Endoscopic management of refractory benign oesophageal strictures

Refractory benign oesophageal strictures are an infrequent presentation but a cause of significant morbidity and mortality. The treatment of these strictures has changed little in recent years, yet new evidence is emerging for the optimal timing and application of different therapies. In this article, we have carefully reviewed the current literature on the evaluation and management of refractory strictures and provided practical advice as to their management. A number of areas require attention in future research, including carefully designed randomised trials of endoscopic and medical therapies, and a focus on risk factors at a patient and molecular level to facilitate development of medical therapies that can reduce recurrent fibrosis in these patients.

SAFETY AND EFFICACY OF EUS-GUIDED COIL PLUS CYANOACRYLATE VERSUS CONVENTIONAL CYANOACRYLATE TECHNIQUE IN THE TREATMENT OF GASTRIC VARICES: A RANDOMIZED CONTROLLED TRIAL

BACKGROUND

One of the most feared complications with the use of cyanoacrylate for treatment of gastric varices is the occurrence of potentially life-threatening systemic embolism. Thus, endoscopists are turning towards new techniques, including endoscopic coiling, as a potentially safer and more effective treatment option. However, no studies have been performed comparing the two techniques.

OBJECTIVE

This study aims to compare the safety and efficacy of endoscopic ultrasound guided coil and cyanoacrylate injection versus the conventional technique of injection of cyanoacrylate alone.

DESIGN

A pilot randomized controlled trial.

METHODS

Patients randomized into group I were treated with coil and cyanoacrylate, and those in group II with cyanoacrylate alone. Flow within the varix was evaluated immediately after the treatment session and one month following initial treatment. If thrombosis was confirmed, additional follow-up was performed 4 and 10 months following initial treatment. All patients underwent a thoracic computerized tomography scan after the procedure.

RESULTS

A total of 32 patients, 16 in each group, were followed for an average of 9.9 months (range 1-26 months). Immediately after the procedure, 6 (37.5%) group-I patients and 8 (50%) group-II patients presented total flow reduction in the treated vessel (P=0.476). After 30 days, 11 (73.3%) group-I patients and 12 (75%) group-II patients were found to have varix thrombosis. In both groups, the majority of patients required only one single session for varix obliteration (73.3% in group I versus 80% in group II). Asymptomatic pulmonary embolism occurred in 4 (25%) group-I patients and 8 (50%) group-II patients (P=0.144). No significant difference between the groups was observed.

CONCLUSION

There is no statistical difference between endoscopic ultrasound guided coils plus cyanoacrylate versus conventional cyanoacrylate technique in relation to the incidence of embolism. However, a greater tendency towards embolism was observed in the group treated using the conventional technique. Both techniques have similar efficacy in the obliteration of varices. Given the small sample size of our pilot data, our results are insufficient to prove the clinical benefit of the combined technique, and do not yet justify its use, especially in light of higher cost. Further studies with larger sample size are warranted.

EUS-Guided Intragastric Injection of Botulinum Toxin A in the Preoperative Treatment of Super-Obese Patients: a Randomized Clinical Trial

BACKGROUND

Obesity is a disease that is highly prevalent in Brazil, and the associated comorbidities represent a major global public health challenge. Botulinum toxin type A (BTX-A) is a potent neurotoxin and inhibitor of gastric smooth muscle activity. In theory, BTX-A administration should promote early satiety and weight loss because it delays gastric emptying by inhibiting acetylcholine-mediated peristalsis, which is primarily responsible for gastric motility. Because results in the literature are discrepant, the efficacy of intragastric injections of BTX-A as a primary treatment for obesity remains unknown. The objective of this prospective, double-blind, single-center randomized study was to evaluate the effects of endoscopic ultrasound-guided intragastric BTX-A injections, as a bridge to bariatric surgery, in super-obese patients.

METHODS

Thirty-two super-obese patients were randomized to one of two groups: BTX-A, in which 200 units of BTX-A were injected into the gastric antrum and body; and control, in which the same injections were performed with 0.9% saline. Weight, body mass index (BMI), and loss of excess weight were measured monthly over a 6-month period. Gastric emptying scintigraphy was performed before and after the procedure.

RESULTS

The patients in both groups showed significant weight loss over the course of the study (p < 0.001). There were no statistically significant differences between the groups regarding weight loss, excess weight, total loss of excess weight, total weight loss, or change in BMI.

