A case series of incidents reported to webAIRS relating to glucagon-like peptide 1 agonist use

The increasing prescription of glucagon-like peptide 1 (GLP-1) agonists presents a peri-operative challenge for anaesthetists. These drugs delay gastric emptying, potentially increasing pulmonary aspiration risk. Despite recent recommendations from the Australian and New Zealand College of Anaesthetists, Australian Society of Anaesthetists, and American Society of Anesthesiologists, there remain no formalised guidelines regarding preoperative optimisation for patients taking GLP-1 agonists. Given the current lack of evidence, we present a case series of incidents involving patients treated with GLP-1 agonists reported to webAIRS, a web-based anaesthetic incident reporting system in Australia and New Zealand. Among 11,700 reports from July 2009 to April 2024, 13 incidents related to GLP-1 agonist use were identified, including seven cases concerning aspiration. Patient factors potentially contributing to increased aspiration risks in these incidents included a higher body mass index, type 2 diabetes mellitus, gastro-oesophageal reflux disease, emergency case, and time from GLP-1 agonist cessation. Most incidents involved a rapid sequence induction for general anaesthesia with no cases utilising gastric ultrasound, preoperative nasogastric tube insertion, or intravenous erythromycin use. This case series highlights the potential concerns relating to GLP-1 treatment in the perioperative setting. Interdisciplinary collaboration and communication between anaesthetists, surgeons, general practitioners and endocrinologists are required to further investigate and establish preoperative guidelines for safe GLP-1 agonist use. Specifically, consideration in determining actual gastric contents of each patient despite generic fasting guidelines is needed. Early preoperative risk stratification should also improve patient safety and outcomes.

Semaglutide use is associated with higher rates of pseudarthrosis and dysphagia in patients undergoing posterior cervical fusion

BACKGROUND CONTEXT

Semaglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, has shown efficacy in managing glycemic control and obesity but its effects on surgical outcomes, particularly in posterior cervical fusion (PCF), are underexplored.

PURPOSE

To evaluate the association between semaglutide use and postoperative complications, costs, and readmissions in patients undergoing PCF.

DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Patients undergoing PCF were queried from the PearlDiver Mariner database between 2010 and 2022.

OUTCOME MEASURES

Outcomes included medical and surgical complications, readmissions, emergency department visits, and associated costs within 90 days and 2 years postoperatively.

METHODS

Patients with an active semaglutide prescription were propensity score-matched in a 1:5 ratio to controls based on age, sex, Elixhauser Comorbidity Index, and other clinical variables. Statistical analyses included chi-square tests and logistic regression, with significance set at p<.003 after Bonferroni correction.

RESULTS

A total of 340 semaglutide users and 1,540 matched controls were included. Semaglutide use was associated with significantly higher odds of pseudoarthrosis at 2 years (OR 4.79, 95% CI 3.11-7.37; p<.001) and dysphagia (OR 2.12, 95% CI 1.46-3.03; p<.001). Hospital cost analyses revealed significant differences between groups. Same-day ($5,000 vs. $11,700; p<.001) and mean 90-day costs were significantly lower ($12,200 vs. $18,800; p<.001) in the semaglutide group. No differences were observed in emergency department visits or readmissions (p>.003 for all).

CONCLUSIONS

Semaglutide use is associated with an increased risk of long-term complications, including pseudoarthrosis and dysphagia, as well as lower same-day and 90-day costs in patients undergoing PCF. These findings highlight the importance of careful perioperative management of semaglutide users to optimize outcomes while leveraging its purported benefits.

Fecal microbiota transplantation: application scenarios, efficacy prediction, and factors impacting donor-recipient interplay

Fecal microbiota transplantation (FMT) represents a therapeutic approach that directly regulates the gut microbiota of recipients, normalizes its composition and reaping therapeutic rewards. Currently, in addition to its general application in treating Clostridium difficile (C. difficile) infection (CDI), FMT treatment has also been extended to the fields of other gastrointestinal diseases, infections, gut-liver or gut-brain axis disorders, metabolic diseases and cancer, etc. Prior to FMT, rigorous donor screening is essential to reduce the occurrence of adverse events. In addition, it is imperative to evaluate whether the recipient can safely and effectively undergo FMT treatment. However, the efficacy of FMT is influenced by the complex interactions between the gut microbiota of donor and recipient, the degree of donor microbiota engraftment is not necessarily positively related with the success rate of FMT. Furthermore, an increasing number of novel factors affecting FMT outcomes are being identified in recent clinical trials and animal experiments, broadening our understanding of FMT treatment. This article provides a comprehensive review of the application scenarios of FMT, the factors influencing the safety and efficacy of FMT from the aspects of both the donors and the recipients, and summarizes how these emerging novel regulatory factors can be combined to predict the clinical outcomes of patients undergoing FMT.

Glucagon-like peptide-1 receptor agonists increase the risk of residual gastric content and pulmonary aspiration on upper endoscopy: A meta-analysis

BACKGROUND AND AIMS

Glucagon-like peptide-1 receptor agonists (GLP1-RA) are associated with increased residual gastric content (RGC); however, there is debate about their impact on RGC-related clinical outcomes, particularly aspiration.

METHODS

PubMed, Embase, Web of Science and Cochrane Library databases were systematically searched for studies published up to January 4, 2025, comparing GLP1-RA with control groups (non-GLP1-RA) in patients undergoing endoscopy. The outcomes of interest included the risk of RGC, pulmonary aspiration, interrupted and repeated endoscopic procedures, and delays in gastric transit time during capsule endoscopy. For the meta-analysis, a random-effects model was used to calculate the pooled odds ratio (OR) and mean difference (MD) with 95 % confidence intervals (CIs).

RESULTS

Thirty-nine studies composed of a total of 1,253,498 subjects, were included. The pooled analysis demonstrated that the GLP1-RA group had a significantly increased risk of RGC (OR 4.86, 95 % CI 3.85-6.14; adjusted OR 5.24, 95 % CI 3.49-7.87), pulmonary aspiration (OR 2.29, 95 % CI 1.36-3.87), interrupted endoscopic procedures (OR 3.22, 95 % CI 1.65-6.29), repeated endoscopy (OR 2.16, 95 % CI 1.14-4.11), and delays in gastric transit time during capsule endoscopy (MD 45.51, 95 % CI 1.33-89.68).

CONCLUSIONS

GLP1-RA use increased the risk of RGC, pulmonary aspiration, interrupted and repeated endoscopy and gastric transit time, reducing the safety and completion of upper endoscopy.

Evidence Report on the Safety of Gastrointestinal Endoscopy in Patients on Glucagon-like Peptide-1 Receptor Agonists: A Systematic Review and Meta-Analysis

Background/Objectives: Glucagon-like peptide-1 receptor agonists are increasingly used worldwide for weight and hyperglycemia management. There is an ongoing debate on the presence of increased gastric residue, leading to complications such as aspiration and overall safety in patients receiving upper gastrointestinal endoscopy. We aimed to study the effect of GLP-RAs on endoscopy outcomes. Methods: We conducted a detailed search of online databases to select the studies which provided details of the effects of GLP-RAs on patients undergoing endoscopy. The outcomes of interest were odds of retained gastric content (RGC), aspiration risk, and aborted and repeated procedures. A random effect model was used to calculate the pooled odds of outcomes with a 95% CI. We further calculated the pooled odds of predictive factors associated with an increased rate of retained gastric residues in the study population. Results: We included 12 studies with a total of 105,515 patients, of which 32,144 were on GLP-1 RAs and 73,273 were in the control group. A total of 234 (0.73%) aspiration events in GLP-RA users were noted compared to 257 (0.35%) events in the control group. No increased odds (1.26, 95% CI 0.86-1.87, I2 34%) of aspiration were found in GLP-1 users compared to the non-GLP-1 group. Patients on GLP-1 RA had increased RGC compared to the control group (OR 6.30, 95% CI 5.30-7.49, I2 0%). The pooled odds of aborted (OR 5.50, 95% CI 3.25-9.32, I2 0%) and repeated procedures (OR 2.19, 95% CI 1.42-3.38, I2 0%) were significantly higher in GLP-1 RA users. Patients taking Tirazepatide had the highest percentage of RGC (18.9%), while exenatide users had the lowest rate (6.2%) of food retention. Patients undergoing concomitant colonoscopy were found to have significantly low pooled odds of RGC (OR 0.26, 95% CI 0.04-0.48). GLP-1 RAs use was independently associated with increased odds of RGC (3.91, 95% CI 3.21-4.62, I2 0%). The results were homogenous and stayed consistent in the sensitivity analysis. Conclusions: Although the odds of RGC and aborted procedures are high in the GLP-1 RAs group compared to the control, no significant difference in the odds of aspiration was found between the two groups. Simple measures such as a clear liquid diet for 24 h, as routinely set for patients undergoing colonoscopy, may reduce the risk of retaining gastric residue in these patient populations.

