical procedures. This article concludes with a call for a deeper understanding of electrosurgical principles and their application in GI endoscopy to ensure patient safety and procedural success, backed by references to relevant literature and detailed tables summarizing electrosurgical modes and settings for various therapeutic interventions.

Role of artificial intelligence in diagnosing Barrett's esophagus-related neoplasia.

Barrett's esophagus is associated with an increased risk of adenocarcinoma. Thorough screening during endoscopic surveillance is crucial to improve patient prognosis. Detecting and characterizing dysplastic or neoplastic Barrett's esophagus during routine endoscopy are challenging, even for expert endoscopists. Artificial intelligence-based clinical decision support systems have been developed to provide additional assistance to physicians performing diagnostic and therapeutic gastrointestinal endoscopy. In this article, we review the current role of artificial intelligence in the management of Barrett's esophagus and elaborate on potential artificial intelligence in the future.

Simulation-Based Mastery Learning With Virtual Coaching: Experience in Training Standardized Upper Endoscopy to Novice Endoscopists

Simulation-Based Mastery Learning With Virtual Coaching: Experience in Training Standardized Upper Endoscopy to Novice Endoscopists

Argon plasma coagulation in therapeutic endoscopy

Argon plasma coagulation (APC) is used widely and effectively in therapeutic gastrointestinal endoscopy, mainly to achieve both haemostasis and tissue ablation. The main advantages of APC treatment are its ease of application, cost effectiveness, improved safety and reduced time for application. This review gives an insight into the safe and effective use of APC in the gastrointestinal tract with flexible endoscopy. It discusses the technical aspects of the APC generator, the different types of APC probes tailored to the indication and the target tissue. It also discusses patient preparation, including the optimal pre- and post-APC care instructions.

Risk Factors for Delayed Bleeding after Therapeutic Gastrointestinal Endoscopy in Patients Receiving Oral Anticoagulants: A Multicenter Retrospective Study

Background/Aims: Delayed bleeding is among the adverse events associated with therapeutic gastrointestinal endoscopy. The aim of this study was to evaluate risk factors for delayed bleeding after gastrointestinal endoscopic resection in patients receiving oral anticoagulants as well as to compare the rates of occurrence of delayed bleeding between the oral anticoagulants used. Methods: We retrospectively analyzed a total of 772 patients receiving anticoagulants. Of these, 389 and 383 patients were receiving direct oral anticoagulants (DOACs) and warfarin, respectively. Therapeutic endoscopic procedures performed included endoscopic submucosal dissection (ESD), endoscopic mucosal resection, polypectomy, and cold polypectomy. Results: Delayed bleeding occurred in 90 patients (11.7%) with no significant difference between the DOAC and warfarin groups (9.5 and 13.8%, respectively). Delayed bleeding occurred significantly more frequently with apixaban than with rivaroxaban (13.5 vs. 6.4%; p < 0.05). A multivariate analysis identified continued anticoagulant therapy (OR 2.29), anticoagulant withdrawal with heparin bridging therapy (HBT; OR 2.18), anticoagulant therapy combined with 1 antiplatelet drug (OR 1.72), and ESD (OR 3.87) as risk factors for delayed bleeding. Conclusion: This study identified continued anticoagulant therapy, anticoagulant withdrawal with HBT, anticoagulant therapy combined with 1 antiplatelet drug, and ESD as risk factors for delayed bleeding after therapeutic endoscopy in patients receiving oral anticoagulants. Delayed bleeding rates were not significantly different between those receiving DOACs and warfarin. It was also suggested that the occurrence of delayed bleeding may vary between different DOACs and that oral anticoagulant withdrawal should be minimized during therapeutic gastrointestinal endoscopy, given the thromboembolic risk involved.

Medical Dispute Related to Gastrointestinal Endoscopy Complications: Prevention and Management

Because gastrointestinal (GI) endoscopy examinations are being performed increasingly frequently, the rate of detection of cancer and of precancerous lesions has increased. Moreover, development of more advanced endoscopic technologies has expanded the indications for, and thus frequency of, therapeutic endoscopic procedures. However, the incidence of complications associated with diagnostic or therapeutic GI endoscopy has also increased. The complications associated with GI endoscopy can be ameliorated by endoscopic or conservative treatment, but caution is needed as some of the more serious complications, such as perforation, can lead to death. In this chapter, we review the possible complications of GI endoscopy and discuss methods for their prevention and treatment.