CONCLUSIONS

Intragastric injection of BTX-A does not appear to be an effective method of achieving preoperative weight loss in super-obese patients.

Video capsule endoscopy vs double-balloon enteroscopy in the diagnosis of small bowel bleeding: A systematic review and meta-analysis

AIM

To compare the diagnostic accuracy of video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) in cases of obscure gastrointestinal bleeding (OGIB) of vascular origin.

METHODS

MEDLINE (via PubMed), LILACS (via BVS) and Cochrane/CENTRAL virtual databases were searched for studies dated before 2017. We identified prospective and retrospective studies, including observational, cohort, single-blinded and multicenter studies, comparing VCE and DBE for the diagnosis of OGIB, and data of all the vascular sources of bleeding were collected. All patients were subjected to the same gold standard method. Relevant data were then extracted from each included study using a standardized extraction form. We calculated study variables (sensitivity, specificity, prevalence, positive and negative predictive values and accuracy) and performed a meta-analysis using Meta-Disc software.

RESULTS

In the per-patient analysis, 17 studies (1477 lesions) were included. We identified 3150 exams (1722 VCE and 1428 DBE) in 2043 patients and identified 2248 sources of bleeding, 1467 of which were from vascular lesions. Of these lesions, 864 (58.5%) were diagnosed by VCE, and 613 (41.5%) were diagnosed by DBE. The pretest probability for bleeding of vascular origin was 54.34%. The sensitivity of DBE was 84% (95%CI: 0.82-0.86; heterogeneity: 78.00%), and the specificity was 92% (95%CI: 0.89-0.94; heterogeneity: 92.0%). For DBE, the positive likelihood ratio was 11.29 (95%CI: 4.83-26.40; heterogeneity: 91.6%), and the negative likelihood ratio was 0.20 (95%CI: 0.15-0.27; heterogeneity: 67.3%). Performing DBE after CE increased the diagnostic yield of vascular lesion by 7%, from 83% to 90%.

CONCLUSION

The diagnostic accuracy of detecting small bowel bleeding from a vascular source is increased with the use of an isolated video capsule endoscope compared with isolated DBE. However, concomitant use increases the detection rate of the bleeding source.

Transhepatic forceps biopsy combined with biliary drainage in obstructive jaundice: safety and accuracy

PURPOSE

This study was conducted in order to investigate the safety and accuracy of percutaneous transluminal forceps biopsy (PTFB) during percutaneous biliary drainage (PTBD) in patients with a suspicion of malignant biliary stricture.

MATERIAL AND METHODS

Fifty consecutive patients with obstructive jaundice underwent PTFB during PTBD. Biopsy specimens were obtained using 5.2-F flexible biopsy forceps and these specimens were independently analysed by two pathologists. Consensus was obtained in case of discrepancy. Biopsy was considered as a true positive when tumour cells were retrieved. In the absence of tumour cells, comparison with available surgical findings and/or endoscopic ultrasound fine-needle aspiration (EUS-FNA) and/or percutaneous liver biopsy and/or imaging or clinical follow-up was made to distinguish true and false negatives. Specificity, sensitivity, positive predictive value, negative predictive value and accuracy were calculated. Influence of tumour location and pre-operative imaging findings was evaluated. Adverse events were reported.

RESULTS

Biliary drainage and tissue sampling were achieved in 100% of patients. Sensitivity and specificity were 70 and 100%, respectively, while overall accuracy was 72%. After excluding the first 25 patients, accuracy and sensitivity for tissue sampling reached 80 and 78%, respectively. Sensitivity was better (87%) if stenosis was located at the upper part of the biliary tree, compared to the lower part (55%). In case of cholangiocarcinoma or intraductal invasion suspected on imaging, biopsy was contributive in 84 and 81% of patients, respectively. Four complications occurred consisting of one bile leak, two haemobilia and one pneumoperitoneum.

CONCLUSION

PTFB combined with PTBD is a safe and effective technique for both histopathological diagnosis and biliary decompression of biliary strictures.

KEY POINTS

Implications for patient care: • Percutaneous transbiliary forceps biopsy is technically feasible (100% of tissue sampling in our study) and is a safe technique. • Radiological management combining PTFB plus PTBD may allow diagnosis and treatment of the biliary stricture at the same time. • Sensitivity and accuracy for PTFB reached 78 and 80%, respectively, with a 100% specificity.