Efficacy and applications for PuraStat® use in the management of unselected gastrointestinal bleeding: A retrospective observational study

BACKGROUND

Hemostatic powders have been used as primary or salvage therapy to control gastrointestinal bleeding in a number of scenarios. PuraStat® is a novel, self-assembling peptide gel that has properties that differ from hemostatic powders. It is transparent, can be used in narrow spaces and combined with other modalities. Also, it is pre-filled in a syringe ready to use and easy to handle and deliver. PuraStat® has been shown to be effective and safe in treating gastrointestinal bleeding lesions. But, its role as a hemostatic agent in all bleeding indications remains to be clarified.

AIM

To evaluate PuraStat® efficacy and its applications, feasibility and safety in treating gastrointestinal bleeding lesions.

METHODS

We performed a retrospective single-centre analysis of all consecutive patients with gastrointestinal bleeding, that required endoscopic treatment and where PuraStat® was applied, from June 2020 to October 2022. Demographics, biochemical, endoscopic, endoscopist assessment and outcome data were collected. We analysed the whole cohort and the subgroup with upper gastrointestinal bleeding. The primary outcome was to evaluate the efficacy of PuraStat® at achieving initial hemostasis. The patients were followed-up for 30 days after the episode of bleeding.

RESULTS

In total 45 patients were included, and 17/45 (37.8%) females. The mean age was 65.8 years. Charlson score was > 2 in 27/45 (60%) and 26/45 (57.8%) required transfusion. The procedures were gastroscopy (77.8%), colonoscopy (15.5%), endoscopic retrograde cholangiopancreatography (4.4%) and enteroscopy (2.2%). The most common bleeding lesion was peptic ulcer (33.3%). PuraStat® was used alone in 36% of the cases. One hundred percent achieved initial hemostasis and no complications were documented. There were no significant differences between the use of PuraStat® alone or in combination in terms of re-bleeding (P = 0.64) or mortality (P = 0.69). In 46.6% of cases, the reason for applying PuraStat® was as addition to standard of care, in 35.5% as an alternative because standard of care was not possible and in 17.8% as a rescue therapy.

CONCLUSION

PuraStat® is an effective therapy for multiple etiologies and is considered very easy to use in the majority. Its role as front line agent should be considered in the future.

Advancements in Endoscopic Treatment for Gastric Subepithelial Tumors

Peroral flexible endoscopy is a minimally invasive technique that enables the local resection of gastric subepithelial tumors (SETs) with malignant potential. Resection techniques are mainly chosen on the basis of the lesion size. Minute SETs less than 1 cm should be managed through a watch and wait strategy, with the exception of histologically diagnosed superficial lesions, which require endoscopic mucosal resection or endoscopic submucosal dissection. For 1- to 3-cm small SETs, endoscopic enucleation techniques, such as endoscopic submucosal excavation, submucosal tunneling endoscopic resection, and peroral endoscopic tumor resection, can be used. However, endoscopic full-thickness resection is preferred for histologically complete removal with negative surgical margins. When endoscopic full-thickness resection is considered technically difficult, laparoscopic and endoscopic cooperative surgery (LECS) is a safe and dependable alternative. Moderate-sized SETs (3 to 5 cm) require surgical intervention because the lesions must be removed transabdominally. LECS is a less invasive surgical procedure as it reduces the resection area; however, some LECS techniques that require transoral tumor retrieval are not available. Endoscopic intervention for lesions larger than 5 cm should be used with caution for research purposes. With advancements in endoscopic diagnosis, the indications for endoscopic treatment for SETs are expected to improve, thereby enhancing patients' quality of life.

Role of duodenal mucosal resurfacing in controlling diabetes in rats

BACKGROUND

The duodenum plays a significant role in metabolic regulation, and thickened mucous membranes are associated with insulin resistance. Duodenal mucosal resurfacing (DMR), a new-style endoscopic procedure using hydrothermal energy to ablate this thickened layer, shows promise for enhancing glucose and lipid metabolism in type 2 diabetes (T2D) patients. However, the mechanisms driving these improvements remain largely unexplored.

AIM

To investigate the mechanisms by which DMR improves metabolic disorders using a rat model.

METHODS

Rats with T2D underwent a revised DMR procedure via a gastric incision using a specialized catheter to abrade the duodenal mucosa. The duodenum was evaluated using histology, immunofluorescence, and western blotting. Serum assays measured glucose, lipid profiles, lipopolysaccharide, and intestinal hormones, while the gut microbiota and metabolomics profiles were analyzed through 16S rRNA gene sequencing and ultra performance liquid chromatography-mass spectrum/mass spectrum, severally.

RESULTS

DMR significantly improved glucose and lipid metabolic disorders in T2D rats. It increased the serum levels of cholecystokinin, gastric inhibitory peptide, and glucagon-like peptide 1, and reduced the length and depth of duodenal villi and crypts. DMR also enhanced the intestinal barrier integrity and reduced lipopolysaccharide translocation. Additionally, DMR modified the gut microbiome and metabolome, particularly affecting the Blautia genus. Correlation analysis revealed significant links between the gut microbiota, metabolites, and T2D phenotypes.

CONCLUSION

This study illustrates that DMR addresses metabolic dysfunctions in T2D through multifaceted mechanisms, highlighting the potential role of the Blautia genus on T2D pathogenesis and DMR's therapeutic impact.

Efficacy of intragastric botulinum toxin A injection on patients with side effects caused by intragastric balloon placement intolerance: A case series study

RATIONALE

Obesity is a global health concern, with intragastric balloon (IGB) placement serving as a nonsurgical intervention for weight management. However, intolerance due to severe gastrointestinal side effects often leads to premature removal, limiting its effectiveness. Botulinum toxin A (BTX-A) injection has been proposed as a potential strategy to improve IGB tolerance by modulating gastric motility.

PATIENT CONCERNS

This study reports a case series of patients who developed severe intolerance to IGB placement, including persistent nausea, vomiting, fluid intolerance, dehydration, and reduced urine output, necessitating medical intervention.

DIAGNOSES

Patients were diagnosed with IGB intolerance due to obstructive gastric effects, characterized by impaired gastric emptying and intolerance to oral fluids, leading to dehydration and electrolyte imbalances.

INTERVENTIONS

A total of 14 patients with IGB intolerance were treated with 500 U of BTX-A injected around the pyloric canal. Prokinetic drugs were also administered to support gastric motility. Patients were monitored for 6 months following the intervention.

OUTCOMES

Among the 14 patients, 11 (78.57%) showed a significant improvement in fluid tolerance within 12 hours of BTX-A injection and were able to retain the IGB without additional complications. Three patients (21.43%) did not improve and required early IGB removal. No major adverse effects related to BTX-A injection were observed.

LESSONS

BTX-A injection appears to be a promising adjunctive therapy to improve IGB tolerance in patients experiencing severe intolerance. These findings suggest a potential role for BTX-A in reducing the need for premature balloon removal, thereby enhancing weight loss outcomes. However, further randomized controlled trials with larger sample sizes are needed to confirm its efficacy, optimize dosage, and establish standardized treatment protocols.

Weight Reduction with GLP-1 Agonists and Paths for Discontinuation While Maintaining Weight Loss

Worldwide, nearly 40% of adults are overweight and 13% are obese. Health consequences of excess weight include cardiovascular diseases, type 2 diabetes, dyslipidemia, and increased mortality. Treating obesity is challenging and calorie restriction often leads to rebound weight gain. Treatments such as bariatric surgery create hesitancy among patients due to their invasiveness. GLP-1 medications have revolutionized weight loss and can reduce body weight in obese patients by between 15% and 25% on average after about 1 year. Their mode of action is to mimic the endogenous GLP-1, an intestinal hormone that regulates glucose metabolism and satiety. However, GLP-1 drugs carry known risks and, since their use for weight loss is recent, may carry unforeseen risks as well. They carry a boxed warning for people with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2. Gastrointestinal adverse events (nausea, vomiting, diarrhea) are fairly common while pancreatitis and intestinal obstruction are rarer. There may be a loss of lean body mass as well as premature facial aging. A significant disadvantage of using these medications is the high rate of weight regain when they are discontinued. Achieving success with pharmacologic treatment and then weaning to avoid future negative effects would be ideal.

