Tianyu Liu

INTRODUCTION: Visual endoscopic retrograde appendicitis therapy (V-ERAT) involves a single-use video scope, allowing for real-time visualization of the appendiceal lumen during the procedure to treat uncomplicated acute appendicitis (AA). This study aims to compare V-ERAT to antibiotic therapy in treating uncomplicated AA. METHODS: This multicenter, retrospective cohort study was conducted at 9 hospitals in China from August 2021 to July 2023. Propensity score matching was performed to minimize selection bias. A total of 692 uncomplicated AA patients were included, with 188 undergoing V-ERAT and 504 receiving antibiotic therapy. The primary outcome was treatment success rate. The secondary outcomes included recurrent appendicitis rate, the appendectomy rate during the initial hospitalization, length of initial hospitalization, time to disease recurrence, and overall adverse events. RESULTS: The treatment success rate did not differ between the V-ERAT and antibiotic groups (93.6%; 95% confidence interval [CI] 89.1%–96.7% vs 90.5%; 95% CI, 87.6%–92.9%) ( P = 0.225). However, V-ERAT demonstrated a significantly lower risk of appendicitis recurrence compared with antibiotic therapy during the follow-up (log-rank P < 0.001), with a hazard ratio of 0.14 (95% CI, 0.07–0.29, P < 0.001). V-ERAT was associated with a lower appendectomy rate during the initial hospitalization (4.3%; 95% CI, 1.9%–8.2% vs 9.5%; 95% CI, 7.1%–12.4%) ( P = 0.027), a shorter length of initial hospitalization (3 [interquartile range (IQR), 3–4] vs 4 [IQR, 4–6] days, P < 0.001), and a longer time to recurrence (269 [IQR, 210–318] vs 70 [IQR, 21–103] days, P < 0.001). The overall adverse event rates did not differ between the 2 groups (log-rank P = 0.064). DISCUSSION: V-ERAT seems to be a safe and effective alternative to antibiotic therapy in treating uncomplicated AA, significantly reducing the risk of appendicitis recurrence.

Introduction Patients with clinically significant portal hypertension (CSPH) are recommended to be treated with non-selective beta-blockers (ie, carvedilol) to prevent the first hepatic decompensation event by the renewing Baveno VII consensus. CSPH is defined by hepatic venous pressure gradient (HVPG)≥10 mm Hg; however, the HVPG measurement is not widely adopted due to its invasiveness. Liver stiffness (LS)≥25 kPa can be used as a surrogate of HVPG≥10 mm Hg to rule in CSPH with 90% of the positive predicting value in majority aetiologies of patients. A compelling argument is existing for using LS≥25 kPa to diagnose CSPH and then to initiate carvedilol in patients with compensated cirrhosis, and about 5%–6% of patients under this diagnosis criteria may not be benefited from carvedilol and are at risk of lower heart rate and mean arterial pressure. Randomised controlled trial on the use of carvedilol to prevent liver decompensation in CSPH diagnosed by LS remains to elucidate. Therefore, we aimed to investigate if compensated cirrhosis patients with LS≥25 kPa may benefit from carvedilol therapy. Methods and analysis This study is a randomised, double-blind, placebo-controlled, multicentre trial. We will randomly assign 446 adult compensated cirrhosis patients with LS≥25 kPa and without any previous decompensated event and without high-risk gastro-oesophageal varices. Patients are randomly divided into two groups, with 223 subjects in group A and 223 subjects in group B. Group A is a carvedilol intervention group, while group B is a placebo group. All patients in both groups will receive aetiology therapies and are followed up at an interval of 6 months. The 3-year incidences of decompensated events of cirrhosis-related and liver-related death are the primary outcome. The secondary outcomes include development of each complication of portal hypertension individually (ascites, variceal bleeding or overt hepatic encephalopathy), development of spontaneous bacterial peritonitis and other bacterial infections, development of new varices, growth of small varices to large varices, delta changes in LS and spleen stiffness, change in hepatic dysfunction assessed by Child-Pugh and model for end-stage liver disease score, change in platelet count, development of hepatocellular carcinoma, development of portal vein thrombosis and adverse events with a 3-year follow-up. A predefined interim analysis will be performed to ensure that the calculation is reasonable. Ethics and dissemination The study protocol has been approved by the ethics committees of the Sixth People’s Hospital of Shenyang (2023-05-003-01) and independent ethics committee for clinical research of Zhongda Hospital, affiliated to Southeast University (2023ZDSYLL433-P01). The results from this trial will be submitted for publication in peer-reviewed journals and will be presented at international conferences. Trial registration number ChiCTR2300073864.

A 36-year-old woman presented with recurrent lower abdominal pain for 6 months. Abdominal contrast-enhanced computed tomography (CT) showed a 1.2-mm enhancing lesion in the upper rectum ([Fig. 1]). Intestinal endoscopy revealed a 1.5 × 1.2-cm rectal mass located 15 cm from the anal dentate line ([Fig. 2]). Mucosal biopsy indicated mild chronic inflammation. Endoscopic ultrasonography revealed a 2.2-cm submucosal lesion with an intact mucosal layer ([Fig. 3]). After obtaining consent from the patient, submucosal tumor endoscopic resection was planned, but formation of the liquid pad by injection proved difficult. The margins of the lesion on the mucosal surface were marked using electrocoagulation ([Fig. 4]). After obtaining a second consent, rectal endoscopic full-thickness resection was performed ([Video 1]). A balloon catheter was placed in the sigmoid colon to block fecal matter. An endoscopic mucotomy knife (KD-650Q; Micro-Tech Co., Ltd., Nanjing, China) was used to incise the marked mucosa until an orifice formed. Then, an IT knife (KD-650L; Micro-Tech Co., Ltd.) was used to incise the full thickness around the lesion. After inspecting the outer intestinal wall fascia, an endoscopic electrified snare was used to dissect the lesion into two sections. The defect in the rectal wall was sutured using three three-armed clips (STA00002; Micro-Tech Co., Ltd.) and several titanium clips (ROCC-D-26–195-C; Micro-Tech Co., Ltd.). Histological examination of the biopsy specimen showed chronic submucosal inflammation with foam cell reaction and no abnormal cells at the horizontal and vertical margins. During the operation, no gas entered the abdominal cavity, all abdominopelvic cavity organs remained unaffected, and there was minimal bleeding. Follow-up after 6 weeks showed no residual mass on contrast-enhanced CT, with only scars and two clips at the junction site observed. The postoperative biopsy revealed foam cells, consistent with the characteristics of peritoneal loose bodies [1]. This is the first reported case of endoscopic resection of a peritoneal loose body. The endoscopic procedure demonstrated efficiency and safety in this case. However, large-scale clinical studies are needed in the future. Endoscopy_UCTN_Code_TTT_1AQ_2AH Article published online: 07 August 2024 © 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