PRISMA - Practical meta-analysis of applying local triamcinolone acetonide injection for stenosis after esophageal cancer surgery

Objectives

To explore the practical method of endoscopic triamcinolone acetonide (TA) injection immediately after endoscopic surgery and combined with endoscopic dilation (ED) in the management of stenosis after esophageal cancer surgery based on their efficacy and safety.

Methods

A comprehensive search was performed in electronic databases including MEDLINE, EMBASE, the Cochrane Library, Web of Science, and China National Knowledge Infrastructure for possible controlled studies. Meta-analyses of the included studies were completed using Reviewer Manager software and were reported based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Results

Eight randomized studies and five controlled studies containing 575 patients were obtained. In five studies (n=282), TA injected after surgery reduced the risk of stenosis (risk difference [RD] =-0.51, 95% CI [-0.64, -0.39], P<0.01) and the required ED sessions (RD =-3.66, 95% CI [-5.87, -1.46], P<0.01). In eight studies (n=293), TA injection combined with ED reduced the risk of recurrence of stenosis (RD =-0.28, 95% CI [-0.47, -0.08], P<0.01) and the required ED sessions (RD =-0.71, 95% CI [-1.39, -0.04], P<0.05). TA injection therapy did not increase the risk of complications in seven studies (n=380; RD =-0.01, 95% CI [-0.04, 0.02], P=0.53) compared with control.

Conclusion

TA injection therapy after esophageal cancer surgery and combined with ED are both effective and safe in the management of stenosis, as they reduce the risk of stenosis and sequentially the required ED sessions without increasing complications.

Laparoscopic extraction of gastric self-expandable metallic stent after migration in ileum: A case report

Revisional surgery in bariatric patients can sometimes lead to life-threatening complications that need a fast diagnosis and treatment as well as a multidisciplinary approach. If left undiagnosed or untreated, this may lead to sepsis, multiple organ failure, and death. In this case report, we describe the management of a gastric perforation which occurred after conversion of a gastric banding to a sleeve gastrectomy.

Exclusively endoscopic approach to treating gastric perforation caused by an intragastric balloon: case series and literature review

Background and study aims  Obesity is a serious disease, resulting in significant morbidity and mortality. Intragastric balloons (IGBs) have been in use since the 1980s. After the insertion of an IGB, complications such as migration of the device and even severe gastric perforation can occur, requiring laparoscopic surgery. Here, we report three cases of gastric perforation after IGB insertion. In all three cases, the perforation was successfully repaired through an exclusively endoscopic approach.

CT diagnosis for metastasis of clear cell renal cell carcinoma to the pancreas: Three case reports

RATIONALE

Clear cell renal cell carcinoma (CCRCC) metastasis to pancreas is clinically rare. Misdiagnosis for these cases is frequently due to the low incidence, lack of specific clinical symptoms, and laboratory results.

PATIENT CONCERNS

Three female patients aged 47 years, 69 years, and 76 years, respectively, were admitted to hospital for routine examination after resection of clear cell carcinoma of kidney for 69 months, 57 months, and 123 months, respectively. All 3 cases had no specific clinical symptoms. Routine laboratory tests and common tumor markers including CEA, AFP, CA19-9, and CA125 showed no obvious abnormality.

DIAGNOSIS

All 3 cases were finally diagnosed with CCRCC metastasis to pancreas on the basis of CT and pathological findings. On unenhanced CT, foci of the pancreas showed single or multiple nodules or masses with mildly low or equal density and obscure boundary. On enhanced CT, the enhanced mode of foci was similar to CCRCC and showed "fast in fast out." The main body was confined in the pancreas. The peripheral structure was clear relatively. Obstruction of common bile duct, main pancreatic duct, and local infringement of foci cannot be seen. Additional metastases of right adrenal gland can be seen in one case.

INTERVENTIONS

All 3 cases underwent CT examination and surgical treatment, with complete removal of metastatic tumors.

OUTCOMES

All 3 cases underwent surgical treatment successfully, and recovered successfully after operation.

LESSONS

The manifestations of pancreatic metastases from CCRCC on CT show certain characteristics, which may be useful to assess the histological features of pancreatic metastases from CCRCC and facilitate the preoperative diagnosis.