Comparison of endoscopic submucosal dissection and transanal endoscopic surgery for the treatment of rectal neoplasia: A systematic review and meta-analysis

BACKGROUND AND AIM

Minimally invasive techniques offer alternatives to conventional surgery in the treatment of early-stage colorectal cancer, reducing morbidity. Transanal Endoscopic Microsurgery (TEM) and Transanal Minimally Invasive Surgery (TAMIS) are widely used, while Endoscopic Submucosal Dissection (ESD) is gaining attention for its ability to achieve complete resection with low recurrence rates. This study compares the efficacy and safety of ESD with Transanal Endoscopic Surgery (TES).

METHODS

The authors performed a systematic review and meta-analysis of comparative studies involving patients with endoscopically resectable rectal lesions. Electronic searches were conducted in MEDLINE, EMBASE, Cochrane, and LILACS. Outcomes included recurrence rate, complete resection, en bloc resection, hospital stay, procedure time, and complication rate.

RESULTS

The analysis included ten observational studies and one Randomized Controlled Trial (RCT) involving 1,094 patients. No significant differences were found in terms of recurrence rate, en bloc resection, R0 resection, and complications between techniques. The RCT showed a shorter procedure time in the TES (RD = 16.6; 95 % CI 8.88 to 24.32; p < 0.0001), whereas observational studies found no significant difference. In addition, observational studies found a shorter hospital stay duration in the ESD (MD = -1.22; 95 % CI -2.11 to -0.33; I2 = 82 %; p < 0.007), while the RCT found no difference.

CONCLUSION

ESD and TES are safe and effective for the treatment of early-stage rectal tumors. Rates of local recurrence, block resection, R0 resection, complications, and procedure time were similar. However, the RCT showed a shorter procedure time with TES, while observational studies showed a shorter hospital stay with ESD.

The Endoscopic Management of Anastomotic Strictures After Esophagogastric Surgery: A Comprehensive Review of Emerging Approaches Beyond Endoscopic Dilation

Anastomotic strictures are a common complication following esophagogastric surgery, with prevalence varying depending on the type of surgery and anatomical site. These strictures can lead to debilitating symptoms such as dysphagia, pain, and malabsorption, significantly impacting patients' quality of life. Endoscopic treatment of anastomotic strictures has established a role as the first-line strategy in this setting instead of revision surgery, offering benefits in terms of lower morbidity. Various endoscopic methods are available for anastomotic stricture management, including balloon dilation, stent placement, the new lumen-apposing metal stent, and endoscopic incision techniques. However, there is currently no strong evidence and established guidelines for the optimal treatment strategy. Available data suggest that endoscopic treatments, when performed in tertiary referral centers, can provide favorable outcomes in terms of symptom relief and reduced need for rescue surgical intervention. Nonetheless, challenges remain regarding the management of recurrent strictures and procedural complications, underscoring the need for a personalized, multidisciplinary approach to optimize clinical outcomes. This review aims to provide an updated overview of endoscopic techniques and available evidence with a focus on the most recent technologies, supporting clinicians in effectively managing anastomotic strictures in complex clinical settings.

Primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a chronic biliary inflammation associated with periductular fibrosis of the intrahepatic and extrahepatic bile ducts leading to strictures, bacterial cholangitis, decompensated liver disease and need for liver transplantation. This rare focal liver disease affects all races and ages, with a predominance of young males. There is an up to 88% association with inflammatory bowel disease. Although the aetiology is unknown and the pathophysiology is poorly understood, PSC is regarded as an autoimmune liver disease based on a strong immunogenetic background. Further, the associated risk for various malignancies, particularly cholangiocellular carcinoma, is also poorly understood. No medical therapy has been approved so far nor has been shown to improve transplant-free survival. However, ursodeoxycholic acid is widely used since it improves the biochemical parameters of cholestasis and is safe at low doses. MRI of the biliary tract is the primary imaging technology for diagnosis. Endoscopic interventions of the bile ducts should be limited to clinically relevant strictures for balloon dilatation, biopsy and brush cytology. End-stage liver disease with decompensation is an indication for liver transplantation with recurrent PSC in up to 38% of patients. Several novel therapeutic strategies are in various stages of development, including apical sodium-dependent bile acid transporter and ileal bile acid transporter inhibitors, integrin inhibitors, peroxisome proliferator-activated receptor agonists, CCL24 blockers, recombinant FGF19, CCR2/CCR5 inhibitors, farnesoid X receptor bile acid receptor agonists, and nor-ursodeoxycholic acid. Manipulation of the gut microbiome includes faecal microbiota transplantation. This article summarizes present knowledge and defines unmet medical needs to improve quality of life and survival.

Management of gastrointestinal bleed in the intensive care setting, an updated literature review

Gastrointestinal (GI) bleeding is a critical and potentially life-threatening condition frequently observed in the intensive care unit (ICU). This literature review consolidates current insights on the epidemiology, etiology, management, and outcomes of GI bleeding in critically ill patients. GI bleeding remains a significant concern, especially among patients with underlying risk factors such as coagulopathy, mechanical ventilation, and renal failure. Managing GI bleeding in the ICU requires a multidisciplinary approach, including resuscitation, endoscopic intervention, pharmacologic therapy, and sometimes surgical procedures. Even with enhanced management strategies, GI bleeding in the ICU is associated with considerable morbidity and mortality, particularly when complicated by multi-organ failure. This review reiterates the need for adequate resuscitation and interventions in managing GI bleeding in critically ill patients, aiming to enhance survival rates and improve the quality of care within the ICU setting.

[Laparoscopic management of gastric schwannoma]

Background

Gastric schwannoma is a rare GI tract tumor. Commonly, cases are asymptomatic and often misdiagnosed as gastrointestinal stromal tumors (GIST) or gastric leiomyomas.

Clinical case

A 34-year-old female presented to the clinic for a gastric sleeve for obesity. Preoperatively, there was a GIST misdiagnosis. A CT scan showed a 16 mm gastric tumor in the lesser curvature adjacent to segment III of the liver. Endoscopic ultrasound showed a lesion arising from the muscularis mucosa. The biopsy was positive for spindle cells. The patient underwent a laparoscopic resection and Roux-en-Y gastric bypass. The pathology report showed S100-positive spindle cells compatible with gastric schwannoma.

Conclusions

Like our case, gastric schwannomas are usually asymptomatic and arise in middle-aged women. However, their submucosal location in imaging studies, even endoscopic ultrasound, often leads to misdiagnosis. Postoperative pathology and immunohistochemical examinations are critical for final diagnosis and distinguishing features of other malignant stromal cell tumors. Care must be taken in cases with prominent lymph nodes on diagnostic laparoscopy.

Postoperative Aspiration Pneumonia Among Adults Using GLP-1 Receptor Agonists

Importance

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have been increasingly prescribed for weight management in recent years. However, little is known about whether preoperative GLP-1 RA use is associated with a greater risk of complications after surgery.

Objective

To investigate whether preoperative GLP-1 RA use is associated with postoperative aspiration pneumonia among patients undergoing common surgical procedures.

Design, Setting, and Participants

This retrospective cohort study, conducted using MarketScan commercial claims databases, included patients who underwent 1 of 14 common surgical procedures from April 1, 2020, to September 30, 2022. Individuals who were younger than 18 years, underwent multiple surgical procedures, or had a preoperative history of pneumonia or acute respiratory failure in the 90 days preceding surgery were excluded. Data were analyzed from December 2023 to March 2024.

Main Outcome and Measures

The primary outcome was aspiration pneumonia in the 30-day postoperative period. Multivariable logistic regressions were performed, adjusting for patient and surgical characteristics.

Results

This study included 366 476 patients (median age, 53 years [IQR, 43-62 years]), of whom 56.4% were women. In the cohort, 5931 patients (1.6%) had a preoperative prescription for a GLP-1 RA. Patients using GLP-1 RAs were more likely to be female (3502 [59.0%] vs 203 288 [56.4%]) and diagnosed with both obesity and diabetes (2819 [47.5%] vs 24 635 [6.8%]) compared with nonusers. Adjusted analysis showed no significant differences in the odds of postoperative pneumonia (odds ratio, 0.78; 95% CI, 0.57-1.06; P = .12) between GLP-1 RA users and nonusers.