Future directions in therapeutic gastrointestinal endoscopy

Future directions in therapeutic gastrointestinal endoscopy

24th Seah Cheng Siang Lecture: Seeing Better, Doing Better—Evolution and Application of Gastrointestinal (GI) Endoscopy

Gastrointestinal (GI) endoscopy has evolved tremendously from the early days when candlelight was used to illuminate scopes to the extent that it has now become an integral part of the practice of modern gastroenterology. The first gastroscope was a rigid scope first introduced by Adolf Kussmaul in 1868. However this scope suffered from the 2 drawbacks of poor illumination and high risk of instrumental perforation. Rudolf Schindler improved on this by inventing the semiflexible gastroscope in 1932. But it was Basil Hirschowitz, using the principle of light conduction in fibreoptics, who allowed us to "see well" for the first time when he invented the flexible gastroscopy in 1958. With amazing speed and innovation, instrument companies, chiefly Japanese, had improved on the Hirschowitz gastroscope and invented a flexible colonoscope. Walter McCune introduced the technique of endoscopic retrograde cholangiopancreatography (ERCP) in 1968 which has now evolved into a sophisticated procedure. The advent of the digital age in the 1980s saw the invention of the videoendoscope. Videoendoscopes have allowed us to start seeing the gastrointestinal tract (GIT) "better" with high magnification and resolution and optical/digital enhancements. Fusing confocal and light microscopy with endoscopy has allowed us to perform an "optical biopsy" of the GI mucosa. Development of endoscopic ultrasonography has allowed us to see "beyond" the GIT lumen. Seeing better has allowed us to do better. Endoscopists have ventured into newer procedures such as the resection of mucosal and submucosal tumours and the field of therapeutic GI endoscopy sees no end in sight.

Sketch of International Digestive Endoscopy Network 2012 Meeting: Overview

International Digestive Endoscopy Network (IDEN) is an international meeting covering scientific subjects of diverse topics about upper gastrointestinal (GI) endoscopy, colonoscopy, endoscopic ultrasonography, and PB endoscopy. IDEN is organized by Korean Society of Gastrointestinal Endoscopy and the Korean Gastrointestinal Endoscopy Research Foundation, and took its first step in 2011 in Seoul, Korea. IDEN inaugurated a new era of diagnostic and therapeutic GI endoscopy. IDEN 2012 was designed to offer participants from all over the world with opportunities to share up-to-date knowledge about basic and clinical aspects of GI endoscopy and to engage in in-depth discussion with worldwide well-known experts. During the 2 days of meeting, there were 62 invited lectures, 28 case-based discussions, 20 video lectures, and 6 breakfast with the experts. There were a total of 598 participants registered from 12 countries, including Asian countries, Europe, and USA as well as Korea.

Therapeutic and interventional endoscopy for gastrointestinal bleeding.

Gastrointestinal (GI) bleeding remains a common clinical problem encountered by every emergency room and trauma physician. Endoscopy remains the main approach to the diagnosis and therapy of GI bleeding. To present the modern endoscopic approach for GI bleeding. Narrative review based on our expertise and inclusion of classic articles dealing with interventional and therapeutic GI endoscopy. GI hemorrhage is now classified as upper, middle, and lower GI bleeding. Upper GI bleeding is defined as hemorrhage originating from the oropharynx to the ligament of Treitz (or papilla of Vater), middle GI bleeding occurs distal to the papilla of Vater to the terminal ileum, and lower GI bleeding is defined as bleeding distal to the ileocecal valve, including the entire colon and anorectum. Endoscopic methods used to diagnosed and treat GI bleeding include esophagogastroduodenoscopy, duodenoscopy, capsule endoscopy, double- and single-balloon enteroscopy, spiral enteroscopy, and colonosocopy. This is the first review paper dedicated to endoscopic therapy for bleeding involving any part of the luminal GI tract (i.e., esophagus, stomach, small bowel, and colon). Modern endoscopy permits the investigation and treatment of the majority of conditions affecting the entire hollow GI tract.