Whether a Short or Long Alimentary Limb Influences Weight Loss in Gastric Bypass: a Systematic Review and Meta-Analysis

Roux-en-Y gastric bypass, the most commonly performed procedure in bariatric surgery, still lacks a consensus on whether alimentary limb length (ALL) influences weight loss. Studies were identified by searching multiple electronic databases. Studies with enough data including body mass index (BMI) loss and percent excess weight loss (% EWL) were eligible. The statistical analysis was performed with Stata 14.0. In total, eight studies with 1714 patients were included. The meta-analysis suggested that short ALLs weakened the efficacy of Roux-en-Y gastric bypass in terms of BMI loss (standard mean deviation (SMD), - 0.33 [95% confidence intervals (CI), - 0.60, - 0.05], p = 0.021) with 3 years of follow-up and % EWL (SMD, - 0.17 [95% CI, - 0.31, - 0.04], p = 0.013) with 2 years of follow-up. The subgroup analysis demonstrated that the group with a BMI ≥ 50 kg/m2 had a significant SMD between the use of short and the standard ALLs (- 0.71 [95% CI, - 1.07, - 0.35], p = 0.000), while the subgroup with a BMI < 50 kg/m2 (SMD, - 0.29 [95% CI, - 0.78, 0.20], p = 0.247) did not. Compared with a standard ALL (130-150 cm), a short ALL (40-100 cm) may reduce the efficacy of the Roux-en-Y gastric bypass surgery, while a long ALL (170-250 cm) did not significantly improve the effects in terms of BMI loss and % EWL. In addition, a potential view of the meta-analysis indicated patients with a BMI < 50 kg/m2 might get more benefits with a short ALL, while those patients with a BMI ≥ 50 kg/m2 might benefit more from a standard ALL.

Endoscopic Full-Thickness Defects and Closure Techniques

PURPOSE OF REVIEW

Gastrointestinal transmural defects are defined as total rupture of the gastrointestinal wall and can be divided into three main categories: perforations, leaks, and fistulas. Due to an increase in the number of therapeutic endoscopic procedures including full-thickness resections and the increase incidence of complications related to bariatric surgeries, there has been an increase in the number of transmural defects seen in clinical practice and the number of non-invasive endoscopic treatment procedures used to treat these defects.

RECENT FINDINGS

The variety of endoscopic approaches and devices, including closure techniques using clips, endoloop, and endoscopic sutures; covering techniques such as the cardiac septal occluder device, luminal stents, and tissue sealants; and drainage techniques including endoscopic vacuum therapy, pigtail, and septotomy with balloon dilation are transforming endoscopy as the first-line approach for therapy of these conditions. In this review, we describe the various transmural defects and the endoscopic techniques and devices used in their closure.

Double plication for spring-mediated in-continuity intestinal lengthening in a porcine model

BACKGROUND

Short bowel syndrome is a condition with substantial morbidity and mortality, yet definitive therapies are lacking. Distraction enterogenesis uses mechanical force to "grow" new intestine. In this study, we examined whether intestinal plication can be used to safely achieve spring-mediated intestinal lengthening in a functioning segment of jejunum in its native position.

METHODS

A total of 12 juvenile, miniature Yucatan pigs underwent laparotomy to place either compressed springs or expanded springs within a segment of jejunum (n = 6 per group). The springs were secured within the jejunum by performing intestinal plication to narrow the intestinal lumen around the spring. After 3 weeks, the jejunum was retrieved and examined for lengthening and for histologic changes.

RESULTS

There were no intraoperative or postoperative complications, and the pigs tolerated their diets and gained weight. Segments of jejunum containing expanded springs showed no significant change in length over the 3 weeks. In contrast, jejunum containing compressed springs showed nearly a 3-fold increase in length (P < .001). Histology of the retrieved jejunum showed a significant increase in thickness of the muscularis propria and in crypt depth relative to normal jejunum.

CONCLUSION

Intestinal plication is effective in securing endoluminal springs to lengthen the jejunum. This approach is a clinically relevant model because it allows for normal GI function and growth of animals during intestinal lengthening, which may be useful in lengthening intestine in patients with short bowel syndrome.

Over-the-Scope Clips Are More Effective Than Standard Endoscopic Therapy for Patients With Recurrent Bleeding of Peptic Ulcers

BACKGROUND & AIMS

Endoscopic hemostasis is effective in treatment of bleeding peptic ulcers. However, rebleeding is difficult to treat and associated with substantial morbidity and mortality. We performed a prospective randomized trial to determine whether over-the-scope clips (OTSCs) are more effective than standard treatment of severe recurrent upper gastrointestinal bleeding.

METHODS

We performed our study at 9 academic referral centers (in Germany, Switzerland, and Hong Kong) from March 2013 through September 2016. Adult patients with recurrent peptic ulcer bleeding following initially successful hemostasis (66 patients in the intent-to-treat analysis) were randomly assigned to groups (1:1) that underwent hemostasis with either OTSC or standard therapy. Standard therapy was defined as hemostasis with through-the-scope clips (TTSC, n = 31) or thermal therapy plus injection with diluted adrenaline (n = 2). The primary endpoint was further bleeding (a composite endpoint of a persistent bleeding despite endoscopic therapy according to the protocol or recurrent bleeding within 7 days after successful hemostasis). Patients with further bleeding were allowed to cross over to OTSC therapy. Main secondary endpoints were mortality, necessity of surgical or angiographic salvage therapy, duration of stay in the hospital or intensive care, number of blood units transfused, and complications associated with endoscopic therapy.

RESULTS

Persistent bleeding after per-protocol hemostasis was observed in 14 patients (42.4%) in the standard therapy group and 2 patients (6.0%) in the OTSC group (P = .001). Recurrent bleeding within 7 days occurred in 5 patients (16.1%) in the standard therapy group vs 3 patients (9.1%) in the OTSC group (P = .468). Further bleeding occurred in 19 patients (57.6%) in the standard therapy group and in 5 patients (15.2%) in the OTSC group (absolute difference 42.4%; 95% confidence interval 21.6-63.2; P = .001) Within 30 days of follow-up, 1 patient in the standard therapy group (3.0%) and 1 patient in the OTSC group (3.0%) required surgical therapy (P = .999). Within 30 days of the procedure, 2 patients died in the standard therapy group (6.3%) and 4 patients died in the OTSC group (12.1%) (P = .672). There were no significant differences in the other secondary endpoints.

CONCLUSIONS

In prospective randomized trial, we found endoscopic treatment with OTSCs to be superior to standard therapy with TTSCs for patients with recurrent peptic ulcer bleeding. STING Study, Clinicaltrials.gov no: NCT1836900.

The Effectiveness of Endoscopic Gastroplasty for Obesity Treatment According to FDA Thresholds: Systematic Review and Meta-Analysis Based on Randomized Controlled Trials

Endoscopic bariatric therapies (EBTs) are promising alternatives to conventional surgery for obesity. The aim of this study is to compare efficacy and safety through a systematic review and meta-analysis of the endoscopic gastroplasty techniques versus conservative treatment. We searched MEDLINE, EMBASE, Cochrane CENTRAL, Lilacs/Bireme. Randomized controlled trials (RCTs) enrolling obese patients comparing endoscopic gastroplasty to sham or diet/exercise were considered eligible. Among 6014 records, three RCTs were selected for meta-analysis. The total sample was 459 patients (312 EBTs vs 147 control). Mean total body weight loss in the intervention group (IG) was 4.8% higher than the control group (CG) at 12 months (p = 0.01). The IG responder rate was 44.31% at 12 months. Therefore, the endoscopic gastroplasty is more effective than conservative therapies but do not achieve FDA thresholds.

Quality in upper gastrointestinal endoscopic submucosal dissection

Progress in the endoscopy technology field led to an increase in the diagnosis of early gastrointestinal (GI) superficial lesions and to an improvement of their treatment. Endoscopic submucosal dissection (ESD) has been developed in Japan with the aim of removing such lesions in one piece, in order to obtain a curative resection and to minimize the risk of local recurrence, and to preserve the native organ. ESD is widely used in Asia for the treatment of early upper and lower GI lesions and is currently gaining attention in Western countries too. However, ESD can be safely performed only by expert endoscopists and in specific clinical settings. Therefore, prior to decide whether ESD is feasible or not, the target lesion must be carefully assessed, in order to understand whether or not it is eligible for submucosal dissection. The aim of this paper is to review indications, limitations and technical aspects of upper GI ESD.

Review article: Asia-Pacific consensus recommendations on endoscopic tissue acquisition for biliary strictures

BACKGROUND

Pre-operative tissue diagnosis for suspected malignant biliary strictures remains challenging.

AIM

To develop evidence-based consensus statements on endoscopic tissue acquisition for biliary strictures.

METHODS

The initial draft of statements was prepared following a systematic literature review. A committee of 20 experts from Asia-Pacific region then reviewed, discussed, and modified the statements. Two rounds of independent voting were conducted to reach a final version. Consensus was considered to be achieved when 80% or more of voting members voted "agree completely" or "agree with some reservation."