Conclusions and Relevance

This cohort study found no significant association between the preoperative use of GLP-1 RAs and short-term postoperative aspiration pneumonia despite growing concerns about the adverse effects of these medications after surgery. This finding suggests that it may be beneficial to reassess the preoperative withholding guidelines for GLP-1 RAs.

What is the evidence regarding the safety of new obesity pharmacotherapies

The use of gut-hormone receptors agonists as new therapeutic options for obesity and some of its related comorbidities, such as type 2 diabetes, has resulted in an unprecedented efficacy in the medical management of people living with obesity (PLWO). Appraisal of the safety of these drugs is of utmost importance considering the large number of PLWO, and the potentially long exposure to these pharmacotherapies. In this narrative review we summarize the evidence on the safety of liraglutide, semaglutide, and tirzepatide as derived from randomized clinical trials conducted in adults living with obesity. Additionally, the safety of these drugs is put into perspective with that of other drugs currently approved for the treatment of PLWO. Overall, the available data support a favorable efficacy versus safety balance for gut-hormone hormone receptor analogues in the treatment of these subjects. Nonetheless, it should be acknowledged that in the context of a chronic disease that has reached epidemic proportions, data from randomized clinical trials aimed primarily at proving the efficacy of these drugs may have been insufficient to unveil all the safety issues. Thus, continuous surveillance on the adverse effects of liraglutide, semaglutide, and tirzepatide is required as we use these drugs in a broader population than that represented in currently available clinical trials.

Innovative Endoscopic Management of Recurrent Gastrogastric Fistula Post-Roux-en-Y Gastric Bypass Patient Using Cardiac Septal Occluder and Lumen-Apposing Metal Stent

Gastrogastric fistula (GGF) is a rare complication of post-Roux-en-Y gastric bypass, often challenging to manage. This case report presents a 63-year-old patient with recurrent GGF and gastrojejunal stricture, refractory to prior endoscopic treatments. Using a minimally invasive approach with atrial septal defect closure device and a lumen-apposing metal stent, the fistula was successfully closed, and stricture relieved. The patient reported complete symptom resolution at follow-up. This innovative approach of combining a cardiac septal occluder and lumen-apposing metal stent for management of complex GGF cases offers a promising alternative to surgical interventions.

Perioperative glucagon-like peptide-1 receptor agonist use and retained gastric contents: A retrospective analysis of patients undergoing elective upper endoscopy

INTRODUCTION

Glucagon-like peptide-1 receptor (GLP-1R) agonists have been increasingly prescribed for weight loss and glycemic control. The potential side effect of slowed gastric emptying may increase risk of regurgitation and aspiration. Our primary aim was to investigate the incidence of retained gastric contents (RGCs) among appropriately fasted patients taking a GLP-1R agonist compared to those not taking a GLP-1R agonist presenting for upper gastrointestinal endoscopy (UE).

METHODS

A retrospective chart review of patients undergoing UE was conducted. For the GLP-1R group, included were patients aged 18 years or older who had documentation of taking a GLP-1R agonist within 30 days prior to the procedure, adhered to standard fasting guidelines, and had clear documentation in the electronic medical record of gastric findings during endoscopy. This group was compared to a group of agematched controls. The primary outcome was the incidence of RGCs. Secondary outcome included a propensity-weighted analysis of the odds ratio of taking a GLP-1R and having RGCs.

RESULTS

Included were 940 patients who presented for UE between July 2022 and December 2023 (470 GLP-1R and 470 controls). RGCs were found in 59/470 (12.6 %) of GLP-1R patients compared to 26/470 (5.5 %) of controls (P < 0.001). Propensity-weighted analysis found a significant association between the use of GLP-1R and retained gastric contents [OR = 1.92, 95 % CI (1.04, 3.53)].

CONCLUSIONS

A higher incidence of RGCs was found in appropriately fasted patients on a GLP-1R agonist who presented for UE. After controlling for the differences between the two study groups, RGC's were correlated to GLP-1R agonist use. Anesthesiologists should remain vigilant regarding a potential increased risk of RGCs in appropriately fasted patients taking a GLP-1R agonist who present for surgery.

Weight and cardiometabolic effects of a novel oral shape-shifting superabsorbent hydrogel capsule: Prespecified and exploratory analysis of the Epitomee capsule RESET study

Background

Management of obesity potentially improves cardiometabolic risk factors in patients with metabolic syndrome (MetS). The Epitomee capsule is a non-pharmacological, biodegradable device treatment for weight reduction in patients with overweight and obesity.

Methods

This secondary analysis of the Randomized Evaluation of Safety and Efficacy of the Epitomee capsule Trial (RESET) (a randomized, 24-week, multicenter, placebo-controlled, double-blind trial that enrolled 279 adults aged ≥18 years with a BMI of 27-40 kg/m2) evaluated changes in cardiometabolic parameters in participants treated with Epitomee or placebo combined with lifestyle counseling among (a) the entire RESET study population, and (b) participants meeting diagnostic criteria for prediabetes. Predefined and exploratory endpoints included changes in waist circumference, glycemic parameters, blood pressure, and lipid blood levels; this analysis also assessed percent weight loss in participants with MetS.

Results

Waist circumference, systolic and diastolic blood pressure and some measures of glycemia and lipids, improved with both Epitomee and placebo with no significant differences. Participants with prediabetes treated with Epitomee showed significantly greater reductions in HOMA-IR (p < 0.007) and insulin levels (p < 0.003) than the placebo group. Participants with MetS at baseline experienced significantly greater percent change in initial weight when treated with the Epitomee capsule (n = 27) compared to placebo (n = 31), -8.3% vs -5.2 %, respectively (p < 0.0004). Similar percentages of participants with MetS in both groups achieved ≥5 % weight reduction (59.3 % and 54.8 %, in Epitomee and placebo groups respectively). Significantly more participants with MetS treated with Epitomee achieved ≥10 % weight reduction compared with those treated with placebo (40.7 % vs. 6.5 %, respectively, p < 0.002).

Conclusion

Treatment with either Epitomee and placebo combined with lifestyle improve cardiometabolic risk factors. Compared to placebo, Epitomee significantly reduced HOMA-IR and insulin levels in participants with prediabetes. Among participants with MetS, Epitomee significantly reduced body weight [ClinicalTrials.gov ID NCT04222322].

Comparative effectiveness of balloons, adjustable balloons, and endoscopic sleeve gastroplasty: a network meta-analysis of randomized trials

BACKGROUND AND AIMS

Individual randomized controlled trials (RCTs) and pairwise meta-analyses do not compare all commercially available endoscopic bariatric therapies (EBTs) head-to-head. Therefore, the choice among them is currently made by inference or indirect data. We therefore assessed the comparative efficacy and safety of EBTs through a network meta-analysis.

METHODS

We searched MEDLINE, EMBASE, and Cochrane CENTRAL from inception for intragastric balloons (IGBs) and from 2013 for endoscopic sleeve gastroplasty (ESG) until May 2023. Only RCTs comparing any of the currently commercially available EBTs with controls were considered eligible. Outcomes included percentage of total weight loss (%TWL), serious adverse events (SAEs), and intolerability.

RESULTS

We identified 821 citations, of which 10 and 8 were eligible for the qualitative and quantitative analysis, respectively. Considering %TWL at the time of IGB removal, all EBTs were associated with statistically higher %TWL than controls. There were no significant differences among EBTs. However, considering the %TWL at the follow-up closest to 12 months, both ESG and the Spatz3 gastric balloon (Spatz Medical, Fort Lauderdale, Fla, USA) were more effective than the Orbera gastric balloon (Apollo Endosurgery, Austin, Tex, USA), with no statistical difference between ESG and Spatz3. For both outcomes, P score and ranking score suggested that ESG was probably associated with a greater weight loss (.889272 and .899469, respectively), followed by Spatz3 (.822894 and .842773, respectively), and Orbera (.536968 and .507165, respectively).

CONCLUSIONS

All currently available EBTs approved by the U.S. Food and Drug Administration are more effective than both diet plus lifestyle intervention and sham procedures with an acceptable safety profile. ESG seems the most effective and may be prioritized for patients fit for both ESG and IGBs. Direct controlled trials between EBTs are warranted to confirm these findings.

Postcholecystectomy Gut Microbiome Changes and the Clinical Impact: A Systematic Review With Narrative Synthesis

BACKGROUND

Cholecystectomy (CCE) can affect the enterohepatic circulation of bile acids and result in gut microbiome changes. This systematic review aimed to clarify the effect of CCE on gut microbiome composition and its clinical impact.

