Systematic treatment in gastric cancer patients with overt bleeding: A propensity score matching analysis

BACKGROUND

Hemorrhage, which is not a rare complication in patients with gastric cancer (GC)/gastroesophageal junction cancer (GEJC), can lead to a poor prognosis. However, no study has examined the effectiveness and safety of chemotherapy as an initial therapy for GC/GEJC patients with overt bleeding (OB).

AIM

To investigate the impact of OB on the survival and treatment-related adverse events (TRAEs) of GC/GEJC patients.

METHODS

Patients with advanced or metastatic GC/GEJC who received systematic treatment at Peking University Third Hospital were enrolled in this study. Propensity score matching (PSM) analysis was performed.

RESULTS

After 1:2 PSM analysis, 93 patients were assessed, including 32 patients with OB before treatment (OBBT) and 61 patients without OBBT. The disease control rate was 90.6% in the group with OBBT and 88.5% in the group without OBBT, and this difference was not statistically significant. There was no difference in the incidence of TRAEs between the group with OBBT and the group without OBBT. The median overall survival (mOS) was 15.2 months for patients with OBBT and 23.7 months for those without OBBT [hazard ratio (HR) = 1.101, 95% confidence interval (CI): 0.672-1.804, log rank P = 0.701]. The mOS was worse for patients with OB after treatment (OBAT) than for those without OBAT (11.4 months vs 23.7 months, HR = 1.787, 95%CI: 1.006-3.175, log rank P = 0.044).

CONCLUSION

The mOS for GC/GEJC patients with OBBT was similar to that for those without OBBT, but the mOS for patients with OBAT was worse than that for those without OBAT.

Hemostatic palliative radiotherapy for gastric cancer: A literature review

Background

Gastric cancer has a high prevalence in Asia and may only be diagnosed in advanced stages. Therefore, patients with gastric cancer may experience fatal symptoms, such as bleeding or stenosis at the time of consultation. In this review, we aimed to describe the effectiveness and toxicity of hemostatic radiotherapy (RT).

Methods

A total of 17 retrospective and 3 prospective studies were analyzed. The prescription dose, biologically effective dose, equivalent dose in 2 Gy fractions, response rate, survival prognosis, and toxicities were also reported.

Results

Using 20 studies, the following observations were made the hemostatic effect was ∼ 80 %, the mean survival time after irradiation was about 3 months, and prescribed doses of 30 Gy/10 fractions and 20 Gy/5 fractions were considered suitable.

Conclusion

In this review, studies on hemostatic irradiation have been summarized, and the most optimal treatment method has been proposed. 30 Gy/10 fractions and 20 Gy/5 fractions were ideal. However, because palliative RT is preferably completed within a short period of time, a randomized trial is needed to determine whether the 8 Gy/single fraction treatment is equivalent to fractionated RT. Therefore, more prospective studies are warranted to establish a standard of care for palliative RT in gastric cancer.

Endoscopic application of magnetic compression anastomosis: a review

Magnetic compression anastomosis (MCA) is a new method that provides sutureless passage construction for tubular organs. Due to the high recurrence rate of conventional endoscopic treatment and the high morbidity and mortality of surgical procedures, the MCA technique shows promise. The aim of this review is to comprehensively examine the literature related to the use of MCA in different gastrointestinal diseases over the past few years, categorizing them according to the anastomotic site and describing in detail the various methods of magnet delivery and the clinical outcomes of MCA. MCA is an innovative technique, and its use represents an advancement in the field of minimally invasive interventions. Comparison studies have shown that the anastomosis formed by MCA is comparable to or better than surgical sutures in terms of general appearance and histology. Although most of the current research has involved animal studies or studies with small populations, the safety and feasibility of MCA have been preliminarily demonstrated. Large prospective studies involving populations are still needed to guarantee the security of MCA. For technologies that have been initially used in clinical settings, effective measures should also be implemented to identify, even prevent, complications. Furthermore, specific commercial magnets must be created and optimized in this emerging area.

Efficacy of Endoscopic Tissue Adhesive in Patients with Gastrointestinal Tumor Bleeding

BACKGROUND

Gastrointestinal tumors bleeding remains a significantly clinical challenge due to its resistance to conventional endoscopic hemostasis methods. While the efficacy of endoscopic tissue adhesives (ETA) in variceal bleeding has been established, its role in gastrointestinal tumor bleeding (GITB) remains ambiguous.

AIMS

This study aims to assess the feasibility and effectiveness of ETA in the treatment of GITB.

METHODS

The study enrolled 30 patients with GITB who underwent hemostasis through Histoacryl® tissue glue injection. Hemostasis success rates, ETA-related adverse events, and re-bleeding rates were evaluated.

RESULTS

ETA application achieved successful hemostasis at all tumor bleeding sites, with immediate hemostasis observed in all 30 (100.0%) patients. Among the initially hemostasis cases, 5 patients (17.0%) experienced re-bleeding within 30 days, and the 60 day re-bleeding rate was 20.0% (6/30). Expect for one case of vascular embolism, no adverse events related with ETA application were reported. The 6 month survival was 93%.

CONCLUSION

ETA demonstrated excellent immediate hemostasis success rate in GITB cases and showed promising outcomes in prevention re-bleeding.

A case of immunoglobulin G4-related kidney disease manifesting after dipeptidyl peptidase-4 inhibitor treatment

A 68-year-old man with type 2 diabetes mellitus was admitted with decreased renal function. He had high IgG4 (1070 mg/dL) and hypocomplementemia (CH50, 25 U/mL). Kidney biopsy showed tubulointerstitial nephritis with IgG4-positive plasma cell infiltration. Four years later, a second kidney biopsy revealed a new manifestation of membranous nephropathy and tubulointerstitial nephritis with exacerbated fibrosis formation. Six years later, the patient developed bullous pemphigoid, which was thought to be caused by DPP4 inhibitors, so DPP4 inhibitor treatment was discontinued. The use of DPP4 inhibitors correlated with changes in renal function, and the patient was diagnosed with IgG4-related kidney disease related to DPP4 inhibitors.

A case of early gastric cancer with metastatic recurrence following curative endoscopic submucosal dissection

A 70-year-old man was diagnosed with early gastric cancer with ulcerative findings. Endoscopic submucosal dissection as an absolute indication was performed, and en bloc resection was achieved. Pathological examination revealed a well-differentiated adenocarcinoma, 3 × 2 mm in size, intramucosal, with an ulcerative scar, no lymphovascular invasion, and a tumor-free margin. We diagnosed it as a curative resection and followed up with annual endoscopy. Sixteen months after endoscopic submucosal dissection, esophagogastroduodenoscopy revealed a singular ulcer scar; however, serum carcinoembryonic antigen level was elevated. Computed tomography scan showed wall thickening of the gastric antrum and an irregular mass on the dorsal side. Additionally, 18F-fluorodeoxyglucose positron emission tomography/coomputed tomography showed 18F-fluorodeoxyglucose uptake in the gastric antrum, irregular mass, and liver. Endoscopic ultrasonography revealed an internally heterogeneous mass in the gastric antrum region extending from the submucosal layer to the muscularis propria layer. Using an endoscopic ultrasonography-guided fine needle biopsy with a 22-gauge needle for the mass, we diagnosed local recurrence with the submucosal tumor-like appearance, lymph node metastasis, and liver metastases. Unfortunately, the patient died of gastric cancer 3 months after the diagnosis. Here, we report a rare case of local recurrence in the submucosal layer, lymph node metastasis, and liver metastases 16 months after curative endoscopic submucosal dissection.

