Background: Isolated laryngeal pemphigus vulgaris (LPV) is rare; however, early diagnosis is crucial in determining its course and prognosis. This paper aims to describe mucosal vascular changes typical for LPV using advanced endoscopic methods, which include Narrow Band Imaging (NBI), IMAGE1-S video-endoscopy and enhanced contact endoscopy (ECE). Materials and Methods: Retrospective analysis of all laryngeal mucosal lesion examined using advanced endoscopic methods during 2018-2020 at tertiary hospital was performed. Results: Videolaryngoscopy examination records of 278 patients with laryngeal mucosal lesions were analyzed; three of them were diagnosed with LPV. Epithelial vascularization of LPV included specific pattern. Intraepithelial papillary capillary loops were symmetrically stratified and were organized into "contour-like lines". This specific vascularization associated with LPV were different from other laryngeal mucosal pathologies. Conclusions: Using advanced endoscopic methods supports early diagnosis of LPV and accelerate the diagnosis and treatment.
- Keywords
- IMAGE1-S, Narrow Band Imaging (NBI), enhanced contact endoscopy (ECE), larynx, pemphigus vulgaris,
- MeSH
- Endoscopy MeSH
- Humans MeSH
- Laryngeal Neoplasms * MeSH
- Pemphigus * diagnosis MeSH
- Retrospective Studies MeSH
- Narrow Band Imaging MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
Increasing worldwide prevalence of type 2 diabetes mellitus and its accompanying pathologies such as obesity, arterial hypertension and dyslipidemia represents one of the most important challenges of current medicine. Despite intensive efforts, high percentage of patients with type 2 diabetes does not achieve treatment goals and struggle with increasing body weight and poor glucose control. While novel classes of antidiabetic medications such as incretin-based therapies and gliflozins have some favorable characteristics compared to older antidiabetics, the only therapeutic option shown to substantially modify the progression of diabetes or to achieve its remission is bariatric surgery. Its efficacy in the treatment of diabetes is well established, but the exact underlying modes of action are still only partially described. They include restriction of food amount, enhanced passage of chymus into distal part of small intestine with subsequent modification of gastrointestinal hormones and bile acids secretion, neural mechanisms, changes in gut microbiota and many other possible mechanisms underscoring the importance of the gut in the regulation of glucose metabolism. In addition to bariatric surgery, less-invasive endoscopic methods based on the principles of bariatric surgery were introduced and showed promising results. This review highlights the role of the intestine in the regulation of glucose homeostasis focusing on the mechanisms of action of bariatric and especially endoscopic methods of the treatment of diabetes. A better understanding of these mechanisms may lead to less invasive endoscopic treatments of diabetes and obesity that may complement and widen current therapeutic options.
- Keywords
- bariatric surgery, duodenum exclusion, endoscopic treatment, mechanism, type 2 diabetes,
- MeSH
- Bariatric Surgery methods trends MeSH
- Diabetes Mellitus, Type 2 microbiology surgery MeSH
- Endoscopy, Gastrointestinal methods trends MeSH
- Gastrointestinal Hormones therapeutic use MeSH
- Blood Glucose metabolism MeSH
- Humans MeSH
- Obesity metabolism pathology surgery MeSH
- Intestines microbiology physiology surgery MeSH
- Gastrointestinal Microbiome physiology MeSH
- Animals MeSH
- Check Tag
- Humans MeSH
- Animals MeSH
- Publication type
- Journal Article MeSH
- Research Support, Non-U.S. Gov't MeSH
- Review MeSH
- Names of Substances
- Gastrointestinal Hormones MeSH
- Blood Glucose MeSH
Peroral endoscopic myotomy (POEM) is an advanced endoscopic procedure that has become a first-line treatment for esophageal achalasia and other esophageal spastic disorders. Structured training is essential to optimize the outcomes of this technique. The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in POEM. This Position Statement presents the results of a systematic review of the literature and a formal Delphi process, providing recommendations for an optimal training program in POEM that aims to produce endoscopists competent in this procedure. In a separate document (POEM curriculum Part II), we provide technical guidance on how to perform the POEM procedure based on the best available evidence. 1: POEM trainees should acquire a comprehensive theoretical knowledge of achalasia and other esophageal motility disorders that encompasses pathophysiology, diagnostic tool proficiency, clinical outcome assessment, potential adverse events, and periprocedural management. 2: Experience in advanced endoscopic procedures (endoscopic mucosal resection and/or endoscopic submucosal dissection [ESD]) is encouraged as a beneficial prerequisite for POEM training. 3: ESGE suggests that POEM trainees without ESD experience should perform an indicative minimum number of 20 cases on ex vivo or animal models before advancing to human POEM cases with an experienced trainer. 4: ESGE recommends that the trainee should observe an indicative minimum number of 20 live cases at expert centers before starting to perform POEM in humans. 5: The trainee should undertake an indicative minimum number of 10 cases under expert supervision for the initial human POEM procedures, ensuring that trainees can complete all POEM steps independently. 6: ESGE recommends avoiding complex POEM cases during the early training phase. 7: POEM competence should reflect the technical success rate, both the short- and long-term clinical success rates, and the rate of true adverse events. 8: A POEM center should maintain a prospective registry of all procedures performed, including patient work-up and outcomes, procedural techniques, and adverse events.