METHOD

A systematic search was conducted in PubMed, Web of Science, and Scopus, combining keywords such as "cholecystectomy" or "post-cholecystectomy" with "gut microbiome," "stool microbiome," or "gut dysbiosis." Data were extracted and synthesized using narrative review. Study quality was assessed using the Newcastle-Ottawa scale.

RESULTS

A total of 1373 articles were screened and 14 studies were selected. Significant but inconsistent microbiome changes were reported. Changes were observed in alpha and beta diversity. At phylum level, an increase in Bacteroides and Ascomycota, decrease in Firmicutes, Actinomycetes, and Basidiomycota, and both increase and decrease in Fusobacteria were reported. At genus level, an increase in Prevotella and a decrease in Faecalibacterium were reported. In post-CCE diarrhea, decreased beta diversity, a decreased F/B ratio, an increase in Prevotella, an increase in Phocaeicola vulgatus, and a decrease in Prevotella copri were noted. For post-CCE syndrome, a higher abundance of Proteobacteria and decreased Firmicutes/Bacteroides (F/B) ratio were reported. A decreased relative abundance of Bifidobacterium longum subsp. longum from controls to CCE without colonic neoplasia to CCE with colonic neoplasia, and an increased abundance of Candida glabrata from controls, to CCE without colonic neoplasia and CCE with colonic neoplasia, were reported.

CONCLUSION

Patients who underwent CCE had significant gut dysbiosis. However, current studies could not clarify the detailed gut microbial structural and functional changes associated with CCE.

Endoscopic Vacuum Therapy for the Treatment of Atrial Fibrillation Ablation-Induced Esophageal Perforation

Esophageal thermal injury from atrial fibrillation ablation is not uncommon; however, full-thickness perforation is rare. Such injuries are often treated with surgical revision, stent placement, or medical management. Endoscopic vacuum therapy is a novel and emerging technique to repair transmural gastrointestinal defects; however, its use in the management of esophageal thermal ulceration and perforation after a cardiac ablation procedure is limited. We present a 52-year-old man who developed a refractory esophageal perforation and leak secondary to atrial fibrillation radiofrequency ablation that was successfully treated with endoscopic vacuum therapy, demonstrating a minimally invasive endoscopic treatment modality when alternative therapies fail.

Endoscopic Weight Loss Options

Endoscopic therapies for obesity have emerged as safe, effective, and minimally-invasive alternatives to traditional approaches, including lifestyle modification, anti-obesity medications, and bariatric surgery. Currently, in the United States, 2 types of endoscopic weight loss therapies are Food and Drug Administration (FDA)-approved and are commercially available-intragastric balloons and endoscopic gastric remodeling. These devices and procedures are associated with approximately 10% to 20% total weight loss at 1 year and have distinct technical features, benefits, and risks that providers should be familiar with. This article will focus on the primary FDA-approved endoscopic treatments for obesity and also cover those in development.

Tissue Remodeling for a More Homogenous Ablation in Transoral Outlet Reduction Using Suturing and Noncontact Argon Plasma Coagulation

The study is the first to assess the argon-plasma coagulation ArC Smart linear beam for mucosal ablation in transoral outlet reduction for weight regain after Roux-en-Y gastric bypass. The noncontact design of the linear beam can enhance tissue healing and remodeling of gastrojejunal anastomosis by causing a uniform scarring with minimal tissue injury. We followed patients for 45 days, during which none experienced gastrointestinal bleeding, stenosis, or ulcers, reporting 9.8% average of total body weight loss. The ArC Smart beam may offer a safer, more effective alternative to traditional argon-plasma coagulation for transoral outlet reduction, with better reduction in weight loss, although comparative studies are needed.

Glucagon-Like Peptide Receptor Agonists Use Before Endoscopy Is Associated With Low Retained Gastric Contents: A Multicenter Cross-Sectional Analysis

INTRODUCTION

While ubiquity of glucagon-like peptide receptor agonists (GLP1-RAs) is rising, guidance from the gastroenterology societies and American Society of Anesthesiologist (ASA) remains in conflict on recommendations regarding preoperative holding before endoscopy. The aim of this study was to address this by evaluating the effect of GLP1-RAs on gastric retention during upper endoscopy.

METHODS

This multicenter cross-sectional study included patients on confirmed GLP1-RAs receiving an endoscopy from 2021 to 2023. Demographics, prescribing practices, and procedure outcomes were captured. GLP1-RA management of preoperative holding was retroactively classified per ASA guidance. Multivariable logistic regression was performed to assess factors influencing retained gastric contents.

RESULTS

Of 815 patients, 70 (8.7%) had retained gastric contents on endoscopy of whom 65 (93%) had type 2 diabetes mellitus. Only 1 (1.4%) of these patients required unplanned intubation, and none had aspiration events. Those with GLP1-RA held per ASA guidance (406, 49.8%) were less likely to have retained contents (4.4% vs 12.7%, P < 0.001), but there were no significant differences to intubation (0% vs 2%, P = 0.53) or aborting procedure rates (28% vs 18%, P = 0.40) due to gastric retention. On multivariable analysis, likelihood of food retention increased 36% (95% confidence interval 1.15-1.60) for every 1% increase in hemoglobin A1C after adjusting for GLP1-RA type and preoperative medication hold.

DISCUSSION

In this multicenter study, very low rates of retained gastric contents were seen during endoscopy in patients on GLP1-RAs and most were in patients with type 2 diabetes mellitus. Our findings suggest an individualized approach rather than universal preoperative holding of medications before endoscopy.

A Meta-analysis of Severe Acute Respiratory Syndrome Coronavirus 2 Anti-spike Immunoglobulin G Antibody Durability up to 9 Months After Full Vaccination in Adults

This meta-analysis aims to estimate temporal decline in vaccine-induced antibodies against severe acute respiratory syndrome coronavirus 2 up to 9 months after full vaccination contributing to overall understanding of coronavirus disease 2019 infection protection. We identified 15 eligible studies and calculated standardized mean differences (SMD) between antibody concentrations at 1, 3, 6, and 9 months after full vaccination. Overall SMD between 1 month after vaccination and 3 months was -1.14 (95% CI -1.52, -0.76), at 6 months was -1.06 (95% CI -1.30, -0.81), and at 9 months, it was -0.77 (95% CI -0.94, -0.60) suggesting a moderate decline over time.

Efficacy of hemostatic powder monotherapy versus conventional endoscopic treatment for nonvariceal GI bleeding: a meta-analysis and trial sequential analysis

BACKGROUND AND AIMS

Hemostatic powder (HP) is a novel hemostasis modality for nonvariceal GI bleeding. This meta-analysis was performed to evaluate the efficacy of HP monotherapy versus conventional endoscopic treatment (CET) for nonvariceal GI bleeding.

METHODS

PubMed, EMBASE, and Cochrane Library databases were systematically searched from inception to October 16, 2023. The primary outcomes were the initial hemostatic rate and the 30-day recurrent bleeding rate. After the meta-analysis, a trial sequential analysis (TSA) was also conducted to decrease the risk of random errors and validate the result.

RESULTS

The meta-analysis included 8 studies, incorporating 653 patients in total. Given significant heterogeneity, all analyses were segregated into malignancy-related and nonmalignancy-related GI bleeding lesions. For the former, HP monotherapy significantly improved the initial hemostasis rate and 30-day recurrent bleeding rate compared with CET (relative risk [RR], 1.50; 95% confidence interval [CI], 1.28-1.75; P < .001; RR, .32; 95% CI, .12-.86; P = .02, respectively), and TSA supported the results. For nonmalignancy-related GI bleeding, HP monotherapy and CET have similar initial hemostasis and 30-day recurrent bleeding rates (RR, 1.08; 95% CI, .98-1.19; P = .11; RR, 1.15; 95% CI, .46-2.90; P = .76, respectively), but the TSA failed to confirm the results.

CONCLUSIONS

HP monotherapy surpassed CET in terms of the initial hemostasis rate and 30-day recurrent bleeding rate for patients with malignancy-related GI bleeding. However, their relative efficacy for nonmalignancy-related GI bleeding remains unresolved.

Variation in acute cholecystitis outcomes and processes of care in patients with cancer

BACKGROUND

Patients undergoing active cancer therapy or with metastatic cancer are at increased risk for acute cholecystitis and often present to general surgeons for evaluation and management. There is a paucity of data regarding the treatment processes used in these patients and the clinical outcomes achieved. Optimal management of acute cholecystitis in patients with cancer requires understanding their unique risk profile and options for treatment.