Emergency Endoscopic Hemostasis Using the Endoscopic Mucosal Resection Technique for Severe Bleeding From Early Gastric Cancer: A Case Report

Bleeding from gastric cancer may lead to severe anemia and hypovolemic shock, and can be a life-threatening condition in affected patients; thus, achieving hemostasis is essential to improving their clinical course. While endoscopic hemostasis is recommended as the hemostatic modality of first choice, endoscopic hemostasis involving the endoscopic mucosal resection (EMR) technique is also being used, though under-reported. An 85-year-old man diagnosed with bleeding from gastric cancer was raced to our hospital for hemostasis. Emergency esophagogastroduodenoscopy (EGD) revealed a 45 mm-sized elevated lesion involving the coagula due to dripping bleeding from the surface of the posterior wall of the gastric lower body. EMR was performed without any technical difficulty, and hemostasis was achieved immediately. The patient was discharged without rebleeding. This case appears to support the usefulness of EMR as an emergency endoscopic hemostatic modality for severe bleeding from early gastric cancer.

Prospective study on planned biliary stent placement to treat small common bile duct stones

Aims

Small common bile duct stones are known to occasionally clear spontaneously. This study aimed to prospectively assess the role of biliary stent placement in promoting the spontaneous clearance of small common bile duct stones.

Methods and Results

We analyzed patients presenting with common bile duct stones of ≤5 mm diameter between June 2020 and May 2022. The exclusion criteria included asymptomatic patients, biliary pancreatitis, altered gastrointestinal anatomy, bile duct strictures (malignant or benign), and a history of EST. The biliary stents were inserted without stone removal. Stone clearance was assessed using endoscopic ultrasonography or endoscopic retrograde cholangiopancreatography after 3 months. Our primary endpoint was the clearance rate of common bile duct stones over 6 months, targeting a lower limit for the 95% confidence interval (CI) exceeding 25%. Of the 32 enrolled patients, 18 (56.3%; 95% CI: 37.7-73.6%) exhibited stone clearance. Early complications occurred in 11 patients (34.4%), totaling 12 incidents: acute cholecystitis in four, acute pancreatitis in three, biliary pain in three, and cholangitis in two patients. No severe complications occurred. Six (18.8%) patients experienced asymptomatic stent migration. Following stone clearance, four (12.5%) patients experienced stone recurrence, with an average duration of 256 ± 164 days.

Conclusion

Biliary stenting appeared to effectively promote the clearance of small common bile duct stones in approximately half of the patients. However, the potential complications and risks of stone recurrence warrant close monitoring.This trial was registered in the Japan Registry of Clinical Trials (jRCT1042200020).

Early gastric cancer recurrence after endoscopic submucosal dissection: Not to be ignored!

This editorial comments on the article "Efficacy of multi-slice spiral computed tomography in evaluating gastric cancer recurrence after endoscopic submucosal dissection". We focus on the importance of paying more attention to post-endoscopic submucosal dissection (ESD) gastric cancer recurrence in patients with early gastric cancer (EGC) and how to manage it effectively. ESD has been a well-known treatment and the mainstay for EGC, with the advantages of less invasion and fewer complications when compared with traditional surgical procedures. Despite a lower local recurrence rate after ESD, the problem of postoperative recurrence in patients with EGC has become increasingly non-ignorable with the global popularization of ESD technology and the increasing number of post-ESD patients.

Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event

BACKGROUND

Gallstone disease will affect 15% of the adult population with concomitant common bile duct stone (CBDS) occurring in up to 30%. Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for removal of CBDS, as cholecystectomy for the prevention of recurrent biliary event (RBE). RBE occurs in up to 47% if cholecystectomy is not done. The goal of this study was to evaluate the timing of occurrence of RBE after common bile duct clearance with ERCP and associated outcomes.

METHODS

The records of all patients who underwent ERCP for gallstone disease followed by cholecystectomy, in a single center from 2010 to 2022, were reviewed. All RBE were identified. Actuarial incidence of RBE was built. Patients with and without RBE were compared.

RESULTS

The study population is composed of 529 patients. Mean age was 58.0 (18-95). There were 221 RBE in 151 patients (28.5%), 39/151 (25.8%) having more than one episode. The most frequent RBE was acute cholecystitis (n = 104) followed by recurrent CBDS (n = 95). Median time for first RBE was 34 days. Actuarial incidence of RBE started from 2.5% at 7 days to reach 53.3% at 1 year. Incidence-rate of RBE was 2.9 per 100 person-months. Patients with RBE had significant longer hospitalisation time (11.7 vs 6.4 days; P < 0.0001), longer operative time (66 vs 48 min; P < 0.0001), longer postoperative stay (2.9 vs 0.9 days; P < 0.0001), higher open surgery rate (7.9% vs 1.3%; P < 0.0001), and more complicated pathology (23.8% vs 5.8%; P < 0.0001) and cholecystitis (64.2% vs 25.9%; P < 0.0001) as final diagnoses.

CONCLUSIONS

RBE occurred in 28.5% of the subjects at a median time of 34 days, with an incidence of 2.5% as early as 1 week. Cholecystectomy should be done preferably within 7 days after common bile duct clearance in order to prevent RBE and adverse outcomes.

A Comprehensive Primer on Radiation Oncology for Non-Radiation Oncologists

Background: Multidisciplinary management is crucial in cancer diagnosis and treatment. Multidisciplinary teams include specialists in surgery, medical therapies, and radiation therapy (RT), each playing unique roles in oncology care. One significant aspect is RT, guided by radiation oncologists (ROs). This paper serves as a detailed primer for non-oncologists, medical students, or non-clinical investigators, educating them on contemporary RT practices. Methods: This report follows the process of RT planning and execution. Starting from the decision-making in multidisciplinary teams to the completion of RT and subsequent patient follow-up, it aims to offer non-oncologists an understanding of the RO's work in a comprehensive manner. Results: The first step in RT is a planning session that includes obtaining a CT scan of the area to be treated, known as the CT simulation. The patients are imaged in the exact position in which they will receive treatment. The second step, which is the primary source of uncertainty, involves the delineation of treatment targets and organs at risk (OAR). The objective is to ensure precise irradiation of the target volume while sparing the OARs as much as possible. Various radiation modalities, such as external beam therapy with electrons, photons, or particles (including protons and carbon ions), as well as brachytherapy, are utilized. Within these modalities, several techniques, such as three-dimensional conformal RT, intensity-modulated RT, volumetric modulated arc therapy, scattering beam proton therapy, and intensity-modulated proton therapy, are employed to achieve optimal treatment outcomes. The RT plan development is an iterative process involving medical physicists, dosimetrists, and ROs. The complexity and time required vary, ranging from an hour to a week. Once approved, RT begins, with image-guided RT being standard practice for patient alignment. The RO manages acute toxicities during treatment and prepares a summary upon completion. There is a considerable variance in practices, with some ROs offering lifelong follow-up and managing potential late effects of treatment. Conclusions: Comprehension of RT clinical effects by non-oncologists providers significantly elevates long-term patient care quality. Hence, educating non-oncologists enhances care for RT patients, underlining this report's importance.

Role of Biliary Stent in Recurrence of Biliary Stones and Complications After Stone Clearance in Patients Awaiting Cholecystectomy: A Randomized Trial

INTRODUCTION

The role of prophylactic biliary stenting after clearance of choledocholithiasis in patients awaiting cholecystectomy for concomitant cholelithiasis is controversial. We planned a randomized controlled trial to study the effect of prophylactic biliary stenting after achieving biliary clearance in reducing recurrence of choledocholithiasis and biliary complications in patients awaiting cholecystectomy.

METHODS

Patients with concomitant cholelithiasis and choledocholithiasis were included, and those who had evidence of clearance of choledocholithaisis (documented on occlusion cholangiogram during endoscopic retrograde cholangiography [ERC]) were randomized to prophylactic biliary stenting or no stenting. Choledocholithaisis recurrence rate (primary outcome), biliary complications and need for repeat/emergency ERC (secondary outcomes) were compared till 3 months after clearance.

RESULTS

Between September 2021 and July 2022, 70 patients were randomized into group A, stenting (n = 35), and group B, no stenting (n = 35). Sixty-six patients were included in the final analysis. Baseline characteristics were comparable between the 2 groups. Ten (15.2%) patients had recurrence of choledocholithiasis, and it was comparable between the 2 groups (7/34 [20.6%] and 3/34 [9.4%], P = 0.306). Five patients (2 cholecystitis and 3 post-ERC pancreatitis) from the stent group while none from the no stent group developed complications, and this difference was statistically significant ( P = 0.024). None of the patients in both the groups needed emergency ERC during the follow-up.

DISCUSSION

This randomized trial shows a higher complication rate with prophylactic stenting, while there is no benefit in preventing choledocholithiasis recurrence in patients waiting for cholecystectomy after biliary clearance (CTRI registration number: CTRI/2021/09/036538).

Predictive factors and prognosis of upper gastrointestinal bleeding in gastric cancer: A large population-based study (UGIB-GC trial)

BACKGROUND

Gastric cancer remains the fourth leading cause of cancer-related death worldwide. Significant number of gastric cancer patients presented with bleeding.

OBJECTIVE

This study aimed to identify risk factors and overall survival rates of bleeding gastric cancer patients.

METHODS

This retrospective cohort study was conducted between 2007-2022 at tertiary care center in Thailand. Clinical information, endoscopic findings and histological type were extensively reviewed and were compared between bleeders and non-bleeders. Patients were monitored for at least 5 years.

RESULTS

There were 20,981 patients who underwent upper gastrointestinal endoscopy during study period. Total of 201 gastric cancer patients were included in this study, 21 were excluded due to incomplete medical records. 180 gastric cancer patients were included with mean age of 60.5±14.3 years. There were 65 (36.1%) patients with gastrointestinal bleeding. Hypertension and chronic kidney disease were significantly more common in bleeders than non-bleeders (43.1% vs 23.5%, OR2.51, 95%CI 1.14.-5.52, p = 0.022; and 16.9% vs 5.2%, OR2.00, 95%CI 1.56-6.63, p = 0.025, respectively). current H. pylori infection was also significantly more common in bleeders than non-bleeders (84.6% vs. 55.7%, OR 4.39, 95%CI 1.90-10.12, p<0.001). Median overall survival of bleeders was significantly lower than non-bleeders (7±0.93 vs 10±2.10 months, p = 0.001).

CONCLUSIONS

Bleeding gastric cancer was not an uncommon condition. Majority of patients presented at advanced stage with grave prognosis. Male gender, hypertension, chronic kidney disease, and current H. pylori infection were reliable predictors for bleeding. Early diagnosis and prompt treatment are the key to improve clinical outcome.

Self-assembled short peptides: Recent advances and strategies for potential pharmaceutical applications

Self-assembled short peptides have intrigued scientists due to the convenience of synthesis, good biocompatibility, low toxicity, inherent biodegradability and fast response to change in the physiological environment. Therefore, it is necessary to present a comprehensive summary of the recent advances in the last decade regarding the construction, route of administration and application of self-assembled short peptides based on the knowledge on their unique and specific ability of self-assembly. Herein, we firstly explored the molecular mechanisms of self-assembly of short peptides, such as non-modified amino acids, as well as Fmoc-modified, N-functionalized, and C-functionalized peptides. Next, cell penetration, fusion, and peptide targeting in peptide-based drug delivery were characterized. Then, the common administration routes and the potential pharmaceutical applications (drug delivery, antibacterial activity, stabilizers, imaging agents, and applications in bioengineering) of peptide drugs were respectively summarized. Last but not least, some general conclusions and future perspectives in the relevant fields were briefly listed. Although with certain challenges, great opportunities are offered by self-assembled short peptides to the fascinating area of drug development.

Superior mesenteric artery syndrome: Diagnosis and management

Superior mesenteric artery (SMA) syndrome (also known as Wilkie's syndrome, cast syndrome, or aorto-mesenteric compass syndrome) is an obstruction of the duodenum caused by extrinsic compression between the SMA and the aorta. The median age of patients is 23 years old (range 0-91 years old) and predominant in females over males with a ratio of 3:2. The symptoms are variable, consisting of postprandial abdominal pain, nausea and vomiting, early satiety, anorexia, and weight loss and can mimic anorexia nervosa or functional dyspepsia. Because recurrent vomiting leads to aspiration pneumonia or respiratory depression via metabolic alkalosis, early diagnosis is required. The useful diagnostic modalities are computed tomography as a standard tool and ultrasonography, which has advantages in safety and capability of real-time assessments of SMA mobility and duodenum passage. The initial treatment is usually conservative, including postural change, gastroduodenal decompression, and nutrient management (success rates: 70%-80%). If conservative therapy fails, surgical treatment (i.e., laparoscopic duodenojejunostomy) is recommended (success rates: 80%-100%).

Knowledge and Awareness About Gastric Cancer Among the General Population in Al-Baha City, Saudi Arabia

Background Gastric cancer is a significant health concern worldwide, and its incidence varies across different populations. This study aimed to assess the level of knowledge and awareness of gastric cancer among the general population in Al-Baha City, Saudi Arabia.  Methodology This is a cross-sectional study that was conducted among the residents of Al-Baha city older than 18 years. The study was conducted based on a questionnaire that has been developed by a previous study. Data were initially recorded in an Excel sheet before being exported to the SPSS program, version 25 for data analysis. Results The survey included 426 respondents from Al-Baha city, Saudi Arabia, with 56.8% being females and the majority being in the age groups (21-30 years). Alcohol consumption (mean=4.5, SD= 0.77), smoking cigarettes or Shisha (mean= 4.38, SD=0.852), family history of gastric cancer (mean= 4, SD=1.008), a past medical history of gastric cancer (mean= 3.99, SD=0.911), stomach ulcer (mean=3.76, SD=0.898), and consumption of smoked food (mean= 3.69, SD=0.956) are the most widely recognized risk factors. The most highly recognized symptoms are gastrointestinal bleeding (mean= 4.03, SD=0.875), abdominal lump (mean= 3.94, SD=0.926), weight loss (mean= 3.93, SD=0.963), recurrent nausea and vomiting (mean=3.76, SD=0.956), and abdominal pain (mean= 3.57, SD=0.995). The study also identified several subgroups of the population that may benefit from targeted educational programs, including individuals in the age group of 41-50 years and those in non-medical occupations. Conclusion The study found that participants had a moderate level of knowledge about the risk factors and symptoms of gastric cancer, with significant variability among different subgroups of the population. Further research is needed to investigate the prevalence and risk factors of gastric cancer in Saudi Arabia and other similar populations, to develop effective prevention and management strategies for this disease.

Clinical Management of Gastric Cancer Treatment Regimens

Gastric cancer is the fifth most common cancer and the fourth leading cause of cancer-associated death in the world. Endoscopic resection can be the treatment in selected cases of very early gastric cancer. Surgery is recommended for tumors that do not meet the criteria for endoscopic resection or for tumors with lymph node invasion but without distant metastases. Gastrectomy should include D2 lymphadenectomy without splenectomy. Perioperative or adjuvant chemotherapy improves survival and is recommended in locally advanced gastric cancer (>T1 and/or with lymph nodes positive). In locally advanced cancer with microsatellite instability (MSI), immunotherapy should be considered. Advanced unresectable or metastatic gastric cancer has a poor prognosis. The basis of the treatment is cytotoxic chemotherapy, with platinum and fluoropyrimidine doublet in the first line. Targeted therapies can be combined with chemotherapy. Trastuzumab (anti-HER2) is recommended in the first line in HER2-positive cancer. Ramucirumab (anti-VEGFR2) is recommended in the second line, in addition to paclitaxel chemotherapy. Zolbetuximab (anti-Claudine 18.2) should also be considered in the first line in Claudine 18.2-positive cancer. Immunotherapy can also be associated with chemotherapy in the first line of PD-L1-positive cancer. In HER2-positive and PD-L1-positive cancer, adjunction of trastuzumab and immunotherapy should be considered. In advanced and metastatic cancer with microsatellite instability (MSI), immunotherapy should be the first choice depending on its availability. Important progress has been made in recent years in the treatment of gastric cancer, especially due to a better understanding of molecular characteristics and heterogeneity of this disease. New targets and therapeutic approaches are being developed, which will very likely lead to changes in the management of gastric cancer.

The Impact of Palliative Radiation Therapy on Patients With Advanced Gastric Cancer: Results of a Retrospective Cohort Study

Aim In advanced gastric cancer, symptoms such as loss of appetite, stomach tightness, occasional pain, vomiting blood, and melena may occur. Palliative radiation therapy may be indicated in such cases. This study aimed to investigate the clinical outcomes of palliative radiotherapy in patients with advanced-stage gastric carcinoma. Methods From April 2018 to October 2022, consecutive patients with non-resected advanced gastric cancer who received radiation therapy for palliation of symptoms were included. Results A total of 23 patients with advanced-stage gastric carcinoma were analyzed in this study. Twelve male and 11 female patients were included. The median overall survival period was 3.9 months (95% confidence interval: 1.0-8.7 months). Sixteen patients required erythrocyte transfusion before radiotherapy; for 13 patients (83%), the required units of erythrocyte transfusion decreased after palliative radiotherapy. The mean erythrocyte transfusion units significantly decreased from 4.2 (standard deviation [SD]: 4.3) to 1.7 (SD: 3.6) (p = 0.02). No adverse events of grade ≥3 were observed in this study population. Conclusion Palliative radiation therapy for advanced gastric cancer yielded a good response rate and can be a useful treatment option.

Treating an Intractable Jejunocutaneous Fistula by Endoscopic Metallic Stent Placement: A Case Report of Successful Palliative Endoscopic Treatment in a Case Demonstrating Peritoneal Dissemination with Terminal Stage Gastric Cancer

A 74-year-old woman with recurrent gastric cancer underwent laparotomy for peritoneal dissemination, and the damaged jejunum formed a jejunocutaneous fistula. Because conservative treatment alone could not cure the fistula, we performed an endoscopic placement of a partially covered self-expandable metallic stent (SEMS) to cover the fistula. After the procedure, the contrast medium no longer leaked from the intestinal lumen. One month after stent placement, the cutaneous opening had closed. This case report demonstrates the potential for using partially covered SEMS to treat intractable jejunocutaneous fistula in patients with terminal-stage malignant tumors.

Multiple Gastric Metastases after Distal Pancreatectomy for Pancreatic Cancer

A 67-year-old woman underwent distal pancreatectomy for pancreatic cancer. Recurrence in the form of lung metastasis was discovered eight months after surgery, and chemotherapy was initiated. Two years after the surgery, she was admitted for the evaluation of melena. Esophagogastroduodenoscopy revealed multiple subepithelial lesions with ulceration from the gastric body to the fornix. The histopathology of biopsy specimens was consistent with ductal adenocarcinoma, which appeared similar to the resected pancreatic cancer. The patient was diagnosed with multiple gastric metastases of pancreatic cancer. We herein report a case of pancreatic cancer with multiple gastric metastases that occurred after surgery for pancreatic tail cancer.

Laparoscopic versus open surgery for locally advanced and metastatic gastric cancer complicated with bleeding and/or stenosis: short- and long-term outcomes

Background

Laparoscopic surgery has justified its efficacy in the treatment of early gastric cancer. There are limited data indicating the eligibility of laparoscopic interventions in locally advanced gastric cancer. Publications describing the safety of laparoscopic techniques in the treatment of local and metastatic gastric cancer complicated by bleeding and stenosis are scarce.

Methods

The study included patients with histologically confirmed locally advanced and disseminated gastric cancer and complicated with bleeding and/or stenosis who underwent gastrectomy with vital indications between February 2012 and August 2018. Surgical and oncologic outcomes after laparoscopic surgery (laparoscopic surgery) and open surgery (OS) were compared.

Results

In total, 127 patients (LS, n = 52; OS, n = 75) were analyzed. Baseline characteristics were similar between the groups. Forty-four total gastrectomies with resection of the abdominal part of the esophagus, 63 distal subtotal (43 Billroth-I and 20 Billroth-II), and 19 proximal gastrectomies were performed. The median duration of surgery was significantly longer in the LS group, 253 min (interquartile range [IQR], 200–295) versus 210 min (IQR, 165–220) (p < 0.001), while median intraoperative blood loss in the LS group was significantly less, 180 ml (IQR, 146—214) versus 320 ml (IQR, 290–350), (p < 0.001). Early postoperative complications occurred in 35% in the LS group and in 45 % of patients in the OS group (p = 0.227). There was no difference in postoperative mortality rates between the groups (3 [6 %] versus 5 (7 %), p = 1.00). Median intensive care unit stay and median postoperative hospital stay were significantly shorter after laparoscopy, 2 (IQR, 1–2) versus 4 (IQR, 3–4) days, and 8 (IQR, 7–9) versus 10 (IQR, 8–12) days, both p < 0.001. After laparoscopy, patients started adjuvant chemotherapy significantly earlier than those after open surgery, 20 vs. 28 days (p < 0.001). However, overall survival rates were similar between the group. Three-year overall survival was 24% in the LS group and 27% in the OS groups.

Conclusions

Despite the technical complexity, in patients with complicated locally advanced and metastatic gastric cancer, laparoscopic gastrectomies were associated with longer operation time, reduced intraoperative blood loss, shorter reconvalescence, and similar morbidity, mortality rates and long-term oncologic outcomes compared to conventional open surgery.

Palliative Radiotherapy for Bleeding from Unresectable Gastric Cancer Using Three-Dimensional Conformal Technique

Optimal regimens using recent radiotherapy (RT) equipment for bleeding gastric cancer (GC) have not been fully investigated yet. We retrospectively reviewed the clinical data of 20 patients who received RT for bleeding GC in our institution between 2016 and 2021. Three-dimensional conformal RT was performed. The effectiveness of RT was evaluated by the mean serum hemoglobin (Hb) level and the number of transfused red blood cell (RBC) units 1 month before and after RT. The median first radiation dose was a BED of 39.9 Gy. The treatment success rate was 95% and the rebleeding rate was 10.5%. There was a significant increase in the mean Hb level (8.0 ± 1.1 vs. 9.8 ± 1.3 g/dL, p = 0.01), and a significant decrease in the mean number of transfused RBC units (6.8 ± 3.3 vs. 0.6 ± 1.5 units, p < 0.01). Severe toxicity was observed in two patients (anorexia [n = 1] and gastrointestinal [GI] perforation [n = 1]). Reirradiation was attempted in three patients (for hemostasis [n = 2] and for mass reduction [n = 1]). The retreatment success rate for rebleeding was 100%. GI perforation occurred in two patients who had received hemostatic reirradiation. Palliative RT for bleeding GC using recent technology had excellent efficacy. However, it may be associated with a risk of GI perforation.

[Gastric cancer complicated by bleeding. (A systematic review)]

Bleeding as the most common complication of gastric cancer is a significant problem of modern surgery. Both oncologists and surgeons in ordinary hospitals deal with this adverse event. In addition to the well-known drugs for hemostasis, there are also generally recognized traditional methods of endoscopic hemostasis and transcatheter angiographic embolization. Surgical interventions do not lose their role too if previous hemostatic methods turned out to be ineffective. The reports devoted to radiotherapy for treatment and prevention of gastric bleeding following malignant process have been recently published. Such a wide choice of hemostatic methods prompted us to analyze the most significant recent studies regarding effectiveness of various methods and choice of the most optimal one.

The importance of pH adjustment for preventing fibrin glue dissolution in the stomach: an in vitro study

Combined use of fibrin glue and polyglycolic acid (PGA) sheets has attracted attention as a preventive measure for complications associated with endoscopic submucosal dissection. However, fibrin glue is a protein that may be dissolved by gastric acid. We evaluated the effect of artificial gastric acid on fibrin clot. The dissolution time of three layers of fibrin glue with PGA sheets was measured in five groups (pH 1.2, 2.0, 4.0, 5.5, and 6.0 with pepsin). Measurements of three samples per group were made. The mean number of the remaining layers at each measurement point was observed for 168 h. The time to complete dissolution of the three layers of fibrin gel in the three samples was 2.5 h at pH 1.2, 5 h at pH 2.0, 24 h at pH 4.0, and 48 h and 6 h at pH 5.5. In order to maintain fibrin glue in the stomach for a long period, there was a need to avoid pepsin activation secondary to acidification of gastric juice. The use of strong antacids is recommended.

Treatment response after palliative radiotherapy for bleeding gastric cancer: a multicenter prospective observational study (JROSG 17-3)

BACKGROUND

Palliative radiotherapy seems to be rarely performed for incurable gastric cancer. In this first multicenter study, we examined the effectiveness of palliative radiotherapy and investigated whether biologically effective dose (BED) is associated with survival, response, or re-bleeding.

METHODS

Eligibility criteria included blood transfusion or hemoglobin levels < 8.0 g/dL. The primary endpoint was the intention-to-treat (ITT) bleeding response rate at 4 weeks. Response entailed all of the following criteria: (i) hemoglobin levels ≥ 8.0 g/dL; (ii) 7 consecutive days without blood transfusion anytime between enrollment and blood sampling; and (iii) no salvage treatment (surgery, endoscopic treatment, transcatheter embolization, or re-irradiation) for bleeding gastric cancer. Re-bleeding was defined as the need for blood transfusion or salvage treatment.

RESULTS

We enrolled 55 patients from 15 institutions. The ITT response rates were 47%, 53%, and 49% at 2, 4, and 8 weeks, respectively. The per-protocol response rates were 56%, 78%, and 90% at 2, 4, and 8 weeks, respectively. Neither response nor BED (α/β = 10) predicted overall survival. Multivariable Fine-Gray model showed that BED was not a significant predictor of response. Univariable Cox model showed that BED was not significantly associated with re-bleeding. Grades 1, 2, 3, and, ≥ 4 radiation-related adverse events were reported in 11, 9, 1, and 0 patients, respectively.

CONCLUSIONS

The per-protocol response rate increased to 90% during the 8-week follow-up. The frequent occurrence of death starting shortly after enrollment lowered the ITT response rate. BED was not associated with survival, bleeding response, or re-bleeding.

Management of non-variceal upper gastrointestinal bleeding: role of endoscopic ultrasound-guided treatments

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common type of upper gastrointestinal emergency with high risk of life-threatening conditions. Nowadays some standard guidelines for the treatments of NVUGIB have been established based on endoscopic therapies, including injection of glues or sclerosing agents, coiling, band ligation, and thermal therapies. Nevertheless, some patients are refractory to standard endoscopic treatments. We have noticed that endoscopic ultrasound (EUS)-guided treatments have been performed by some endoscopists in certain conditions. This review aims to evaluate the role of EUS-guided treatments in the management of NVUGIB. We performed a MEDLINE/PubMed search, and relevant studies were extracted and examined. According to the existing literature, the most common lesions were Dieulafoy's lesion, pancreatic pseudoaneurysms, and gastrointestinal stromal tumors. EUS-guided treatments mainly include injection, mechanical therapies, and combined therapies, and seem to be a promising technique in the management of NVUGIB, especially for refractory bleeding.

[Gastric cancer complicated by bleeding: a systematic review]

Bleeding as the most common complication of gastric cancer is a significant problem of modern surgery. Both oncologists and surgeons in ordinary hospitals deal with this adverse event. In addition to the well-known drugs for hemostasis, there are also generally recognized traditional methods of endoscopic hemostasis and transcatheter angiographic embolization. Surgical interventions do not lose their role too if previous hemostatic methods turned out to be ineffective. The reports devoted to radiotherapy for treatment and prevention of gastric bleeding following malignant process have been recently published. Such a wide choice of hemostatic methods prompted us to analyze the most significant recent studies regarding effectiveness of various methods and choice of the most optimal one.

Endoscopic ultrasonography for pre-operative local assessment and endoscopic ultrasonography-guided marking before gastrojejunostomy for duodenal obstruction using magnetic compression anastomosis

BACKGROUND AND AIM

A 93-year-old woman who was bedridden with severe dementia was referred to our department with a 3-day history of repeated vomiting after meals. Computed tomography revealed significant dilatation of the duodenum up to the level of the third portion, which was compressed by a large, low-density mass. Upper gastrointestinal endoscopy showed narrowing of the third portion of the duodenum with edematous mucosa covered with multiple white spots, where the endoscope was able to pass through with mild resistance. B-cell lymphoma was histopathologically suspected from biopsy specimens of the mucosa. We performed gastrojejunostomy through the magnetic compression anastomosis (MCA) technique. We prepared two neodymium magnets: Flat plate shaped (15 × 3 mm) with a small hole 3 mm in diameter; a nylon thread was passed through each hole. We then confirmed the absence of no non-target tissue, including large vessels and intestine adjacent to the anastomosis where the magnets were to be placed using endoscopic ultrasonography (EUS) from the stomach. EUS-guided marking using biopsy forceps by biting the mucosa and placing a hemoclip was performed at the anastomosis site in the stomach. The magnet was pushed and delivered to the duodeno-jejuno junction, and another magnet was delivered to the marking point in the stomach. The magnets were attracted toward each other transmurally. The magnets fell into the colon by 11 days after starting the compression, and the completion of gastrojejunostomy was confirmed.

RELEVANCE FOR PATIENTS

Endoscopic gastrojejunostomy using MCA is useful as a minimally invasive alternative treatment for duodenal obstruction. EUS for the pre-operative local assessment and EUS-guided marking can ensure the safety of the MCA procedure.

Radiation treatment for refractory endometriosis: a 38-year-old female presenting with vaginal bleeding

Background

Endometriosis is typically managed with a medical or surgical approach, though some patients have medically refractory disease and are poor surgical candidates.

Case presentation

A 39-year-old woman presented to our facility with uncontrolled bleeding and pain from an endometriotic mass at the vaginal cuff. She had a history of abdominal hysterectomy with bilateral salpingo-oophorectomy, now with medically refractive and inoperable disease due to prior history of vesicovaginal fistula. We prescribed 30 Gy in 10 fractions with 10 MV and 18 MV photons to the target. At follow-up our patient reported a complete resolution of bleeding and pelvic pain.

Conclusion

Radiation treatment can be an effective treatment for refractory endometriosis.

Sutureless Duodeno-Ileal Anastomosis with Self-Assembling Magnets: Safety and Feasibility of a Novel Metabolic Procedure

BACKGROUND

Less invasive and safer anastomotic techniques are desirable. We aimed to determine technical feasibility and safety of sutureless duodeno-ileal side-to-side anastomosis in obese patients using self-assembling magnets.

METHODS

This was an open-label, prospective, and single-arm study including obese patients (BMI 30-50 kg/m²) with type II diabetes. The ileal magnet was deployed laparoscopically, and the duodenal magnet was deployed endoscopically. Both magnets were coupled under laparoscopic and fluoroscopic guidance. The primary endpoints were technical feasibility and safety. The secondary endpoints were patency of the anastomosis, HbA1c reduction, and weight loss 12 months after the procedure.

RESULTS

A total of 8 patients were enrolled in the study; median age was 51.5 years (range: 34-65), and median BMI was 38.8 kg/m² (range: 35-47.9). The mean procedural duration was 63.5 min (range: 41-95). No intraoperative complications were recorded, and no major postoperative morbidity related to the procedure occurred. Magnets were expelled at a median of 29.5 days after the procedure with no associated complications. Upper endoscopy at 12 months confirmed patent anastomoses with healthy-appearing mucosa in all patients. HbA1c reduced below 7.0% in 6 out of 8 (75%) patients, and greater than 5% of total body weight loss was observed in 7 out of 8 (87.5%) patients at 12 months.

CONCLUSIONS

Sutureless duodeno-ileal side-to-side anastomosis using self-assembling magnets is feasible and safe in obese patients, and a dual-path enteral diversion with large-caliber and durable anastomosis can be achieved.

Novel Use of Intraoperative Fluoroscopy in an Era of ICG for Complex Laparoscopic Cholecystectomy

Background  Laparoscopic cholecystectomy (LC) is increasingly being used as a first-line treatment for acute cholecystitis. Bile duct injury (BDI) remains the most feared complication of the minimally invasive approach specially in cases with an inflamed calots triangle. While use of indocyanine dye (ICG) to delineate biliary anatomy serves to reduce BDI, the high cost of the technology prohibits its use in the developing world. We propose a novel use of common bile duct (CBD) stenting preoperatively in cases of cholecystitis secondary to choledocholithiasis as a means of identification and safeguarding the CBD.

Methods  A retrospective review was conducted on 22 patients of Grade 2 or Grade 3 cholecystitis who underwent an early LC at our institution. All patients were stented preoperatively and the stent was used for a much-needed tactile feedback during dissection. A c-arm with intraoperative fluoroscopy was used to identify the CBD prior to clipping of the cystic duct.

Results  The gall bladder was gangrenous in all the cases while two cases had evidence of end organ damage. This innovative use of CBD stenting allowed us to correctly delineate biliary anatomy in all of the cases and we report no instances of BDI despite a severely inflamed local environment.

Conclusion  This technique can become a standard of care in all teaching institutions in developing countries further enhancing the safety of cholecystectomy in gangrenous cholecystitis with a distorted biliary anatomy.

Digital compression for hemostasis in acute hemorrhagic rectal ulcer: a report of 4 cases and review of the literature

Acute hemorrhagic rectal ulcer is a relatively rare cause of lower gastrointestinal bleeding. It most commonly occurs in bedridden elderly patients with multiple comorbidities. While the diagnosis can be confirmed on colonoscopy, achieving hemostasis may be difficult due to the poor visual field resulting from severe bleeding and stool remaining in the rectum, the stiffness of ulcers which may preclude effective clipping, the poor tolerability of patients for the procedure, and high risk of recurrence. Here, we present 4 cases of acute hemorrhagic rectal ulcer, where hemostasis could not be achieved through traditional methods. In each case, the assistant introduced his finger into the rectal lumen and digitally compressed the bleeding vessel under endoscopic guidance. Once hemostasis was achieved, the responsible vessel could be visualized and traditional hemostatic measures were taken. No recurrence was observed in any of the cases during follow-up. This simple maneuver can be applied safely and effectively even by assistants attempting the maneuver for the first time. The technique was effective with the endoscope in retroflexed position and could be combined with gel immersion endoscopy to first identify the location of hemorrhage. We also review the existing literature on acute hemorrhagic rectal ulcers.

Efficacy of a novel hemostatic adhesive powder in patients with upper gastrointestinal tumor bleeding

Background

Gastrointestinal tumor bleeding remains a clinical challenge because it is difficult to treat with conventional endoscopic hemostatic options. Recently, an endoscopic hemostatic powder (UI-EWD) was developed and reported to provide effective control of upper gastrointestinal bleeding. The aim of current study was to evaluate the feasibility and efficacy of this novel hemostatic powder in tumor bleeding.

Methods

A total of 41 consecutive patients with upper gastrointestinal tumor bleeding were included. UI-EWD was applied in all patients as an auxiliary hemostatic method as a salvage therapy or monotherapy during endoscopic treatment. Hemostasis success rates, adverse event related to UI-EWD, and rates of re-bleeding were evaluated.

Results

In all cases, UI-EWD application was successful at tumor bleeding sites. Immediate hemostasis occurred in 40/41 (97.5%) patients, and re-bleeding within 28 days occurred in 10 of 40 (22.5%) patients that achieved initial hemostasis. The success rate of immediate hemostasis for UI-EWD monotherapy was 100% (23/23). The re-bleeding rate at 28 days after UI-EWD monotherapy was 26.1% (6/23). No adverse events associated with UI-EWD application were encountered.

Conclusions

The success rate of UI-EWD for immediate hemostasis in cases of GI tumor bleeding was excellent and UI-EWD produced promising results with respect to the prevention of re-bleeding. Based on these results, we suggest that UI-EWD be considered an effective salvage therapy or even monotherapy for GI tumor bleeding.

Beta adrenergic antagonists and antianginal drugs

Beta adrenergic antagonists and antianginal drugs are used with the aim to ultimately decrease mortality and enable patients to lead an improved quality of life by avoidance of anginal episodes. Each class of medications used for this purpose have a variety of actual or potential side effects associated with their use. Side effects and drug interactions involving these medications are discussed in the following chapter. A special review is included that examines available evidence in the context of the current COVID-19 pandemic. Evidence presented should be used in the context of the patient populations described and may aid clinical decision making through avoidance or identification of actual or potential side effects. This review includes literature published from November 2019 to January 2021.

Jejunal Dieulafoy's Lesion: A Systematic Review of Evaluation, Diagnosis, and Management

Jejunal Dieulafoy's lesion is an exceedingly rare but important cause of gastrointestinal bleeding. It frequently presents as a diagnostic and therapeutic conundrum due to the rare occurrence, intermittent bleeding symptoms often requiring prompt clinical action, variability in the detection and treatment methods, and the risk of rebleeding. We performed a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases regarding jejunal Dieulafoy's lesio from inception till June 2020. A total of 136 cases were retrieved from 76 articles. The mean age was 55 ± 24 years, with 55% of cases reported in males. Patients commonly presented with melena (33%), obscure-overt gastrointestinal bleeding (29%), and hemodynamic compromise (20%). Hypertension (26%), prior gastrointestinal surgery (14%), and valvular heart disease (13%) were the major underlying disorders. Conventional endoscopy often failed but single- and double-balloon enteroscopy identified the lesion in 96% and 98% of patients, respectively. There was no consensus on the treatment. Endoscopic therapy was instituted in 64% of patients. Combination therapy (34%) with two or more endoscopic modalities, was the preferred approach. With regard to endoscopic monotherapy, hemoclipping (19%) and argon plasma coagulation (4%) were frequently employed procedures. Furthermore, direct surgical intervention in 32% and angiographic embolization was performed in 4% of patients. The rebleeding rate was 13.4%, with a mean follow-up duration of 17.6 ± 21.98 months. The overall mortality rate was 4.4%. Jejunal Dieulafoy's lesion is still difficult to diagnose and manage. Although the standard diagnostic and therapeutic modalities remain to be determined, device-assisted enteroscopy might yield promising outcomes.

Fedora-type magnetic compression anastomosis device for intestinal anastomosis

BACKGROUND

Although previous studies have confirmed the feasibility of magnetic compression anastomosis (MCA), there is still a risk of long-term anastomotic stenosis. For traditional MCA devices, a large device is associated with great pressure, and eventually increased leakage.

AIM

To develop a novel MCA device to simultaneously meet the requirements of pressure and size.

METHODS

Traditional nummular MCA devices of all possible sizes were used to conduct ileac anastomosis in rats. The mean (± SD) circumference of the ileum was 13.34 ± 0.12 mm. Based on short- and long-term follow-up results, we determined the appropriate pressure range and minimum size. Thereafter, we introduced a novel “fedora-type” MCA device, which entailed the use of a nummular magnet with a larger sheet metal.

RESULTS

With traditional MCA devices, the anastomoses experienced stenosis and even closure during the long-term follow-up when the anastomat was smaller than Φ5 mm. However, the risk of leakage increased when it was larger than Φ4 mm. On comparison of the different designs, it was found that the “fedora-type” MCA device should be composed of a Φ4-mm nummular magnet with a Φ6-mm sheet metal.

CONCLUSION

The diameter of the MCA device should be greater than 120% of the enteric diameter. The novel “fedora-type” MCA device controls the pressure and optimizes the size.

New Technique for Magnetic Compression Anastomosis Without Incision for Gastrointestinal Obstruction

BACKGROUND

Magnetic compression anastomosis (MCA) is a novel technique of anastomosis similar to that with surgery, but in a minimally invasive manner. Few reports are available on the utility and feasibility of MCA for gastrointestinal anastomosis without requiring general anesthesia in humans, owing to the difficulty of delivering magnets. We evaluated the safety, efficacy, and feasibility of MCA in gastrointestinal obstruction without requiring general anesthesia.

STUDY DESIGN

In this retrospective single-center study, patients who underwent MCA from January 2013 to October 2019 were included. Adult patients with gastrointestinal obstruction or stenosis, irrespective of the underlying disease, with severe comorbidities, complicated abdominal surgical history, or postoperative complications, and who were unable to tolerate surgery, were eligible for inclusion. Two magnets were delivered by a combination of endoscopic and fluoroscopic procedures and placed in the lumen of the organ to be anastomosed. The main outcome was the technical success of MCA.

RESULTS

Fourteen patients underwent MCA, and the technical success of MCA was achieved in 100% of the cases. The mean procedural time, duration for anastomosis formation, and postoperative hospital stay were 44 minutes, 13 days, and 36 days, respectively. Two patients underwent anastomotic restenosis, and 1 patient had an anastomotic perforation due to balloon dilatation to prevent restenosis. The mean follow-up period was 34 months.

CONCLUSIONS

MCA without general anesthesia for gastrointestinal anastomosis is safe, useful, and feasible. MCA can be a valuable alternative to surgery in gastrointestinal obstruction.

Acute Gastric Hemorrhage due to Gastric Cancer Eroding Into a Splenic Artery Pseudoaneurysm: Two Dangerously Rare Etiologies of Upper Gastrointestinal Bleeding

Splenic artery pseudoaneurysms (SAPs) are rare causes of upper gastrointestinal bleeding (UGIB), with less than 250 reported cases in the literature. The highest incidence of SAPs is in patients with a history of acute or chronic pancreatitis or splenic artery trauma. SAP in the setting of gastric malignancy is an exceedingly rare finding. We present the unusual hospital course of an 82-year-old male with advanced gastric cancer presenting with UGIB secondary to a visceral communication between his known gastric malignancy and a SAP.

Gastric cancer

Gastric cancer is the fifth most common cancer and the third most common cause of cancer death globally. Risk factors for the condition include Helicobacter pylori infection, age, high salt intake, and diets low in fruit and vegetables. Gastric cancer is diagnosed histologically after endoscopic biopsy and staged using CT, endoscopic ultrasound, PET, and laparoscopy. It is a molecularly and phenotypically highly heterogeneous disease. The main treatment for early gastric cancer is endoscopic resection. Non-early operable gastric cancer is treated with surgery, which should include D2 lymphadenectomy (including lymph node stations in the perigastric mesentery and along the celiac arterial branches). Perioperative or adjuvant chemotherapy improves survival in patients with stage 1B or higher cancers. Advanced gastric cancer is treated with sequential lines of chemotherapy, starting with a platinum and fluoropyrimidine doublet in the first line; median survival is less than 1 year. Targeted therapies licensed to treat gastric cancer include trastuzumab (HER2-positive patients first line), ramucirumab (anti-angiogenic second line), and nivolumab or pembrolizumab (anti-PD-1 third line).

Magnetic compression anastomosis is effective in treating stenosis after esophageal cancer surgery: a case report

BACKGROUND

Esophagostomy is important in the treatment of esophageal cancer. However, esophagectomy has a higher risk of postoperative complications. Treatment for complications is often difficult, and in some cases, oral intake is no longer possible. Recently, magnetic compression anastomosis (MCA) was developed; it is a relatively safe method of anastomosis that does not require surgery in patients with stricture, obstruction, or dehiscence of the anastomosis after surgery.

CASE PRESENTATION

The patient was a 76-year-old Japanese man. He underwent esophagectomy with a three-field dissection for esophageal cancer. A cervical esophagostomy and chest drainage were performed for necrosis of the gastric tube. Following infection control, colon interposition was performed. However, after the operation, the colon necrotized and formed an abscess. Drainage controlled the infection, but the colon was completely obstructed. The patient was referred to our hospital to restore oral ingestion. Contrast studies showed that the length of the occlusion was 10 mm. The reconstruction was examined; reanastomosis by surgery was judged to be a high risk, so the strategy of anastomosis by MCA was adopted. In the operation, the anterior chest was opened to expose the colon, and a magnet was inserted directly into the blind end of the colon. The magnet was guided to the blind end of the esophagus using an oral endoscope. Two weeks after MCA, a contrast study confirmed the passage of the contrast agent from the esophagus to the colon. The patient eventually took 18 bougies after the MCA. However, since then, he has not needed a bougie. As of 1 year and 8 months after the MCA, the patient is living at home with oral intake restored.

CONCLUSIONS

MCA is an effective and safe treatment for complete stenosis after esophageal cancer surgery.

Filling of Polyglycolic Acid Sheets for Closure of Gastrointestinal Fistulas With an Easily Deliverable Technique Using a Guidewire

Background

This retrospective study aimed to investigate the suitable indications, methodology and long-term effect of the closure of gastrointestinal (GI) fistulas using polyglycolic acid (PGA) sheets and fibrin glue (FG) and to evaluate the usefulness of a delivery technique using a guidewire.

Methods

It involved 10 applications in six patients (median age 73 (range 53 - 78) years old, three men) with GI fistulas. A guidewire was introduced endoscopically or percutaneously into the fistula beyond the opposite orifice of the fistula with radiologic control. A tapered catheter was inserted over the guidewire, and the fistula was cleaned with an adequate quantity of saline. Subsequently, a small piece of PGA sheet was skewered onto the guidewire at the center and then pushed using the tapered catheter over the guidewire and delivered into the fistula. In cases of endoscopic procedure, the mucosa around the fistula was ablated, and the orifice of the fistula along with the surrounding mucosa was shielded with a piece of PGA sheet fixed with hemoclips and FG.

Results

Technical success of fistula closure was achieved in all applications, and no complications were observed after the procedure. The long-term occlusion of the fistula was ultimately achieved in four of six patients at 202 - 654 days (median duration, 244 days) after the last procedure with one or two applications.