- MeSH
- Esophageal Achalasia * surgery MeSH
- Delphi Technique MeSH
- Natural Orifice Endoscopic Surgery * education MeSH
- Endoscopy, Gastrointestinal * education MeSH
- Clinical Competence MeSH
- Curriculum * MeSH
- Humans MeSH
- Myotomy * education methods MeSH
- Pyloromyotomy * education MeSH
- Societies, Medical MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Consensus Development Conference MeSH
- Systematic Review MeSH
- Geographicals
- Europe MeSH
The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in diagnostic endoscopic ultrasound (EUS). 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 diagnostic EUS. This curriculum is set out in terms of the prerequisites prior to training; the recommended steps of training to a defined syllabus; the quality of training; and how competence should be defined and evidenced before independent practice. 1: Trainees should have achieved competence in upper gastrointestinal endoscopy before training in diagnostic EUS. 2: The development of diagnostic EUS skills by methods that do not involve patients is advisable, but not mandatory, prior to commencing formal training in diagnostic EUS. 3: A trainee's principal trainer should be performing adequate volumes of diagnostic EUSs to demonstrate maintenance of their own competence. 4: Training centers for diagnostic EUS should offer expertise, as well as a high volume of procedures per year, to ensure an optimal level of quality for training. Under these conditions, training centers should be able to provide trainees with a sufficient wealth of experience in diagnostic EUS for at least 12 months. 5: Trainees should engage in formal training and supplement this with a range of learning resources for diagnostic EUS, including EUS-guided fine-needle aspiration and biopsy (FNA/FNB). 6: EUS training should follow a structured syllabus to guide the learning program. 7: A minimum procedure volume should be offered to trainees during diagnostic EUS training to ensure that they have the opportunity to achieve competence in the technique. To evaluate competence in diagnostic EUS, trainees should have completed a minimum of 250 supervised EUS procedures: 80 for luminal tumors, 20 for subepithelial lesions, and 150 for pancreaticobiliary lesions. At least 75 EUS-FNA/FNBs should be performed, including mostly pancreaticobiliary lesions. 8: Competence assessment in diagnostic EUS should take into consideration not only technical skills, but also cognitive and integrative skills. A reliable valid assessment tool should be used regularly during diagnostic EUS training to track the acquisition of competence and to support trainee feedback. 9: A period of supervised practice should follow the start of independent activity. Supervision can be delivered either on site if other colleagues are already practicing EUS or by maintaining contacts with the training center and/or other EUS experts. 10: Key performance measures including the annual number of procedures, frequency of obtaining a diagnostic sample during EUS-FNA/FNB, and adverse events should be recorded within an electronic documentation system and evaluated.
- MeSH
- Endoscopic Ultrasound-Guided Fine Needle Aspiration MeSH
- Endosonography methods MeSH
- Endoscopy, Gastrointestinal * education MeSH
- Curriculum * MeSH
- Humans MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Geographicals
- Europe MeSH
1: ESGE suggests using contrast-enhanced computed tomography (CT) as the first-line imaging modality on admission when indicated and up to the 4th week from onset in the absence of contraindications. Magnetic resonance imaging (MRI) may be used instead of CT in patients with contraindications to contrast-enhanced CT, and after the 4th week from onset when invasive intervention is considered because the contents (liquid vs. solid) of pancreatic collections are better characterized by MRI and evaluation of pancreatic duct integrity is possible. Weak recommendation, low quality evidence. 2: ESGE recommends against routine percutaneous fine needle aspiration (FNA) of (peri)pancreatic collections. Strong recommendation, moderate quality evidence. FNA should be performed only if there is suspicion of infection and clinical/imaging signs are unclear. Weak recommendation, low quality evidence. 3: ESGE recommends initial goal-directed intravenous fluid therapy with Ringer's lactate (e. g. 5 - 10 mL/kg/h) at onset. Fluid requirements should be patient-tailored and reassessed at frequent intervals. Strong recommendation, moderate quality evidence. 4: ESGE recommends against antibiotic or probiotic prophylaxis of infectious complications in acute necrotizing pancreatitis. Strong recommendation, high quality evidence. 5: ESGE recommends invasive intervention for patients with acute necrotizing pancreatitis and clinically suspected or proven infected necrosis. Strong recommendation, low quality evidence.ESGE suggests that the first intervention for infected necrosis should be delayed for 4 weeks if tolerated by the patient. Weak recommendation, low quality evidence. 6: ESGE recommends performing endoscopic or percutaneous drainage of (suspected) infected walled-off necrosis as the first interventional method, taking into account the location of the walled-off necrosis and local expertise. Strong recommendation, moderate quality evidence. 7: ESGE suggests that, in the absence of improvement following endoscopic transmural drainage of walled-off necrosis, endoscopic necrosectomy or minimally invasive surgery (if percutaneous drainage has already been performed) is to be preferred over open surgery as the next therapeutic step, taking into account the location of the walled-off necrosis and local expertise. Weak recommendation, low quality evidence. 8: ESGE recommends long-term indwelling of transluminal plastic stents in patients with disconnected pancreatic duct syndrome. Strong recommendation, low quality evidence. Lumen-apposing metal stents should be retrieved within 4 weeks to avoid stent-related adverse effects.Strong recommendation, low quality evidence.