An anastomotic fistula is a severe complication of post-gastrectomy. In the past, re-surgery has been the most common method to address this complication [1]. However, it may bring many subsequent complications [2]. With the development of endoscopic techniques and related accessories, endoscopy is gradually able to address more post-surgical complications. Here, we report a case of dual-endoscopy detection and suture of an esophageal-jejunal anastomosis fistula. A 72-year-old man was admitted to the hospital complaining of food leakage from the abdominal drainage tube over the past 4 months. The upper gastrointestinal contrast revealed partial contrast medium flowing out of the drainage tube in the anastomotic site ([Fig. 1]). The gastric endoscopy showed a drainage tube inserted into the intestinal lumen from the anastomosis orifice ([Fig. 2 a]). Endoscopic treatment was performed after the patient’s consent. First the drainage tube was removed. The dual-endoscopy detection combined with a superfine gastroscope (Olympus GIF-HQ290; Olympus, Tokyo, Japan) and conventional transoral gastroscope (Olympus GIF-Q260 J) was performed simultaneously by two operators ([Video 1]). The superfine gastroscope was inserted through the sinus tract and docked with the conventional gastroscope. The anastomosis fistula was then sutured with nylon rope and metallic clips in a purse-string manner under the conventional gastroscope. Because the docked dual-endoscopy detection showed the sinus tract was continuous with no infection in the anastomosis and sinus tract, the lateral serous membrane was not sutured. The follow-up gastroscopy 2 months later showed complete healing of the anastomosis ([Fig. 2 b]) and fistula tract. Video 1 Dual-endoscopy detection combined with a superfine gastroscope and conventional transoral gastroscope was performed simultaneously. Dual-endoscopy detection could be applied to determine the therapeutic plan of patients with post-surgical anastomotic fistula and enterocutaneous fistula by detecting whether the sinus tract is continuous, infected, purulent, etc. After confirmation of the leak in the sinus tract and no infection, the suture of the lateral serous membrane is not needed and the sinus tract can be closed without additional processing. Long-term follow-up should be planned for further assessment. Endoscopy_UCTN_Code_TTT_1AO_2AB Article published online: 11 July 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

A 71‐year‐old male developed anastomotic tumor bleeding after subtotal gastrectomy (Billroth II), and the surgery was refused due to coronary atherosclerotic heart disease. Endoscopic sclerotherapy (ES) in the treatment of esophagogastric variceal bleeding has been commonly reported, but few in non‐variceal upper gastrointestinal bleeding. As far as we know, endoscopic sclerotherapy for malignant tumor hemorrhage has not been reported. Here a valuable case is presented: endoscopic sclerotherapy was performed on the anastomotic tumor bleeding, which is an effective try in a particular period.

In recent years, endoscopic retrograde appendicitis therapy (ERAT) has been widely used in the treatment of acute uncomplex appendicitis [1]. However, the treatment of a periappendiceal abscess has always been a challenge. Early surgery may cause serious complications such as total peritonitis and postoperative anastomotic leakage [2]. We report a case of acute appendicitis with a giant periappendiceal abscess and intestinal obstruction. Through ERAT, full endoscopic drainage was achieved and the intestinal obstruction was quickly resolved. A 34-year-old woman presented with abdominal pain, nausea, vomiting, and no anal exhaust defecation for 2 days. Computed tomography (CT) showed acute appendicitis with a giant periappendiceal abscess and intestinal obstruction ([Fig. 1]). After informed consent was given, an ERAT procedure was performed ([Video 1]) with the patient under general anesthesia. The intestine was prepared through colon dialysis. Colonoscopy showed significant protrusion of the mucosa around the appendix. The appendiceal cavity was successfully incised using a duodenal papillary incision knife ([Fig. 2]). Then a guidewire was delivered to the giant periappendiceal abscess, which was clearly visualized by iohexol radiography ([Fig. 3]). After that, a biliary plastic stent was successfully implanted. A large amount of pus flowed out of the stent ([Fig. 4]). The procedure was performed successfully without any adverse events. Postoperative abdominal X-ray indicated no signs of intestinal obstruction. The patient recovered well. Video 1 Endoscopic retrograde appendicitis therapy for continuous drainage of giant periappendiceal abscess and the process of removing the stent under colonoscopy. Follow-up CT after 2 months showed that the periappendiceal abscess had fully disappeared ([Fig. 5]). The stent was removed under colonoscopy ([Video 1]). ERAT may be a safe and effective method for adequate drainage of a periappendiceal abscess in the early stage. Further clinical studies with larger samples and long-term follow-up are needed to evaluate this. Endoscopy_UCTN_Code_CCL_1AD_2AG Article published online: 06 October 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany