Explore the vast range of titles available.

Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical approach, currently performed for an array of conditions. Endoscopic procedures offer significant benefits, including lower cost, no surgical incisions, and shorter hospital stays. These advantages align with the current trends in health care, namely a push for “cost-effective care.” There are a multitude of health issues which are now being addressed by the endoscopic surgical approach, including peroral endoscopic myotomy (POEM), which is a relatively new technique used in the treatment of achalasia. Endoscopic treatment utilized for GERD includes transoral incisionless fundoplication. Endoscopic bariatric surgical procedures include intragastric balloon placement, endoscopic sleeve gastroplasty, and revision of prior bariatric procedures including Roux-en-Y gastric bypass and conventional gastric sleeve procedures. Endoscopic clips are routinely utilized for achieving hemostasis, treating iatrogenic gastric and bowel ulcerations and perforations and for the closure of enteric fistulization. Novel endoscopic procedures are now replacing conventional surgery due to their non-invasive nature, faster recovery and lower healthcare costs. Radiologists need to understand how these procedures are performed, as well as expected post-procedural imaging appearance and potential complications.

A powerful guide to the primary diagnosis of disorders of the external auditory canal, tympanic membrane, middle ear, temporal bone, and skull base Despite the many advances in diagnostic technologies and imaging modalities in recent years, otoscopy remains the first diagnostic option in the diagnosis of otologic disease. This is an easy-to-consult book for residents and specialists, featuring brilliant diagnostic images from the newest generation of endoscopic otoscopes. Written by a renowned team of experts with 30 years of experience, this book helps readers obtain proficiency in otoscopy and in the interpretation of findings. Readers will learn what clinical consequences the diagnoses may have through case examples and treatment suggestions. Key Features: * Richly illustrated with over 1000 mostly full-color photographs and many radiological studies * Shows a vast range of common and rare pathologies that can be visualized and assessed via endo-otoscopy * Juxtaposes, when appropriate, the clinical picture, radiological diagnosis, and intraoperative findings with the endo-otoscopic findings of the patient * In each chapter, a surgical summary lists various approaches that may be used to optimally plan treatment of the patient * A special final chapter covers the assessment of postsurgical findings as seen in otoscopy, so as to distinguish between normal healing and changes that may require further intervention Color Atlas of Endo-Otoscopy, produced with the support of Mario Sanna Foundation, is certain to become a valuable tool for all physicians involved in the care of patients with ear ailments.

ObjectiveProcedure-intense specialties, such as surgery or endoscopy, are a major contributor to the impact of the healthcare sector on the environment. We aimed to measure the amount of waste generated during endoscopic procedures and to understand the impact on waste of changing from reusable to single use endoscopes in the USA.DesignWe conducted a 5-day audit (cross-sectional study) of all endoscopies performed at two US academic medical centres with low and a high endoscopy volume (2000 and 13 000 procedures annually, respectively). We calculated the average disposable waste (excluding waste from reprocessing) generated during one endoscopic procedure to estimate waste of all endoscopic procedures generated in the USA annually (18 million). We further estimated the impact of changing from reusable to single-use endoscopes taking reprocessing waste into account.Results278 endoscopies were performed for 243 patients. Each endoscopy generated 2.1 kg of disposable waste (46 L volume). 64% of waste was going to the landfill, 28% represented biohazard waste and 9% was recycled. The estimated total waste generated during all endoscopic procedures performed in the USA annually would weigh 38 000 metric tons (equivalent of 25 000 passenger cars) and cover 117 soccer fields to 1 m depth. If all endoscopic procedures were performed with single-use endoscopes and accounting for reprocessing, the net waste mass would increase by 40%. Excluding waste from ancillary supplies, net waste generated from reprocessing and endoscope disposal would quadruple with only using single-use endoscopes.ConclusionThis quantitative assessment of the environmental impact of endoscopic procedures highlights that a large amount of waste is generated from disposable instruments. Transitioning to single-use endoscopes may reduce reprocessing waste but would increase net waste.

This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.