RESULTS

Eleven statements achieved consensus. The choice of tissue sampling modalities for biliary strictures depends on the clinical setting, the location of lesion, and availability of expertise. Detailed radiological and endoscopic evaluation is useful to guide the selection of appropriate tissue acquisition technique. Standard intraductal biliary brushing and/or forceps biopsy is the first option when endoscopic biliary drainage is required with an overall (range) sensitivity and specificity of 45% (26%-72%) and 99% (98%-100%), and 48% (15%-100%) and 99% (97%-100%), respectively, in diagnosing malignant biliary strictures. Probe-based confocal laser endomicroscopy and fluorescence in situ hybridisation using 4 fluorescent-labelled probes targeting chromosomes 3, 7, 17 and 9p21 locus may be added to improve the diagnostic yield. Cholangioscopy-guided biopsy and EUS-guided tissue acquisition can be considered after prior negative conventional tissue sampling with an overall (range) sensitivity and specificity of 60% (38%-88%) and 98% (83%-100%), and 80% (46%-100%) and 97% (92%-100%), respectively, in diagnosing malignant biliary strictures.

CONCLUSION

These consensus statements provide evidence-based recommendations for endoscopic tissue acquisition of biliary strictures.

Study of the standard direct costs of various techniques of advanced endoscopy. Comparison with surgical alternatives

INTRODUCTION

The complexity of endoscopy has carried out an increase in cost that has a direct effect on the healthcare systems. However, few studies have analyzed the cost of advanced endoscopic procedures (AEP).

OBJECTIVES

To carry out a calculation of the standard direct costs of AEP, and to make a financial comparison with their surgical alternatives.

METHODS

Calculation of the standard direct cost in carrying out each procedure. An endoscopist detailed the time, personnel, materials, consumables, recovery room time, stents, pathology and medication used. The cost of surgical procedures was the average cost recorded in the hospital.

RESULTS

Thirty-eight AEP were analyzed. The technique showing lowest cost was gastroscopy + APC (€116.57), while that with greatest cost was ERCP with cholangioscopy + stent placement (€5083.65). Some 34.2% of the procedures registered average costs of €1000-2000. In 57% of cases, the endoscopic alternative was 2-5 times more cost-efficient than surgery, in 31% of cases indistinguishable or up to 1.4 times more costly.

CONCLUSION

Standard direct cost of the majority of AEP is reported using a methodology that enables easy application in other centers. For the most part, endoscopic procedures are more cost-efficient than the corresponding surgical procedure.

Efficacy and Safety of Stents in the Treatment of Fistula After Bariatric Surgery: a Systematic Review and Meta-analysis

Fistula development is a serious complication after bariatric surgery. We performed a systematic review and meta-analysis to assess the efficacy of fistula closure and complications associated with endoscopic stent treatment of fistulas, developed after bariatric surgeries, particularly Roux-en-Y gastric bypass (RYGB) and gastric sleeve (GS). Studies involving patients with fistula after RYGB or GS and those who received stent treatment only were selected. The analyzed outcomes were overall success rate of fistula closure, mean number of stents per patient, mean stent dwelling time, and procedure-associated complications. Current evidence from identified studies demonstrates that, in selected patients, endoscopic stent treatment of fistulas after GS or RYGB can be safe and effective.

EUS-FNA versus ERCP for tissue diagnosis of suspect malignant biliary strictures: a prospective comparative study

BACKGROUND AND STUDY AIMS

 Biliary strictures are frequently a challenging clinical scenario and the anatomopathological diagnosis is essential in the therapeutic management, whether for curative or palliative purposes. The acquisition of specimens is necessary since many benign diseases mimic biliopancreatic neoplasms. Endscopic retrograde cholangiopancreatography (ERCP) is the traditionally used method despite the low sensitivity of biliary brush cytology and forceps biopsy. On the other hand, several studies reported good accuracy rates using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). The aim of this prospective study was to compare, the accuracy of EUS-FNA and ERCP for tissue sampling of biliary strictures.

PATIENTS AND METHODS

 After performing the sample size calculation, 50 consecutive patients with indeterminate biliary strictures were included to undergo ERCP and EUS on the same sedation.The gold-standard was surgery or 6 months' follow-up. Evaluation of the diagnostic indices (sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio), concordance and adverse events among the methods were performed. Also, subtype analyses of the techniques, anatomical localization and size of the lesion were included.