- MeSH
- Pancreatitis, Acute Necrotizing diagnosis surgery MeSH
- Endoscopy, Gastrointestinal * MeSH
- Humans MeSH
- Societies, Medical MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Practice Guideline MeSH
- Geographicals
- Europe MeSH
PURPOSE: Oxidized cellulose-based haemostatic agents are widely used for managing bleeding in various surgical procedures. This study evaluates the efficacy and safety of oxidized cellulose powder and an endoscopic applicator across a broad spectrum of surgical settings. METHODS: This was a prospective, multicentre study involving 99 evaluable patients undergoing surgeries with varying bleeding severities and surgical approaches (open, laparoscopic, or thoracoscopic). The primary endpoint was achieving haemostasis within 3 minutes and avoiding revision surgery within 12 hours. The time to haemostasis (TTH) and complications were recorded, and statistical comparisons were made using a paired and unpaired t-test, with a significance threshold of P < 0.05. Data from this study were compared to historical results from fibrillar haemostats. RESULTS: Haemostasis was achieved within 3 minutes in 61.6% (95% CI [52.0, 71.2]) of patients and within 5 minutes in 99.0% (95% CI [97.0, 100.0]) of patients. The overall mean TTH was 153.8 seconds (95% CI: 141.5-166.1), with shorter TTH observed in minimally invasive procedures using the endoscopic applicator. Subgroup analysis revealed higher success rates for patients with mild bleeding (78%) compared to moderate bleeding (50%). CONCLUSION: Oxidized cellulose powder demonstrates reliable haemostatic performance across diverse surgical applications. The endoscopic applicator enhances precision and applicability, particularly in minimally invasive settings, making it a valuable tool in modern surgical practice.
- Keywords
- Traumastem, endoscopic applicator, haemostasis, haemostatic powder, oxidized cellulose,
- MeSH
- Cellulose, Oxidized * administration & dosage therapeutic use MeSH
- Adult MeSH
- Hemostatics * administration & dosage therapeutic use MeSH
- Hemostasis, Surgical * methods instrumentation MeSH
- Blood Loss, Surgical * prevention & control MeSH
- Middle Aged MeSH
- Humans MeSH
- Powders MeSH
- Prospective Studies MeSH
- Aged MeSH
- Treatment Outcome MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Multicenter Study MeSH
- Names of Substances
- Cellulose, Oxidized * MeSH
- Hemostatics * MeSH
- Powders MeSH
Endoscopic methods are critical in the early diagnosis of mucosal lesions of the head and neck. In recent years, new examination methods and classification systems have been developed and introduced into clinical practice. All of these new techniques target the notion of optical biopsy, which tries to assess the nature of the lesion before histology examination. Many methods suffer from interpretation issues due to subjective interpretation of the findings. Therefore, multiple classification systems have been developed to assist the proper interpretation of mucosal findings and reduce the error rate. They provide various perspectives on the assessment and interpretation of mucosa changes. This article provides a comprehensive and critical view of the available classification systems as well as their advantages and disadvantages.
