Endoscopic retrograde appendicitis therapy vs. Laparoscopic appendectomy for uncomplicated acute appendicitis

Background and study aims: To assess the efficacy and clinical outcomes of endoscopic retrograde appendicitis therapy (ERAT) versus laparoscopic appendectomy (LA) for patients with uncomplicated acute appendicitis (AA). Patients and methods: We adopted propensity score matching (1:1) to compare ERAT and LA patients with uncomplicated AA from April 2017 to March 2020. We reviewed a total of 2880 patients with suspected acute appendicitis, of whom 422 patients with uncomplicated AA met the matching criteria (ERAT, 79; LA, 343), yielding 78 pairs of patients. Results: The rate of curative treatment within one year after ERAT was 92.1%; 95% CI, [83.8% - 96.3%]. The percentage of Visual Analog Scale (VAS) ≤ 3 at six hours after treatment was 94.7%; 95% CI [87.2% - 97.9%] in the ERAT group, and significantly higher than that in the LA group 83.3%; 95% CI [73.5% - 90.0%]. Median operative/procedure time and median hospital length of stay in the ERAT group were significantly lower compared to the LA group. At one year, the median recurrence time was 50 days (IQRs, 25-127) in the ERAT group. The overall adverse event rate was 24.3%; 95% CI [14.8% - 33.9%] in the LA group and 18.4%; 95% CI [9.7% - 27.1%] in the ERAT group, with no significant difference between the two groups. Conclusions: ERAT is a technically feasible method to treat uncomplicated AA compared to LA.

Complete Polyp Resection with Cold versus Hot snare Polypectomy for Polyps sized 4-9 mm: A randomized controlled trial

Background and study aims: Endoscopic screening with polypectomy reduces colorectal cancer (CRC) incidence. Incomplete polyp removal may attenuate the effect of screening. This randomized trial compared cold snare polypectomy (CSP) with hot snare polypectomy (HSP) regarding complete polyp resection. Patients and methods: We included patients ≥ 40 years at 8 hospitals in 4 countries who had at least one 4-9 mm non-pedunculated polyp detected at colonoscopy. Patients were randomized 1:1 to CSP or HSP. Biopsies from the resection margins were obtained systematically after polypectomy in both groups. We hypothesized that CSP would be non-inferior to HSP with a non-inferiority margin of 5%. Logistic regression models were fitted to identify factors explaining incomplete resection. Results: In total, 425 patients, with 608 polyps were randomized to either CSP or HSP. Of 318 polyps removed by CSP and 283 polyps removed by HSP, 34 (10.7%) and 21 (7.4%) were incompletely resected, respectively, with an adjusted risk difference of 3.2% (95% CI -1.4 – 7.8). There was no difference between the groups in terms of post-polypectomy bleeding, perforation, or abdominal pain. Independent risk factors for incomplete removal were serrated, odds ratio (OR) 3.96, (95% CI 1.63-9.66) and hyperplastic histology, OR 2.52 (95% CI 1.30-4.86)) in adjusted analyses. Conclusion: In this randomized trial, non-inferiority for cold snare polypectomy could not be demonstrated. Polyps with serrated histology are more prone to incomplete resection compared to adenomas. Cold snare polypectomy for small polyps can be used safely in routine colonoscopy practise.

Post Endoscopy Barrett’s Neoplasia (PEBN) After A Negative Index Endoscopy: A Systematic Review & Proposal For Definitions and Performance Measures in Endoscopy

Background and aims: A high rate of neoplasia (high grade dysplasia; HGD and esophageal adenocarcinoma; EAC) has been reported in Barrett’s Esophagus at index endoscopy but precise rates of post endoscopy Barrett’s neoplasia (PEBN) are unknown. Methods: Systematic review and meta-analysis was performed examining electronic databases (inception to October 2021) for studies reporting PEBN. Consistent with definitions of Post Colonoscopy Colorectal Cancer as proposed by the World Endoscopy Organization, we defined neoplasia(HGD/EAC) detected at index endoscopy and/or within 6 months of a negative index endoscopy as “prevalent” neoplasia; those detected after 6 months of a negative index endoscopy and prior to next surveillance interval(i.e. 3 years) as PEBN or “interval” neoplasia, and those detected after 36 months of a negative index endoscopy as “incident” neoplasia. Pooled incidence rates and proportion relative to total neoplasia were analyzed. Results: 11 studies (n=59,795, age:62.3±3.3 years, 61%males) met inclusion criteria. The pooled incidence rates were: prevalent neoplasia 4.5% (95%confidence interval: 2.2-8.9) at baseline and additional 0.3%(0.1-0.7) within first 6 months, PEBN 0.52%(0.48-0.58) and incident neoplasia: 1.41%(0.93-2.14). At 3 years from index endoscopy, PEBN accounted for 3% while prevalent neoplasia accounted for 97% of total Barrett’s neoplasia. Conclusion: Neoplasia detected at or within 6 months of index endoscopy account for most of the Barrett’s neoplasia(>90%). Post-Endoscopy Barrett’s Neoplasia account for ~3% of cases and can be used for validation in future. This highlights the importance of a high-quality index endoscopy in Barrett’s Esophagus and the need to establish quality benchmarks to measure endoscopists’ performance.

Beneficial effects of endoscopic screening on gastric cancer and its optimal screening interval: a population-based study

Background and study aims: The effectiveness of endoscopic screening on gastric cancer (GC) is less investigated and screening interval of repeated screening is yet to be optimized in China. Patients and methods: In a population-based prospective study, we included 375,800 subjects based on the Upper Gastrointestinal Cancer Early Detection Program in Linqu, a GC high-risk area in China, 14,670 of which underwent endoscopic screening(2012-2018). We assessed the associations of the risk of incident GC and GC-specific deaths with endoscopic screening and examined the changes in overall survival (OS) and disease-specific survival (DSS) of GCs by endoscopic screening. The optimal screening interval of repeated endoscopy for early detection of GC was explored. Results: Ever receiving endoscopic screening significantly decreased the risk of invasive GC(age and sex-adjusted RR=0.69, 95%CI:0.52-0.92) and GC-specific deaths(RR=0.33, 95%CI: 0.20-0.56), particularly for non-cardia GC. Repeated screening strengthened the beneficial effect on invasive GC-specific deaths by one-time screening. Among invasive GCs, screening-detected cases had significantly better OS(RR=0.18, 95%CI: 0.13-0.25) and DSS(RR=0.18, 95%CI: 0.13-0.25) than cases in the unscreened group, particularly for those receiving repeated endoscopy. For individuals with intestinal metaplasia or low-grade intraepithelial neoplasia, repeated endoscopy at an interval of less than two years, particularly within one year, significantly enhanced the detection of early GC, compared with repeated screening after two years(P-trend=0.02). Conclusion: Endoscopic screening prevented GC occurrence and death and improved its prognosis in a population-based study. Repeated endoscopy enhanced the effectiveness, for which screening interval needs to be defined in conformity with the severity of gastric lesions.

Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Main Recommendations 1 ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available.Strong recommendation, moderate quality evidence. 2 ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers.Weak recommendation, moderate quality evidence. 3 ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible.Strong recommendation, low quality evidence. 4 ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events.Strong recommendation, low quality evidence. 5 ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD.Strong recommendation, high quality of evidence. 6 ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery.Strong recommendation, low quality evidence. 7 ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates. Strong recommendation, low quality evidence. 8 ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP.Weak recommendation, low quality evidence.