METHODS

Emergency general surgery data were collected at 10 hospitals from July 1, 2019, to February 29, 2024. Patients presenting with acute cholecystitis were selected for analysis. Propensity score matching was used to create matched cohorts of patients by the presence or absence of an active malignancy. The primary outcome was 30-day mortality. Secondary outcomes included complications, length of stay, readmission, and discharge disposition. Processes investigated include treatment modality, time to operation, and surgical technique.

RESULTS

The analysis included 8,673 patients. Mean age was 53.2 ± 19 years, 61.4% were female, and 17.8% were non-White. In total, 3.3% of patients had an active malignancy. Risk-adjusted 30-day mortality was higher in the cancer cohort (odds ratio: 5.85, 95% confidence interval: 2.38-14.4, P < .001). Patients with cancer also had higher rates of infectious complications (odds ratio: 2.55, 95% confidence interval: 1.54-4.2, P < .001), including sepsis (odds ratio: 2.95, 95% confidence interval: 1.61-5.39, P < .001) and pneumonia (odds ratio: 6.67, 95% confidence interval: 1.75-25.3, P < .005). Patients with cancer were more likely to receive nonoperative management (odds ratio: 2.85, 95% confidence interval: 2.11-3.84, P < .001).

CONCLUSION

Patients with cancer presenting with acute cholecystitis experience worse clinical outcomes after controlling for other factors. Furthermore, there is variation in the treatment process with increased rates of nonoperative management. These results have implications for the management of this population, particularly in relation to the impact on concurrent oncologic treatment plans.

Perioperative and periprocedural management of GLP-1 receptor-based agonists and SGLT2 inhibitors: narrative review and the STOP-GAP and STOP DKA-2 algorithms

The GLP-1 receptor-based agonists (GLP-1RAs) and SGLT2 inhibitors (SGLT2i) are major twenty first century breakthroughs in diabetes and obesity medicine but there are important safety considerations regarding the perioperative and periprocedural management of individuals who are treated with these agents. GLP-1RAs have been linked to an increased risk of retained gastric contents and pulmonary aspiration while SGLT2i can be associated with diabetic ketoacidosis. This manuscript provides a narrative review of the available evidence for perioperative and periprocedural risks in people prescribed GLP-1RAs and SGLT2i. The authors provide expert opinion-driven recommendations and algorithms on how to safely manage GLP-1RAs and SGLT2i under perioperative/periprocedural settings.

The value of a nomogram model based on CT imaging features in differentiating duodenal gastrointestinal stromal tumors from pancreatic head neuroendocrine tumors

OBJECTIVE

To construct a nomogram model based on multi-slice spiral CT imaging features to predict and differentiate between duodenal gastrointestinal stromal tumors (GISTs) and pancreatic head neuroendocrine tumors (NENs), providing imaging evidence for clinical treatment decisions.

METHODS

A retrospective collection of clinical information, pathological results, and imaging data was conducted on 115 cases of duodenal GISTs and 76 cases of pancreatic head NENs confirmed by surgical pathology at Zhongshan Hospital Fudan University from November 2013 to November 2022. Comparative analysis was performed on the tumor's maximum diameter, shortest diameter, long diameter/short diameter ratio, tumor morphology, tumor border, central position of the lesion, lesion long-axis direction, the relationship between tumor and common bile duct (CBD), duodenal side ulceration of the lesion, calcification, cystic and solid proportion within the tumor, thickened feeding arteries, tumor neovascularization, distant metastasis, and CT values during plain and enhanced scans in arterial and venous phases. Statistical analysis was conducted using t-tests, Mann-Whitney U tests, and χ2 tests. Univariate and multivariate logistic regression analyses were used to identify independent predictors for differentiating duodenal GISTs from pancreatic head NENs. Based on these independent predictors, a nomogram model was constructed, and the receiver operating characteristic (ROC) curve was used to evaluate the diagnostic performance of the model. The nomogram was validated using a calibration curve, and decision curve analysis was applied to assess the clinical application value of the nomogram.

RESULTS

There were significant differences in the duodenal GISTs group and the pancreatic head NENs group in terms of longest diameter (P < 0.001), shortest diameter (P < 0.001), plain CT value (P < 0.001), arterial phase CT value (P < 0.001), venous phase CT value (P = 0.002), lesion long-axis direction (P < 0.001), central position of the lesion (P < 0.001), the relationship between tumor and CBD(< 0.001), border (P = 0.004), calcification (P = 0.017), and distant metastasis (P = 0.018). Multivariate logistic regression analysis identified uncertain location (OR 0.040, 95% CI 0.003-0.549), near the duodenum (OR 0, 95% CI 0-0.009), with the lesion long-axis direction along the pancreas as a reference, along the duodenum (OR 0.106, 95% CI 0.010-1.156) or no significant difference (OR 4.946, 95% CI 0.453-54.017), and the relationship between tumor and CBD (OR 0.013, 95% CI 0.001-0.180), shortest diameter (OR 0.705, 95% CI 0.546-0.909), and calcification (OR 18.638, 95% CI 1.316-263.878) as independent risk factors for differentiating between duodenal GISTs and pancreatic head NENs (all P values < 0.05). The combined diagnostic model's AUC values based on central position of the lesion, calcification, lesion long axis orientation, the relationship between tumor and CBD, shortest diameter, and the joint diagnostic model were 0.937 (0.902-0.972), 0.700(0.624-0.776), 0.717(0.631-0.802), 0.559 (0.473-0.644), 0.680 (0.603-0.758), and 0.991(0.982-0.999), respectively, with a sensitivity of 97.3% and a specificity of 93.0% for the joint diagnostic model. The nomogram model's AUC value was 0.985(0.973-0.996), with a sensitivity and specificity of 94.7% and 93.9%, respectively. The calibration curve indicated good agreement between predicted and actual risks. Decision curve analysis verified the clinical application value of the nomogram.

CONCLUSION

The nomogram model based on CT imaging features effectively differentiates between duodenal GISTs and pancreatic head NENs, aiding in more precise clinical treatment decisions.

Diagnostic ability and adverse events of mucosal incision-assisted biopsy for gastric subepithelial tumors: Systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to evaluate the diagnostic ability and examine the efficacy of countermeasures to adverse events of mucosal incision-assisted biopsy (MIAB) for gastric subepithelial tumors (SETs).

METHODS

We performed a literature search and identified 533 relevant articles. Eleven articles, including 339 lesions, were ultimately used in the meta-analysis. The primary end-point was the pathological diagnostic rate of MIAB for gastric SETs, and the secondary end-point was the incidence of adverse events. The efficacy of acid secretion inhibitors in preventing postoperative bleeding and that of local injection before incision to prevent perforation were also examined.

RESULTS

Nine studies were conducted in Japan and two in South Korea, of which only two were prospective studies. The pooled pathological diagnostic rate of MIAB for gastric SETs was 87.8% (95% confidence interval [CI] 80.2-94.0; I2 = 68.7%). The adverse event rate of the pooled population was 0.2% (95% CI 0-1.4; I2 = 0%). The acid secretion inhibitors significantly reduced postoperative bleeding (odds ratio 0.06, 95% CI 0.01-0.66, P = 0.02). Perforation occurred in 0% and 2.6% of the local and nonlocal injection cohorts, respectively, and the pathological diagnostic rates were 50% and 66.7%, respectively.

CONCLUSIONS

MIAB is a reliable technique with a favorable diagnostic rate and few adverse events. Acid secretion inhibitors may effectively prevent postoperative bleeding; however, the efficacy of local injection remains unclear. This technique could be an option for tissue sampling in gastric SETs.

A single-center experience of safety and effectiveness of adjustable intragastric balloon in patients with super obesity

BACKGROUND

The Spatz3® Intragastric Adjustable Balloon (SAB) offers a novel approach to weight loss in super obese patients [body mass index (BMI) ≥50 kg/m 2 ]. This study evaluates the safety, effectiveness, and predictors of success of SAB in this population.

METHODS

A retrospective study was conducted at King Abdullah Medical City, Makkah, Saudi Arabia, involving 94 patients with SAB implantation. Weight loss metrics (%EWL, %TBWL), complications, and predictors of adverse events were analyzed.

RESULTS

Eleven patients required early SAB removal due to severe symptoms. Complications included gastrointestinal bleeding (3.2%), gastric ulcer/erosion (27.7%), and deflation (5.3%). Significant weight loss was observed at 6 and 12 months. The mean absolute weight loss was 22.03 kg at 12 months, with %EWL of 19.27%. Early weight loss at 3 months predicted long-term success. SAB adjustments did not significantly impact outcomes. Post SAB, 57% of patients proceeded to laparoscopic sleeve gastrectomy (LSG) with rare postoperative complications (2.9%).