Confocal Laser Endomicroscopy: Technical Advances and Clinical Applications

Since its introduction in 2004, confocal laser endomicroscopy (CLE) has emerged as a valuable tool for gastrointestinal endoscopic imaging. Endomicroscopy enables the endoscopist to obtain real time in vivo histology during ongoing endoscopy thereby creating “optical biopsies.” To date, numerous studies have shown potential applications of endomicroscopy in the clinical setting, including in vivo diagnosis of esophageal squamous cell carcinoma, Barrett’s esophagus, celiac disease, and colonic polyps. Moreover, recent data suggest the potential application of endomicroscopy in the field of molecular imaging. Additionally, in recent months new applications and developments in the field of confocal imaging were introduced including endomicroscopy of the liver, pancreatic, and bile ducts. Furthermore, by introducing a new needle-based confocal imaging system, which is small enough to be introduced through a 22gauge puncture needle, a wide field for new applications of endomicroscopic imaging has been opened. Currently, 2 CE- and US Food and Drug Administration (FDA)approved devices for endomicroscopy are available (Figures 1 and 2; Supplementary Table 1). In this review, we introduce both systems and discuss new technical advances and clinical applications of CLE.

Transmural gastric closure and NOTES – How far have we come?

The ability to perform secure closure of transmural gastric defects will represent a significant milestone in the evolution of therapeutic gastrointestinal endoscopy. In 1958, the flexible fiberoptic endoscope was introduced by Larry Curtiss and Basil Hirschowitz as a diagnostic modality. Over the ensuing decades, an interventional focus gradually took shape – initially for more invasive diagnostic techniques, such as biopsies and polypectomies, but later encompassing hemostasis, pancreaticobiliary procedures (i. e., endoscopic retrograde cholangiopancreatography and sphincterotomies), fine needle aspirations under endoscopic ultrasound guidance, and endoscopic mucosal resection and endoscopic submucosal dissection for resection of early-stage cancers. However, this growing interventional focus was mostly confined to the gastrointestinal lumen.

Prospective evaluation of a new high-power argon plasma coagulation system (hp-APC) in therapeutic gastrointestinal endoscopy

Objective. The aim of this study was to prospectively evaluate a new high-power argon plasma coagulation system (hp-APC) in therapeutic gastrointestinal (GI) endoscopy. Material and methods. From February to June 2005, 216 patients (167 M (77.3%), mean age 66 years) underwent treatment with hp-APC in a total of 275 sessions. Main indications were additive ablation therapy in Barrett's esophagus, palliative treatment of esophageal cancer, gastric polyps/carcinomas, angiodysplasias, Zenker's diverticula, and duodenal adenomas. The new hp-APC device (VIO 300 D with APC 2) was used (15–120 W) in upper GI endoscopy, push-enteroscopy, and double-balloon enteroscopy. Results. The mean number of treatment sessions required was 1.7 (1–5). For palliative tumor ablation in the esophagus, the number of sessions was 2.3 (1–5). Minor complications (pain, dysphagia, neuromuscular irritation, asymptomatic gas accumulation in the intestinal wall) were observed in 29/216 patients (13.4%). Major complications (perforation, stenosis occured) in 2 patients (0.9%). Conclusions. Hp-APC appears to be safe and effective in the treatment of various GI condition using different types of endoscopes including double-balloon enteroscopy. Because of the low number of treatment sessions required, hp-APC could be used as an alternative to Nd:YAG laser treatment in tumor debulking.

Endoscopic therapy for gastroesophageal reflux disease

Therapeutic gastrointestinal endoscopy has thrived in areas previously claimed by more invasive surgical procedures. Colonoscopic polypectomy, endoscopic retrograde cholangio-pancreatography with sphincterotomy, and endoscopic therapy for upper gastrointestinal bleeding from peptic ulcer are prime examples. Now we are witnessing a major endoscopic offensive into an arena contested not only by surgery but also by medical pharmacological therapy—gastroesophageal reflux disease (GERD). The stakes are high. Millions of Americans have symptomatic GERD. The market for pharmacological agents both over the counter and by prescription can be calculated in billions of dollars. The success of the proton pump inhibitor class of medications for GERD is one of the great pharmaceutical achievements of the current era, with an outstanding record of efficacy and safety. In a minority of patients in whom proton pump inhibitor therapy is not successful and the cost of drug therapy becomes an economic burden, surgical therapy is an alternative. Laparoscopic fundoplication (with technical variations) has emerged as the clear winner in terms of the surgical management of GERD. There are certainly problems in a small number of patients who are left with uncomfortable postoperative symptoms. Furthermore, there are accumulating data indicating that as years go by, a majority of patients who have surgery resume taking antacid medications. Can endoscopic therapy become another option for GERD patients to medical or surgical therapy? There are at least three types of approaches to endoscopic

MANAGEMENT OF GASTROINTESTINAL BLEEDING INDUCED BY GASTROINTESTINAL ENDOSCOPY

Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.

Biliary Tract Disease in Pregnancy

The timely diagnosis and treatment of biliary tract conditions during pregnancy are challenging. Familiarity with the anatomic and physiologic changes present in normal pregnancy is essential, as is the knowledge of relative risk of complications by trimester. Physicians should be aware that virtually all complications that occur in the management of these conditions are caused by delay in the detection of the disease process. Recent advances in minimally invasive therapy including laparoscopic surgery and therapeutic gastro-intestinal endoscopy have changed the traditional approach to biliary tract disease in pregnancy. We present a case report of a patient with acute gallstone pancreatitis during pregnancy managed endoscopically without the use of fluoroscopy.

Management of Esophageal Perforations after Therapeutic Upper Gastrointestinal Endoscopy

Background: Esophageal perforation is one of the most dreaded complications in therapeutic gastrointestinal endoscopy. We assessed the frequency of esophageal perforation after endoscopic procedures in a highly specialized endoscopy unit and compared clinical outcomes in patients undergoing either surgical or conservative management. Methods: From January 1985 to June 1996, 1011 instrumental endoscopic procedures (dilatation and bougienage) were performed in our department. The computerized complication database was searched to identify all patients with esophageal perforation during this same period, and their records were reviewed. Results: Seventeen esophageal perforations (1.7%) occurred in the course of 1011 procedures. Four perforations resulted from balloon dilatation, and 13 were secondary to bougienage. Six patients were managed surgically (35%), all of them recovering uneventfully. Eleven patients were managed conservatively, mainly because they were unfit for surgery. Survival rate in this group was 82% only two patients died, both of whom had underlying malignant disease. Conclusions: The current concept in management of esophageal perforations comprises surgical as well as medical treatment. In well-selected cases, non-operative treatment can be considered with favorable results.

Therapeutic gastrointestinal endoscopy.

The safety, efficacy and utility of various therapeutic gastrointestinal (GI) endoscopic procedures performed on children (January 1992 to July 1995) at a tertiary referral centre in India were studied. A total of 1,030 sessions (upper GI 972 and lower GI 58) of therapeutic GI endoscopy were performed in 162 children (mean age 7.4 +/- 4 years; upper GI 115, lower GI 47). Various upper GI endoscopic procedures done were injection sclerotherapy (EIS), endoscopic variceal ligation (EVL), bougie dilatation of oesophageal strictures, balloon dilatations of oesophageal stricture/pyloric obstruction and retrieval of foreign bodies in 75%, 6%, 9%, 4% and 12% of children respectively. Therapy for bleeding from oesophageal varices constituted the major group (75%). Repeated EIS (sessions total--876, mean 8, range 5-15) performed on 86 children resulted in control of bleeding in all and eradication of oesophageal varices in 85% of cases. Minor complications (oesophageal ulcers and oesophageal strictures) due to EIS were observed in 9% of children. EVL (10 sessions in 7 children) was effective in controlling bleeding and substantial decrease of varices in all without any complication. Oesophageal dilation either by bougie (61 sessions in 10 children) or balloon (6 sessions in 3 children) were performed for benign strictures. Balloon dilatation of pyloric obstruction was successfully done in 2 children. Foreign bodies (retained or sharp) were retrieved from upper GI tract in 14 children. No complications were observed with stricture dilatation/foreign body retrieval. Therapeutic lower GI endoscopies were performed in 47 children (colonoscopic polypectomy in 92%, anal dilatation and piles banding in 4% each). One child with juvenile polyposis coli developed sigmoid colon performation following colonoscopic polypectomy which required surgical correction. We conclude that upper and lower GI endoscopic therapeutic procedures in children are highly effective and safe. The risk of major complication is very small in experienced hands and occasional minor complications, can be managed conservatively.

Endoscopic techniques in gastrointestinal oncology

Gastrointestinal endoscopy continues to play a significant role in gastroenterologic oncology. As a diagnostic tool, it has largely replaced radiology in diseases of the gastrointestinal tract because of its capability to provide a tissue diagnosis by endoscopic biopsy. The still-expanding therapeutic potential of gastrointestinal endoscopy represents the prototype of minimal invasive therapy. This review deals with relevant papers on diagnostic and therapeutic gastrointestinal endoscopy during the past 2 years. The abundance of studies renders a detailed discussion of all or even most of them impossible; therefore, only trends are shown. The reader is referred to the annotations in the reference list for more detailed information.

Complications of therapeutic gastrointestinal endoscopy.

Complications of therapeutic gastrointestinal endoscopy.