RESULTS

 The final diagnoses reported in 50 patients were 47 malignant, 1 suspicious and 2 benign lesions. 31 lesions were extraductal and 19 intraductal, 35 were distal and 15 proximal strictures. In the intention-to-treat analysis, the sensitivity and accuracy of EUS-FNA were superior than ERCP tissue sampling (93,8 %, 94 % vs. 60,4 %, 62 %, respectively) ( P  = 0.034), with similar adverse events. There was no concordance between the methods and combining both methods improved the sensitivity and accuracy for 97.9 % and 98 %, respectively. In the subtype analyses, the EUS-FNA was superior, with a higher accuracy than ERCP tissue sampling in evaluating extraductal lesions (100 % vs. 54.8 %, P  = 0.019) and in those larger than 1.5 cm (95.8 % vs. 61.9 %, P  = 0.031), but were similar in evaluating intraductal lesions and lesions smaller than 1.5 cm. There was no significant difference between the methods in the analyzes of proximal, distal and pancreatic lesions.

CONCLUSION

 EUS-FNA is better than ERCP with brush cytology and intraductal forceps biopsy in diagnosing malignant biliary strictures, mainly in the assessment of extraductal lesions and in those larger than 1.5 cm. Combining ERCP with tissue sampling and EUS-FNA is feasible, the techniques have similar complication rates, and the combination greatly improves diagnostic accuracy.

The Palliative Effect of Endoscopic Uncovered Self-expandable Metallic Stent Placement Versus Gastrojejunostomy on Malignant Gastric Outlet Obstruction: A Pilot Study with a Retrospective Chart Review in Saga, Japan

Objective Endoscopic self-expandable metallic stent (SEMS) placement and gastrojejunostomy (GJY) are palliative treatments for malignant gastric outlet obstruction (GOO). The aim of the present study was to compare the palliative effects of these treatments and identify predictors of a poor oral intake after treatment. Methods and Patients In total, 65 patients with GOO at multiple centers in Saga, Japan, were evaluated. Thirty-eight patients underwent SEMS placement, and 27 underwent GJY from January 2010 to December 2016. The characteristics and outcomes of the two groups were compared to detect predictors of treatment failure. Results No significant differences in the technical success, clinical success, post-treatment total protein, hospital discharge, duration from eating disability to death, or post-treatment overall survival were present between the SEMS and GJY groups. More patients in the GJY group than in the SEMS group received chemotherapy (51.4% vs. 26.3%, respectively; p=0.042). The period from treatment to the first meal was longer in the GJY group than in the SEMS group (4.5 vs. 3.0 days, respectively; p=0.013). The present study did not identify any risk factors for failure of SEMS placement. Although the stent length tended to be associated with a poor prognosis, the correlation was not statistically significant (odds ratio: 0.60, 95% confidence interval: 0.36-1.01, p=0.053). Conclusion Patients with GOO started meals more promptly after SEMS than after GJY, but the clinical outcomes were not markedly different between the SEMS and GJY groups. These findings suggest that endoscopic uncovered SEMS placement might be a feasible palliative treatment for GOO.

Devices and Endoscopic Bariatric Therapies for Obesity

PURPOSE OF REVIEW

In this review, we describe the FDA-approved and investigational devices and endoscopic bariatric therapies for the treatment of obesity. We focus on literature published in the past few years and present mechanisms of action as well as efficacy and safety data.

RECENT FINDINGS

Devices and endoscopic procedures are emerging options to fill the significant treatment gap in the management of obesity. Not only are these devices and procedures minimally invasive and reversible, but they are potentially more effective than antiobesity medications, often safer for poor surgical candidates and possibly less expensive than bariatric surgery. As many patients require a variety of management strategies (medications, devices, procedures, and/or surgery) in addition to lifestyle modifications to achieve clinically significant weight loss, the future of obesity treatment involves a multidisciplinary approach. Combinations of advanced treatment strategies can lead to additive or synergistic weight loss. This is an area that requires further investigation.

Assessment of Weight Loss With the Intragastric Balloon in Patients With Different Degrees of Obesity

INTRODUCTION

The intragastric balloon (IGB) is an endoscopic device for the treatment of obesity. Best results are observed in patients who follow a dietary program but few studies have assessed the results of this treatment in patients with different degrees of obesity.

AIM

The aim of this study is to compare the efficacy of IGB in patients with different degrees of obesity.