Conclusions

The closure of GI fistulas using PGA sheets and FG demonstrated long-term efficacy for upper GI fistula of a certain length, and the filling technique using a guidewire ensured a safe smooth procedure.

Magnetic compression anastomosis for non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction: a case report

BACKGROUND

Postoperative non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction is a rare complication. If endoscopic balloon dilation proves ineffective, patients need re-operation under general anesthesia and experience a high rate of postoperative complications. Magnetic compression anastomosis is a nonsurgical procedure that can create an anastomosis similar to that obtained through surgery. We report a case in which magnetic compression anastomosis was successfully performed to avoid re-operation for non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction.

CASE PRESENTATION

A 70-year-old woman was admitted to our hospital for treatment of non-anastomotic stenosis of the proximal jejunum. Open total gastrectomy and Roux-en-Y reconstruction were performed 2 years previously for advanced gastric cancer at another hospital. She complained of anorexia and obstructed passage of food. No recurrence of gastric cancer was identified. Esophagogastroduodenoscopy showed circumferential membranous stenosis of the jejunum 3 cm distal to the esophago-jejunal anastomosis. Endoscopic balloon dilation was performed three times, but proved ineffective. Magnetic compression anastomosis was planned because the stenosis existed near the esophago-jejunal anastomosis and re-operation was a highly invasive procedure requiring intrathoracic anastomosis. Endoscopic balloon dilation preceded placement of the parent magnet on the anal side of the stenosis. Confirming the improvement of stenosis, the parent magnet was placed on the anal side of the stenosis during esophagogastroduodenoscopy. The parent magnet attached to nylon thread was fixed to the cheek to prevent magnet migration. A week after placing the parent magnet, restenosis was confirmed and the daughter magnet was placed via nylon thread on the oral side of the stenosis. The two magnets were adsorbed in the end-to-end direction across the stenosis. Magnets adsorbed in the end-to-end direction moved to the anal side 11 days after placement. Wide anastomosis was confirmed by esophagogastroduodenoscopy. Endoscopic balloon dilation was regularly performed to prevent restenosis after magnetic compression anastomosis. No complications were observed postoperatively. The patient was able to eat normally and successfully reintegrated into society.

CONCLUSIONS

Magnetic compression anastomosis could be a feasible procedure to avoid surgery for non-anastomotic stenosis of the proximal jejunum after gastrectomy with Roux-en-Y reconstruction.

Endoscopic Gastrojejunostomy for Superior Mesenteric Artery Syndrome Using Magnetic Compression Anastomosis

An 89-year-old woman who was bedridden suffered repeated vomiting due to superior mesenteric artery syndrome (SMAS). We performed gastrojejunostomy via the magnetic compression anastomosis (MCA) technique because her situation was not improved by conservative therapy and because the operative risk was high. We prepared two neodymium magnets: a flat plate-shaped magnet (15 × 3 mm) and a ring-shaped magnet of the same size. The ring-shaped magnet which passed through a guidewire was pushed to the duodenum by an endoscope over the guidewire. The duodenal stricture was balloon-dilated in front of the magnet, and the magnet was pushed all together beyond the stricture and placed at the duodenojejunal junction. Subsequently, the flat plate-shaped magnet was delivered endoscopically to the stomach using a biopsy forceps. The magnets were attracted towards each other transmurally after one more flat plate-shaped magnet was added to the gastric-side magnet. Completion of gastrojejunostomy was confirmed while retrieving the magnets 10 days after starting compression. She has been asymptomatic for 1 month since anastomosis. Endoscopic gastrojejunostomy using MCA was an effective, low-invasive treatment for SMAS.

Experience of Endoscopic Jejunojejunostomy for Anastomotic Obstruction After Subtotal Gastrectomy Using Magnetic Compression Anastomosis

Magnetic compression anastomosis (MCA) was developed as a low-invasive treatment for gastro-enteric or entero-enteric obstruction. A 72-year-old man underwent subtotal gastrectomy with Billroth II reconstruction for early gastric cancer. After the operation, he suffered from repeated aspiration pneumonia due to anastomotic obstruction caused by jejunal kinking at the efferent loop of anastomosis. We therefore performed jejunojejunostomy via the MCA technique, as his situation was not improved despite conservative therapy and he had a high reoperative risk. We prepared two flat plate-shaped neodymium magnets (15 × 3 mm) each with a small hole, and a nylon thread was passed through each hole. Each magnet was then delivered endoscopically to the anal side of the jejunal kinking, subsequently to the anastomosis, using biopsy forceps. The two magnets immediately became attracted towards each other transmurally. Oozing hemorrhage with clot at the mated magnets was observed 10 days after starting the compression. After retrieving the magnets, we confirmed the completion of jejunojejunostomy and then successfully achieved hemostasis of the anastomotic hemorrhage using argon plasma coagulation. The widely patent anastomosis was confirmed endoscopically 1 month after canalization; and he has been asymptomatic and able to eat a normal diet ever since. Endoscopic MCA is an effective, low-invasive treatment for anastomotic obstruction after subtotal gastrectomy. A standardized, safer procedure should be established for general use in the clinical setting.

Defect repair with fibrin glue/polyglycolic acid after endoscopic laryngopharyngeal cancer resection

OBJECTIVES/HYPOTHESIS

In 2013, we introduced a modified technique for mucosal/muscle layer defect coverage with fibrin glue and polyglycolic acid (PGA) sheets (mMCFP technique) in patients undergoing endoscopic transoral surgeries for laryngopharyngeal cancers. This technique allows easy and convenient coverage of the wound surface, even when it involves the laryngopharyngeal lumen. To our knowledge, use of the MCFP technique for coverage of postoperative mucosal and/or muscle layer defects involving the laryngopharyngeal lumen has not been reported. The aim of the present study was to retrospectively evaluate the safety of our mMCFP technique used simultaneously with endoscopic transoral resection of Tis, T1, T2, and select T3 pharyngeal and supraglottic cancers.

STUDY DESIGN

A single centre retrospective study.

METHODS

Between June 2013 and February 2019, 102 patients underwent simultaneous end-flexible-rigidscopic transoral surgery and wound coverage using our mMCFP technique. All patients required mucosal and/or muscle layer resection. For all patients, we recorded the incidence of postoperative complications and the time period for which the PGA sheets could be observed after surgery.

RESULTS

In 41%, 35%, and 8% patients, the PGA sheets could be observed on the wound surface for 2, 3, and 4 weeks, respectively. Other than postoperative bleeding in two patients (2%), no postoperative complications were recorded.

CONCLUSIONS

The findings of this study suggest that our mMCFP technique is a safe and simple method for the repair of mucosal and/or muscle layer defects after endoscopic transoral surgery for laryngopharyngeal cancers.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1740-1745, 2020.

Endoscopic shielding using oxidized regenerated cellulose after argon plasma coagulation under mandatory dual antiplatelet therapy

Endoscopic shielding is an innovative concept in therapeutic endoscopy. Its usage has been mostly restricted to wide‐field endoscopic mucosal resection and/or endoscopic submucosal dissection. A novel potential clinical use may be in bleeding pophylaxis for argon plasma coagulation‐related ulcers under concomitant mandatory dual antiplatelet therapy.

Endoscopic management of tracheoesophageal fistulas

Tracheoesophageal fistulas (TEF) are pathologic communications between the trachea and esophagus. TEF can lead to significant respiratory distress that may result in lethal respiratory compromise, often due to recurrent and intractable infections. Through the use of endoscopy, some TEF can be successfully repaired using different approaches depending on the size, location, availability, and experience of the treating endoscopist. The aim of this manuscript is to provide an up-to-date review of the endoscopic management of TEF for gastroenterologists.