CONCLUSION

SAB is safe and effective for patients with BMI ≥50 kg/m 2 , achieving significant weight loss at 12 months. Early weight loss predicts long-term success, and subsequent LSG can be performed without significant complications. Further research should explore long-term outcomes and comparative analyses.

Endoscopic vacuum therapy for gastrointestinal transmural defects: a literature review

Endoscopic vacuum therapy (EVT) has emerged as a transformative approach for managing gastrointestinal (GI) transmural defects, offering a less invasive and more promising alternative to surgery. Initially developed to address anastomotic leaks after rectal surgery, the application of EVT has expanded to include other locations within the GI tract. This review investigated the principles, indications, procedures, outcomes, challenges, and future perspectives of EVT for the management of GI transmural defects. In conclusion, EVT has demonstrated favorable outcomes in GI defect closure, with reduced complications, shortened hospital stay, and decreased morbidity rates as compared with conventional treatments. Although EVT faces challenges in some specific anatomical locations and in managing severe complications such as major bleeding, ongoing advancements in technology and standardization efforts offer promise for broader indications and better outcomes. Future perspectives include exploring novel EVT devices, refining patient selection criteria and pre-emptive applications, and standardizing procedural protocols.

Point-of-care ultrasound training among anesthesiology residency programs in the United States

BACKGROUND

Point-of-care ultrasound (POCUS) use has become ubiquitous in the field of anesthesiology. However, POCUS training curriculum in anesthesiology residencies vary widely. We performed a survey study to better understand the structure of existing POCUS training and identify barriers to instituting a POCUS curriculum for anesthesiology trainees.

Molecular Abnormalities and Carcinogenesis in Barrett's Esophagus: Implications for Cancer Treatment and Prevention

BACKGROUND

Barrett's esophagus (BE) is described by the transformation of the normal squamous epithelium into metaplastic columnar epithelium, driven by chronic gastroesophageal reflux disease (GERD). BE is a recognized premalignant condition and the main precursor to esophageal adenocarcinoma (EAC). Understanding the molecular mechanisms underlying BE carcinogenesis is crucial for improving prevention, surveillance, and treatment strategies.

METHODS

This narrative review examines the molecular abnormalities associated with the progression of BE to EAC.

RESULTS

This study highlights inflammatory, genetic, epigenetic, and chromosomal alterations, emphasizing key pathways and biomarkers. BE progression follows a multistep process involving dysplasia and genetic alterations such as TP53 and CDKN2A (p16) mutations, chromosomal instability, and dysregulation of pathways like PI3K/AKT/mTOR. Epigenetic alterations, including aberrant microRNA expression or DNA methylation, further contribute to this progression. These molecular changes are stage-specific, with some alterations occurring early in BE during the transition to high-grade dysplasia or EAC. Innovations in chemoprevention, such as combining proton pump inhibitors and aspirin, and the potential of antireflux surgery to halt disease progression are promising. Incorporating molecular biomarkers into surveillance strategies and advancing precision medicine may enable earlier detection and personalized treatments.

CONCLUSIONS

BE is the primary preneoplastic condition for EAC. A deeper understanding of its molecular transformation can enhance surveillance protocols, optimize the management of gastroesophageal reflux inflammation, and refine prevention and therapeutic strategies, ultimately contributing to a reduction in the global burden of EAC.

Short-term and long-term management of caustic-induced gastrointestinal injury: An evidence-based practice guidelines

The Indian Society of Gastroenterology has developed an evidence-based practice guideline for the management of caustic ingestion-related gastrointestinal (GI) injuries. A modified Delphi process was used to arrive at this consensus containing 41 statements. These statements were generated after two rounds of electronic voting, one round of physical meeting, and extensive review of the available literature. The exact prevalence of caustic injury and ingestion in developing countries is not known, though it appears to be of significant magnitude to pose a public health problem. The extent and severity of this preventable injury to the GI tract determine the short and long-term outcomes. Esophagogastroduodenoscopy is the preferred initial approach for the evaluation of injury and contrast-enhanced computed tomography is reserved only for specific situations. Low-grade injuries (Zargar grade ≤ 2a) have shown better outcomes with early oral feeding and discharge from hospital. However, patients with high-grade injury (Zargar grade ≥ 2b) require hospitalization as they are at a higher risk for both short and long-term complications, including luminal narrowing. These strictures can be managed endoscopically or surgically depending on the anatomy and extent of stricture, expertise available and patients' preferences. Nutritional support all along is crucial for all these patients until nutritional autonomy is established.

Addressing recurrent weight gain after Roux-en-Y gastric bypass: efficacy of a dual surgical approach-short-term results of a single-center cohort study

BACKGROUND

There is no gold standard for recurrent weight gain following Roux-en-Y gastric bypass (RYGB). Combining jejuno-jejunostomy distalization type 1 (JJD1) and sleeve resection of the gastrojejunostomy and gastric pouch (GJ-P) may be a potential approach for these patients.

OBJECTIVES

To describe 1-year perioperative and nutritional outcomes of patients who underwent JJD1 with sleeve resection of the GJ-P.

SETTING

High-volume academic bariatric center of excellence.

METHODS

Patients with recurrent weight gain after RYGB who underwent JJD1 with sleeve resection of the GJ-P from 2020 to 2022 were included and studied for 1 year postoperatively. During the procedure, we aimed for a total alimentary limb length (TALL) of 350-500 cm, a new common channel (CC) of 200-350 cm, and a gastrojejunostomy <2 cm in diameter.

RESULTS

A total of 61 patients underwent this combined revisional procedure. The median preoperative body mass index (BMI) was 42.59 kg/m2. The median lengths of the biliopancreatic limb (BPL) before and after distalizatiovn were 50 cm (interquartile range [IQR]: 42.5-75) and 175 cm (IQR: 150-200), respectively. After revision, the median new CC was 270 cm (IQR: 250-300) and the median TALL was 400 cm (interquartile range [IQR]: 362.5-450). The median total small bowel length (TSBL) was 580 cm (IQR 550-640 cm), and the median BPL/TSBL ratio was .32 (IQR .29-.34). At 1, 6, and 12 months, the median BMI of the cohort was reduced to 39.14, 35.55, and 32.9 kg/m2, respectively. At 1 year, the total weight loss (%TWL) was 22.18%. Only 3 (n = 3) patients developed major complications at 1 year. After distalization, the resolution of all obesity-related co-morbidities improved, including type 2 diabetes (3.2%), sleep apnea (13.1%), hypertension (HTN) (11.4%), and hyperlipidemia (HLD) (1.6%).

CONCLUSIONS

The combination of JJD1 and sleeve resection of the GJ-P for RYGB revision was safe and effective, with substantial improvement in weight loss at 1 year.

Strategies to Manage Obesity: Endoscopic Bariatric and Metabolic Therapies

Over the past two decades, numerous endoscopic bariatric and metabolic therapies (EBMTs) have been developed with the goal of providing additional effective and safe tools for the treatment of obesity. These treatments are an ultra-minimally invasive option for patients with class I, class II, and class III obesity. Many of these EBMTs can be utilized as primary therapies for treatment-naïve patients or as a treatment for weight regain after bariatric surgery. While the role of EBMTs is not to compete with bariatric surgery, which provides the most effective treatment of obesity, they provide greater weight loss than lifestyle modifications and pharmacotherapy; additionally, when combined with pharmacotherapy, they may help achieve surgical weight loss without the risk of invasive surgery. This review summarizes the most currently available EBMTs, including intragastric balloons (IGBs), endoscopic sleeve gastroplasty (ESG), and endoscopic surgical revision procedures for treating obesity.

Impact of Weight Loss on Metabolic Dysfunction Associated Steatohepatitis and Hepatic Fibrosis

PURPOSE OF REVIEW

This review highlights the impact of weight loss on metabolic dysfunction associated steatotic liver disease (MASLD), formally known as nonalcoholic fatty liver disease (NAFLD), and its progressive form of metabolic dysfunction associated steatohepatitis (MASH), formally known as nonalcoholic steatohepatitis (NASH). The effects of weight loss, as achieved through lifestyle modification, pharmacotherapy, bariatric surgery or endobariatric procedures on MASLD/MASH and hepatic fibrosis are discussed.