Background and aimsConventional hot snare endoscopic mucosal resection (H-EMR) is effective for the management of large (≥20 mm) non-pedunculated colon polyps (LNPCPs) however, electrocautery-related complications may incur significant morbidity. With a superior safety profile, cold snare EMR (C-EMR) of LNPCPs is an attractive alternative however evidence is lacking. We conducted a randomised trial to compare the efficacy and safety of C-EMR to H-EMR.MethodsFlat, 15–50 mm adenomatous LNPCPs were prospectively enrolled and randomly assigned to C-EMR or H-EMR with margin thermal ablation at a single tertiary centre. The primary outcome was endoscopically visible and/or histologically confirmed recurrence at 6 months surveillance colonoscopy. Secondary outcomes were clinically significant post-EMR bleeding (CSPEB), delayed perforation and technical success.Results177 LNPCPs in 177 patients were randomised to C-EMR arm (n=87) or H-EMR (n=90). Treatment groups were equivalent for technical success 86/87 (98.9%) C-EMR versus H-EMR 90/90 (100%); p=0.31. Recurrence was significantly greater in C-EMR (16/87, 18.4% vs 1/90, 1.1%; relative risk (RR) 16.6, 95% CI 2.24 to 122; p<0.001).Delayed perforation (1/90 (1.1%) vs 0; p=0.32) only occurred in the H-EMR group. CSPEB was significantly greater in the H-EMR arm (7/90 (7.8%) vs 1/87 (1.1%); RR 6.77, 95% CI 0.85 to 53.9; p=0.034).ConclusionCompared with H-EMR, C-EMR for flat, adenomatous LNPCPs, demonstrates superior safety with equivalent technical success. However, endoscopic recurrence is significantly greater for cold snare resection and is currently a limitation of the technique.Trial registration number NCT04138030

BackgroundThe duodenum has become a metabolic treatment target through bariatric surgery learnings and the specific observation that bypassing, excluding or altering duodenal nutrient exposure elicits favourable metabolic changes. Duodenal mucosal resurfacing (DMR) is a novel endoscopic procedure that has been shown to improve glycaemic control in people with type 2 diabetes mellitus (T2D) irrespective of body mass index (BMI) changes. DMR involves catheter-based circumferential mucosal lifting followed by hydrothermal ablation of duodenal mucosa. This multicentre study evaluates safety and feasibility of DMR and its effect on glycaemia at 24 weeks and 12 months.MethodsInternational multicentre, open-label study. Patients (BMI 24–40) with T2D (HbA1c 59–86 mmol/mol (7.5%–10.0%)) on stable oral glucose-lowering medication underwent DMR. Glucose-lowering medication was kept stable for at least 24 weeks post DMR. During follow-up, HbA1c, fasting plasma glucose (FPG), weight, hepatic transaminases, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), adverse events (AEs) and treatment satisfaction were determined and analysed using repeated measures analysis of variance with Bonferroni correction.ResultsForty-six patients were included of whom 37 (80%) underwent complete DMR and 36 were finally analysed; in remaining patients, mainly technical issues were observed. Twenty-four patients had at least one AE (52%) related to DMR. Of these, 81% were mild. One SAE and no unanticipated AEs were reported. Twenty-four weeks post DMR (n=36), HbA1c (−10±2 mmol/mol (−0.9%±0.2%), p<0.001), FPG (−1.7±0.5 mmol/L, p<0.001) and HOMA-IR improved (−2.9±1.1, p<0.001), weight was modestly reduced (−2.5±0.6 kg, p<0.001) and hepatic transaminase levels decreased. Effects were sustained at 12 months. Change in HbA1c did not correlate with modest weight loss. Diabetes treatment satisfaction scores improved significantly.ConclusionsIn this multicentre study, DMR was found to be a feasible and safe endoscopic procedure that elicited durable glycaemic improvement in suboptimally controlled T2D patients using oral glucose-lowering medication irrespective of weight loss. Effects on the liver are examined further.Trial registration number NCT02413567

