Gabriel Marcellier

Background: Time-consuming, burdensome and prone to human error, manual cleaning is the first step of endoscope reprocessing and remains mandatory. Devices automating this step using turbulent hydro-aeric flow (THAF) could bring organizational and environmental benefits. We performed a multiscale evaluation of THAF-assisted cleaning. Methods: The four-pronged assessment of THAF-assisted cleaning comprised: (1) a multicenter microbiological study comparing protein/hemoglobin residue and bacterial contamination after THAF-assisted vs manual cleaning; (2) an ergonomic study of hardship factors associated with cleaning; (3) an efficiency study of time consumption and organizational impact; (4) a life cycle assessment comparing the environmental impact of THAF and manual cleaning methods. Results: Protein/hemoglobin residue was detected after cleaning in 8/50 endoscopes (16%) with manual and 8/34 (24%) with THAF (p=0.41). After complete reprocessing, alert-level contamination occurred in 2/50 (4%) vs 2/34 (6%) (p=1.0) and action-level in 4/50 (8%) vs 6/34 (18%) (p=0.30). THAF halved cleaning time, reduced observed exposure to repetitiveness, moisture, detergent and constrained working postures, and enabled one nurse to operate two stations. In a medium-sized center cleaning 6,800 endoscopes a year, THAF would add €1,890 while avoiding emissions of 1.79 metric-tons CO₂e, 250kg of medical waste and the consumption of 306L of detergent and 200,804L of water. Conclusion: THAF-assisted cleaning reduced dedicated cleaning time, exposure to occupational hardship factors, greenhouse gas emissions, water and detergent consumption as well as waste production. In this exploratory study, which was not powered to establish non-inferiority, contamination rates were not statistically different from those observed after manual cleaning.

INTRODUCTION: Certain biliary or pancreatic duct strictures can be crossed with a guidewire but remain impassable by standard dilation devices. Alternative strategies are sometimes required, such as drilling into the stricture with a cystotome, a 6Fr wire-guided electrocautery catheter. Data on the efficacy and safety of this rescue technique are scarce. We conducted a systematic literature review complemented by our single-center experience using a cystotome for unpassable biliopancreatic strictures. METHODS: A systematic review of PubMed, Embase, Google Scholar, and Cochrane library was performed, including studies using a cystotome for biliary or pancreatic strictures that could not be dilated with standard accessories. Alternative devices (e.g., Soehendra) were excluded. Primary outcomes were the combination of technical success (ability to traverse the stricture and deploy a stent) and safety (absence of procedure-related adverse event). Clinical success (short- and long-term) were collected if available. Our review was supplemented with consecutive cases performed at Beaujon Hospital (Clichy, France) from 2020 to 2025. RESULTS: A total of 102 patients were included (93 patients from 9 studies and 9 from our center). The primary composite outcome, combining technical success and safety, was achieved in 90.2% of patients. Technical success was 100% (102/102), with clinical success reported in 94% (84/89). Cystotome-related mild adverse events occurred in 9.8% of patients. DISCUSSION: Cystotome-assisted electrosurgical drilling seems to be technically reliable and effective for complex biliopancreatic strictures that are resistant to standard dilation. This comprehensive study could encourage to integrate the cystotome in the endoscopists' endoscopic retrograde cholangiopancreatography toolbox.

Benign biliary strictures (BBS) are commonly managed by progressive calibration using plastic or metallic stents. Although fully-covered metallic stents (FC-SEMS) enable immediate calibration to a larger diameter compared with plastic stents, they remain prone to migration and use is limited in intrahepatic and peri-hilar strictures. We report on using uncovered expandable bioresorbable stents (BRES) in a series of selected BBS patients. This retrospective monocentric case series included all consecutive patients treated between 2023 and 2024. Patients were highly selected for uncommon situations for which usual stents were not well suited and followed for at least 12 months after the procedure. Technical success, clinical success, and adverse events (AEs) were systematically recorded. Five procedures were performed in five patients with implantation of a total of eight UNITY-B stents. Three patients underwent internalization of an internal-external drainage across a bilio-digestive anastomotic stricture. One patient was treated with retrograde extra-anatomical endoscopic drainage for an anastomotic stricture. One patient underwent calibration of an intrahepatic stricture following radiofrequency of an IPMN-B. Technical success was achieved in all cases (100%), with clinical success observed in 80% of patients. No AEs were observed. Use of bioresorbable UNITY-B stents appears feasible and safe for selected benign biliary strictures, including in intrahepatic locations. Further studies are needed to confirm these preliminary findings.