RECENT FINDINGS

Although foundational in the treatment of MASLD/MASH, weight loss through life-style modification is challenging for most patients to achieve and sustain long-term. In patients with MASLD/MASH, a multidisciplinary approach may facilitate success with lifestyle modification, individualized consideration of pharmacotherapies and/or surgical approaches that have potential to lend an improvement in MASLD/MASH. Effective and sustained weight loss improves hepatic steatosis, steatohepatitis and potentially hepatic fibrosis. Improvement in hepatic fibrosis can improve patient-related outcomes associated with complications of advanced hepatic fibrosis or cirrhosis in patients with MASLD/MASH. Identifying risk factors that influence MASLD/MASH and early implementation of therapeutic weight loss strategies may improve chronic liver injury and decrease risk for adverse clinical outcomes related to progressive hepatic fibrosis attributable to MASLD/MASH.

Comparison of Weight Loss and Improvement in Metabolic Comorbidities Between Endoscopic Gastroplasty and Lifestyle Modifications: A Meta-analysis

BACKGROUND

Endoscopic gastroplasty (EG) is a less invasive method for managing obesity compared with bariatric surgery. However, evidence on the use of EG is still scarce. This study aims to review existing evidence comparing EG with lifestyle modifications (LM) in terms of weight loss and improvement in metabolic syndrome.

MATERIALS AND METHODS

A systematic search was performed on PubMed, Embase, and the Cochrane Library from inception to August 2023. Exclusion criteria were patients who received concomitant pharmacological therapy for weight loss, the use of other endoscopic interventions apart from EG, and patients with prior bariatric surgery. Based on the heterogeneity of included studies, meta-analysis was performed using either a fixed-effect model or a random-effect model.

RESULTS

There were 5 studies (4 RCTs and 1 retrospective study) with 1007 patients included in the pooled analysis. Only a minority were males (n=199, 19.8%), and only 1 study included a Sham procedure in the LM group. Six-month percentage total body weight loss (%TBWL) (n=3 studies, MD: 6.34, 95% CI: 2.89, 9.78, P<0.01) and 12-month %TBWL (n=4 studies, MD: 6.43, 95% CI: 2.62, 10.25, P<0.01) were significantly higher in EG compared with LM. Patients in the EG group also had significant improvement in control of diabetes mellitus (n=2 studies, OR: 29.10, 95% CI: 5.84, 145.08) and hypertension (n=2 studies, OR: 2.35, 95% CI: 1.18, 4.70) compared with LM. Incidence of serious adverse events ranged from 2% to 5%.

CONCLUSION

EG is effective for weight loss and improvement in metabolic comorbidities compared with LM alone but is suboptimal based on the Food and Drug Administration thresholds.

Advances in Metabolic Bariatric Surgeries and Endoscopic Therapies: A Comprehensive Narrative Review of Diabetes Remission Outcomes

Background and Objectives: Type 2 diabetes (T2D), closely associated with obesity, contributes to increased morbidity and mortality due to complications such as cardiometabolic disease. This review aims to evaluate the effectiveness of metabolic and bariatric surgeries (MBS) and endoscopic bariatric therapies (EBTs) in achieving diabetes remission and to examine key predictors influencing remission outcomes. Materials and Methods: This review synthesizes data from studies on MBS and EBT outcomes, focusing on predictors for diabetes remission such as preoperative insulin use, diabetes duration, HbA1c, and C-peptide levels. Additionally, predictive scoring systems, including the Individualized Metabolic Surgery (IMS), DiaRem, Advanced-DiaRem, ABCD, and Robert et al. scores, were analyzed for their utility in forecasting remission likelihood. Results: Key predictors of T2D remission include shorter diabetes duration, lower HbA1c, and higher C-peptide levels, while prolonged insulin use, and higher insulin doses are associated with lower remission rates. Scoring models like IMS and DiaRem demonstrate that lower scores correlate with a higher likelihood of remission, especially for procedures such as Roux-En-Y gastric bypass (RYGB). RYGB generally shows higher remission rates compared to sleeve gastrectomy (SG), particularly among patients with mild disease severity, while EBTs like ESG and IGBs contribute 5-20% total weight loss (TWL) and moderate glycemic control improvements. Conclusions: Both MBS and EBTs are effective for T2D management, with predictive scoring models aiding in individualized patient selection to optimize remission outcomes. Further research to validate these predictive tools across diverse populations could enhance treatment planning for both surgical and endoscopic interventions.

Effect of etomidate added to propofol target-controlled infusion in bidirectional endoscopy: A randomized clinical trial

BACKGROUND

Propofol has been widely used in bidirectional gastrointestinal endoscopy sedation; however, it frequently leads to cardiovascular adverse events and respiratory depression. Propofol target-controlled infusion (TCI) can provide safe sedation but may require higher dosages of propofol. On the contrary, etomidate offers hemodynamic stability.

AIM

To evaluate the effect of different dose etomidate added to propofol TCI sedation during same-visit bidirectional endoscopy.

METHODS

A total of 330 patients from Fujian Provincial Hospital were randomly divided into three groups: P, 0.1EP, and 0.15EP. Patients in the P group received propofol TCI only, with an initial effect-site concentration of the propofol TCI system of 3.0 mg/mL. Patients in the 0.1EP and 0.15EP groups received 0.1 and 0.15 mg/kg etomidate intravenous injection, respectively, followed by propofol TCI.

RESULTS

Patients in the 0.15EP group had higher mean blood pressure after induction than the other groups (P group: 78 mmHg, 0.1EP group: 82 mmHg, 0.15EP group: 88 mmHg; P < 0.05). Total doses of propofol consumption significantly decreased in the 0.15EP group compared with that in the other groups (P group: 260.6 mg, 0.1EP group: 228.1 mg, 0.15EP group: 201.2 mg; P < 0.05). The induction time was longer in the P group than in the other groups (P group: 1.9 ± 0.7 minutes, 0.1EP group: 1.2 ± 0.4 minutes, 0.15EP group: 1.1 ± 0.3 minutes; P < 0.01). The recovery time was shorter in the 0.15EP group than in the other groups (P group: 4.8 ± 2.1 minutes, 0.1EP group: 4.5 ± 1.6 minutes, 0.15EP group: 3.9 ± 1.4 minutes; P < 0.01). The incidence of hypotension (P group: 36.4%, 0.1EP group: 29.1%, 0.15EP group: 11.8%; P < 0.01) and injection pain was lower in the 0.15EP group than in the other groups (P < 0.05). Furthermore, the incidence of respiratory depression was lower in the 0.15EP group than in the P group (P < 0.05). Additionally, the satisfaction of the patient, endoscopist, and anesthesiologist was higher in the 0.15EP group than in the other groups (P < 0.05).

CONCLUSION

Our findings suggest that 0.15 mg/kg etomidate plus propofol TCI can significantly reduce propofol consumption, which is followed by fewer cardiovascular adverse events and respiratory depression, along with higher patient, endoscopist, and anesthesiologist satisfaction.

Endoscopic ultrasound-guided treatment of isolated gastric varices

In this letter we comment on the article by Zhang et al published in the recent issue of the World Journal of Gastrointestinal Endoscopy 2024. We focus specifically on the management of gastric varices (GV), which is a significant consequence of portal hypertension, is currently advised to include beta-blocker therapy for primary prophylaxis and transjugular intrahepatic portosystemic shunt for secondary prophylaxis or active bleeding. Although it has been studied, direct endoscopic injection of cyanoacrylate glue has limitations, such as the inability to fully characterize GV endoscopically and the potential for distant glue embolism. In order to achieve this, endoscopic ultrasound has been used to support GV characterization, real-time therapy imaging, and Doppler obliteration verification.

Reflux after peroral endoscopic myotomy: The dilemma and the options

Per oral endoscopic myotomy (POEM) is rapidly emerging as the treatment of choice for achalasia cardia, but its success is marred by problematic reflux. Although symptomatic reflux rates are low and often comparable to that after laparoscopic Hellers myotomy (LHM), a high incidence of pathologic reflux has been noted after POEM. This poses a dilemma as to what is true reflux, and in determining the indications and optimal endpoints for managing post-POEM reflux. The two pertinent reasons for the difference in reflux rates between LHM and POEM are the variation in length and location of myotomy and the absence of an anti-reflux procedure in POEM. Proton pump inhibitor remains the most sought-after treatment of POEM derived reflux. Nevertheless, modifications in the procedural technique of POEM and the addition of endoscopic fundoplication can probably emerge as a game changer. This article briefly reviews the incidence, causes, controversies, predictive factors, and management strategies related to post-POEM reflux.