- Keywords
- Storz Professional Image Enhancement System, enhanced contact endoscopy, laryngeal cancer, larynx, leukoplakia, narrow-band imaging,
- Publication type
- Journal Article MeSH
- Review MeSH
INTRODUCTION: Enhanced contact endoscopy (ECE) is a non-invasive technique used for the assessment of superficial vascular changes of mucosal lesions in high magnification. The aim of our study was to evaluate the clinical efficacy of ECE in an intraoperative settlement. METHODS: Structured assessment of laryngeal mucosal lesions using enhanced endoscopy (narrow band imaging (NBI) and ECE) was performed in a prospective clinical trial. Lesions were classified according to the European Laryngological Society Classification into non-suspicious and suspicious. Evaluations of endoscopic methods (NBI and ECE) were correlated with histopathology, histopathology being the gold standard. Sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), area under curve, diagnostic odds ratio (DOR), Kappa, incremental yield, and Youden´s index for NBI and ECE were calculated. RESULTS: A total of 110 patients with 136 lesions were enrolled, 50 benign non-neoplastic lesions, eight squamous cell papillomas, 45 dysplasias, and 33 squamous cell invasive cancers. Compared to NBI, ECE demonstrated higher sensitivity (91.0% vs 83.1%) and accuracy (90.4% vs 86.8%). NBI achieved higher specificity (91.8% vs 89.7%). PPV and NPV for ECE were 92.2% and 88.1%, whereas for NBI 93.1% and 80.4%. ECE showed greater overall diagnostic performance, with a DOR of 88.3 vs 55.2 and Kappa index of 0.805 vs 0.736. CONCLUSIONS: ECE enhances diagnostic sensitivity and accuracy and represents a valuable addition to laryngeal cancer diagnostics.
BACKGROUND & AIMS: Gastric peroral endoscopic myotomy (G-POEM) is an emerging treatment for gastroparesis, but clinical outcomes can be inconsistent; hence, it is vital to enhance our management strategies for patients with clinical failure. METHODS: This was a multicenter retrospective review of patients who underwent G-POEM for refractory gastroparesis from September 2015 to November 2023. Clinical outcomes and management post-G-POEM were assessed and categorized into 4 types based on symptom improvement and gastric emptying metrics. RESULTS: Of the 482 patients, 221 (46%) underwent evaluations with pre- and post-G-POEM gastric emptying tests and were included in the study. Type 1 clinical response (clinical success with improved gastric emptying scintigraphy [GES]) was the most common outcome, occurring in 56%. This was followed by type 4 (clinical failure with no GES improvement) at 23%, type 2 (clinical failure with improved GES) at 15%, and type 3 (clinical success with no GES improvement) at 6.7%. Patients with primary clinical failure (types 2 and 4) showed significantly higher daily opioid use at 23%, compared with 7% in types 1 and 3 (P = .032). Clinical failure overall was observed in 60% during a median follow-up of 48 months, with 31% managed by pylorus-directed retreatment and 7% with gastric neurostimulator placement. In the type 1 response group, clinical success was re-established in 71% following pylorus-directed therapies, with repeat G-POEM being an independent predictor of clinical success post-re-treatment (odds ratio, 2.2; P = .02). CONCLUSION: Our study highlights the importance of post-G-POEM GES assessments for characterizing clinical responses. Type 1 responders are more likely to benefit from subsequent pylorus-directed re-treatments, particularly repeat G-POEM interventions. CLINICALTRIALS: gov, Number: NCT04434781.
BACKGROUND: Scattered, small, dot-like intraepithelial papillary capillary loops (IPCLs) represent type IV epithelial vascularization according to "Ni classification" and are considered to be nonmalignant. According to the European Laryngological Society classification, these loops are malignant vascular changes. This contradiction has high clinical importance; therefore, clarification of the clinical significance of type IV vascularization according to the Ni classification is needed. METHODS: The study was performed between June 2015 and December 2022. All recruited patients (n = 434) were symptomatic, with macroscopic laryngeal lesions (n = 674). Patients were investigated using the enhanced endoscopic methods of narrow band imaging (NBI) and the Storz Professional Image Enhancement System (IMAGE1 S). The microvascular patterns in the lesions were categorized according to Ni classification from 2011 and all lesions were examined histologically. RESULTS: A total of 674 lesions (434 patients) were investigated using flexible NBI endoscopy and IMAGE1 S endoscopy. Type IV vascularization was recognized in 293/674 (43.5%) lesions. Among these 293 lesions, 178 (60.7%) were benign (chronic laryngitis, hyperplasia, hyperkeratosis, polyps, cysts, granulomas, Reinkeho oedema and recurrent respiratory papillomatosis); 9 (3.1%) were squamous cell carcinoma; 61 (20.8%) were mildly dysplastic, 29 (9.9%) were moderately dysplastic, 14 (4.8%) were severe dysplastic and 2 (0.7%) were carcinoma in situ. The ability to recognize histologically benign lesions in group of nonmalignant vascular pattern according to Ni (vascularization type I-IV) and distinguish them from precancers and malignancies was with accuracy 75.5%, sensitivity 54.4%, specificity 94.4%, positive predictive value 89.6% and negative predictive value 69.9%. CONCLUSION: Laryngeal lesions with type IV vascularization as defined by Ni present various histological findings, including precancerous and malignant lesions. Patients with type IV vascularization must be followed carefully and, in case of progression mucosal lesion microlaryngoscopy and excision are indicated.
- Keywords
- IMAGE1 S, Ni classification, enhanced endoscopic methods, laryngeal cancer, laryngeal dysplasia, narrow band imaging (NBI), vascular pattern,
- Publication type
- Journal Article MeSH