Endoscopy is a major producer of hospital waste. Liquid waste collected during endoscopic procedures represents a third of endoscopy waste and is often managed as regulated medical waste (RMW), costing more and emitting more greenhouse gases (GHGs) than regular landfill waste. We assessed the carbon footprint and financial impact of alternative processing methods to RMW. After 1 month of prospectively weighing endoscopic liquid waste, costs (€) and GHG emissions (kgCO2e) were calculated using the Carebone tool to compare the following processing methods to standard RMW: (a) solidification – aspiration canister contents are made less prone to leakage by including a jellifying additive and can be disposed of in landfill waste bags instead of RMW; (b) urban sewer disposal (USD) – fluids are eliminated into sewers by using a dedicated system instead of aspiration canisters. Costs and GHG emissions were modelled according to the different scenarios. Mean procedure-related waste was 1.56 kg per patient, one-third of which was liquid waste. Compared with RMW (assuming 0.5 L of waste per endoscopic procedure), a center treating 4000 patients / year would save 923 € and avoid 1440 kgCO2e in GHG emissions with solidification, while USD would cost 105 898 € more and avoid only 96.5 kgCO2e. Different caseload and volume assumptions are discussed. Endoscopic procedure-related liquid waste represents a third of the waste emitted per patient in an endoscopy unit. Solidification allows fluids to be safely reallocated to landfill waste and may reduce processing costs and environmental impact. USD appears to be neither environmentally nor economically beneficial for endoscopy units.

Electroporation (EPN) is the process by which cell membranes become transiently or permanently permeable upon exposure to pulsed electric fields of suitable intensity and duration. Depending on the pulse parameters, permeabilization can be reversible or irreversible, enabling a wide range of biomedical applications. To improve our understanding of EPN effects on tissues and select efficient treatments and parameters, relevant in vitro tumour models are required. Three-dimensional (3D) cell spheroids have emerged as valuable systems, as they more accurately replicate tumour microenvironment and cell-to-cell interactions than conventional 2D cultures. In this work, we present a new microdevice designed for the culture and gradual electroporation of a population of several hundred uniformly sized spheroids, allowing the systematic study of electroporation over a wide range of electric field intensities within a single experiment. Gradual permeabilization of HT-29 colorectal cancer cell spheroids was performed using a standard electrochemotherapy protocol, and electroporation efficiency was assessed by analysing propidium iodide (PI) uptake. Spheroids were treated with electric fields ranging from 800 V cm⁻¹ to 3400 V cm⁻¹. In toto analysis of PI distribution within spheroids by confocal microscopy revealed highly heterogeneous permeabilization patterns throughout the spheroid volume, for all intensities investigated, even at the highest one of 3400 V cm⁻¹. This study introduces a robust 3D in vitro assay for the systematic evaluation of electroporation-based treatments, providing new insights into the influence of electric field heterogeneity, electrical protocol, and estimation of molecular uptake in the spheroid volume.

INTRODUCTION: Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive malignancy with poor prognosis and limited treatment options. Electroporation-based therapies, such as electrochemotherapy (ECT) and irreversible electroporation (IRE), could be promising alternatives. ECT combines reversible electroporation with chemotherapy, enhancing intracellular drug uptake, while IRE leads to nonthermal tumor ablation. Both have been suggested as immunotherapy potentiators (electroimmunotherapy) in some tumor locations. We conducted a systematic review to evaluate the efficiency and safety of ECT, IRE, and immunoelectroporation in PDAC treatment. METHODS: We searched Medline, Embase, Cochrane, and Google-Scholar for ECT, IRE, and electroimmunotherapy following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. For ECT and electroimmunotherapy, regarding the scarcity of the data, we described independently each study protocol and results. For IRE, we collected protocol, efficiency, and safety data to provide a global analysis. RESULTS: Fifteen studies described the effects of ECT for PDAC treatment: Safety and efficiency were promising in both preclinical and human models. Thirty-eight clinical studies including 2,245 patients were analyzed for IRE, with patients mostly treated for locally advanced pancreatic cancer and a median overall survival of 17.2 months at the expanse of a 36% adverse event rate, half of which severe. Seven (preclinical and clinical) studies investigated electroimmunotherapy suggesting significant potentiation of immunotherapy in both preclinical and human models. DISCUSSION: In the largest systematic review to date regarding electroporation in PDAC treatment, analysis of study results plead against the use of IRE but highlight the potential benefits of ECT and electroimmunotherapy.

Esophageal refractory benign strictures are challenging to manage. Fully-covered metallic stents (FCSEMS) are swiftly efficient but subject to high migration rates. Because new through-the-scope suturing devices (TTSS) are now available, an alternative to over-the-scope/through-the-scope clips (OTSC/TTSC) or over-the-scope suturing devices (OTSS) can be trialed to anchor FCSEMS and prevent their dislodgement. We performed a preclinical comparison on a porcine model of the ability to prevent FCSEMS migration with TTSS, OTSC, and TTSC. Given the promising results, we then performed stent anchoring with TTSS to selected patients with refractory benign strictures. We hereby present these initial procedures and their outcomes. In preclinical trials, TTSS provided significantly higher resistance to traction than OTSC, TTSC, and no anchoring. We performed eight FCSEMS anchoring with TTSS among six patients, with encouraging technical and clinical outcomes. This is the first preclinical and clinical description of the benefits of TTSS for FCSEMS anchoring in esophageal refractory benign strictures. Safe and efficient anchoring with TTSS could allow using double-silicon-layered FCSEMS that can be left in place several months for management of refractory benign strictures. This work paves the way for prospective studies assessing FCSEMS anchoring with TTSS.