BackgroundProphylactic clip closure after endoscopic mucosal resection reduces delayed bleeding in large and proximal colon lesions; however, evidence regarding its effectiveness in colorectal endoscopic submucosal dissection (ESD) is lacking.ObjectiveTo compare clinically significant delayed bleeding rates between a clip closure and a control group for flat and sessile 20–50 mm colorectal polyps following ESD.DesignA multicentre randomised controlled trial conducted at four Japanese institutions randomly assigned patients to closure or non-closure groups. Significant postprocedural bleeding (haematochezia) was classified as severe (requiring endoscopic haemostasis or blood transfusion in patients with haemoglobin levels <70 g/L or haemorrhagic shock) or mild.ResultsThe closure and control groups comprised 150 and 149 cases in the intention-to-treat (ITT) analysis and 142 and 141 cases in the per-protocol (PP) analysis, respectively. Rates of complete clip closure were 88.7% (ITT) and 93.0% (PP). The ITT analysis revealed delayed bleeding rates of 6.7% and 20.1% (OR: 0.28; 95% CI: 0.13 to 0.60; p<0.001; absolute risk difference (ARD): 13.5%; 95% CI: 5.6% to 20.9%) and severe delayed bleeding rates of 1.3% and 8.7% (OR: 0.14; 95% CI: 0.03 to 0.64; p=0.003; ARD: 7.4%; 95% CI: 2.2% to 12.4%) in the closure and control groups, respectively. These differences were confirmed in the PP analysis. Delayed perforation was not observed, and the post-ESD coagulation syndrome rate was not significantly different between the two groups. Multivariate logistic regression analyses identified prophylactic clip closure as a significant independent preventive factor for both delayed bleeding (OR: 0.22; 95% CI: 0.08 to 0.50; p<0.001) and severe delayed bleeding (OR: 0.22; 95% CI: 0.05 to 0.76; p=0.015).ConclusionsProphylactic clip closure, successfully achieved in approximately 90% of cases, reduced the delayed bleeding rate after resection of colorectal polyps measuring 20–50 mm.Trial registration numberUMIN000043675.

Residual or recurrent adenoma (RRA) after endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) of ≥20 mm is a major limitation. Data on outcomes of the endoscopic treatment of recurrence are scarce, and no evidence-based standard exists. We investigated the efficacy of endoscopic retreatment over time in a large prospective cohort. Over 139 months, detailed morphological and histological data on consecutive RRA detected after EMR for single LNPCPs at one tertiary endoscopy centre were prospectively recorded during structured surveillance colonoscopy. Endoscopic retreatment was performed on cases with evidence of RRA and was performed predominantly using hot snare resection, cold avulsion forceps with adjuvant snare tip soft coagulation or a combination of the two. 213 (14.6%) patients had RRA (168 (78.9%) at first surveillance and 45 (21.1%) thereafter). RRA was commonly 2.5-5.0 mm (48.0%) and unifocal (78.7%). Of 202 (94.8%) cases which had macroscopic evidence of RRA, 194 (96.0%) underwent successful endoscopic therapy and 161 (83.4%) had a subsequent follow-up colonoscopy. Of the latter, endoscopic therapy of recurrence was successful in 149 (92.5%) of 161 in the per-protocol analysis, and 149 (73.8%) of 202 in the intention-to-treat analysis, with a mean of 1.15 (SD 0.36) retreatment sessions. No adverse events were directly attributable to endoscopic therapy. Further RRA after endoscopic therapy was endoscopically treatable in most cases. Overall, only 9 (4.2%, 95% CI 2.2% to 7.8%) of 213 patients with RRA required surgery.Thus 159 (98.8%, 95% CI 95.1% to 99.8%) of 161 cases with initially successful endoscopic treatment of RRA and follow-up remained surgery-free for a median of 13 months (IQR 25.0) of follow-up. RRA after EMR of LNPCPs can be effectively treated using simple endoscopic techniques with long-term adenoma remission of >90%; only 16% required retreatment. Therefore, more technically complex, morbid and resource-intensive endoscopic or surgical techniques are required only in selected cases. NCT01368289 and NCT02000141.