METHOD

A total of 2002 patients with IGB were retrospectively evaluated and were divided into groups according to initial body mass index (BMI) range, as follows: group 1, 27 to 29.9 kg/m; group 2, 30 to 34.9 kg/m; group 3, 35 to 39.9 kg/m; group 4, 40 to 44.9 kg/m; group 5, ≥45 kg/m. Weight was assessed in 3 different times: before (T0), 1 month (T1), 6 months (T2), and 6 months after removal of the IGB (T3).

RESULTS

A total of 946 patients lost follow-up. Overall, 40 (3.78%) removed the device before programmed by intolerance, and 1016 patients completed the 6-month treatment. The mean weight loss was 18.9%, excess weight loss 60.1% and an BMI reduction of 6.76 points. 6 months after removal of the balloon 842 patients had continued follow-up (82.8%). At this time, weight loss was 19.84%, excess weight loss was 59.49%, and BMI reduction of 7.06 points. In all groups there was statistical difference between the times T0 and T1 and between T1 and T2 (P<0.001). There was no statistical difference between T2 and T3, in any group.

CONCLUSION

IGB provided sustained weight loss in patients who remained in dietary follow-up for 1 year.

Efficacy of Intragastric Balloon Treatment for Adolescent Obesity

BACKGROUND

Several studies conducted in adults suggest that intragastric balloon (IGB) is an effective and safe method for weight loss. Although the prevalence of obesity in adolescents has increased in recent years, the outcomes of IGB treatment in this age group are not known. The aim of this study was to evaluate the safety and efficacy of IGB treatment for weight loss in adolescents followed up for 6 months.

METHODS

This is a retrospective longitudinal study including 27 adolescents (14-19 years; 23 female). All participants were referred to IGB treatment by their attending physician, presented body mass index (BMI) ≥ 29 kg/m² (>p97 BMI/age index) and failed to lose weight in clinical treatments. A liquid-filled nonadjustable IGB with a volume of 600 to 700 ml was used for 6 months. All patients were included in a multidisciplinary program, and adherence to this program was evaluated as the number of attended appointments.

RESULTS

There were no serious complications or deaths. The BMI decreased from 37.04 to 31.18 kg/m² (p < 0.0001), body weight decreased from 102.21 to 86.23 kg (p < 0.0001), and excess weight diminished from 35.18 to 19.12 kg (p < 0.0001). The % excess weight loss (%EWL) was 56.19 and % total weight loss (%TWL) 16.35. Adherence to the multidisciplinary program correlated directly with %EWL (r = 0.55; p = 0.0033) and %TWL (r = 0.53; p = 0.0052).

CONCLUSION

Endoscopic treatment of obesity with an IGB is safe, effective, and may be an emerging therapeutic option for adolescents.

Single Center Experience of a New Endoscopic Clip in Managing Nonvariceal Upper Gastrointestinal Bleeding

BACKGROUND

To assess the safety and efficacy of the Instinct clip in the acute endoscopic treatment of upper gastrointestinal bleeding (UGIB).

MATERIALS AND METHODS

This is the first large series reporting this clip in achieving hemostasis. A retrospective descriptive chart review was performed on patients presenting with recent overt GI bleeding treated with endoclip therapy at Mount Sinai Beth Israel Medical Center between May 2013 and January 2016. Results are expressed in absolute numbers, percentages, and trends.

RESULTS

In total, 178 consecutive patients with UGIB were included. Source of bleeding was identified as duodenal ulcer (29.2%), gastric ulcer (22.5%), gastro-esophageal junction tear (8.4%), anastomosis (5.6%), erosive gastropathy (5.6%), Dieulafoy (5.1%), gastric polyp (4.5%), postendoscopic procedure (3.9%), angioectasia (3.4%), esophageal ulcer (2.8%), benign duodenal mass (2.8%), peg tube site (2.3%), gastric neoplasm (1.7%), esophagitis (1.1%), and small bowel ulcer (1.1%). Lesions demonstrated active bleeding in 47.5% (11.3% spurting and 36.2% oozing) and nonbleeding lesions in 52.5% (25.0% visible vessel, 11.9% hematin in ulcer base, 10.0% adherent clot, 5.6% flat spot). Initial hemostasis was achieved in 96.6%. Additional methods were used in 24.1% (argon plasma coagulation and epinephrine injection in 21.3%, surgery in 0.6%, and interventional radiology in 2.2%). There were no adverse events. In-hospital rebleeding was 7.3% and 3.9% presented with rebleeding within 30 days. Average procedure duration was 22.9 minutes and average length of hospital stay was 11.3 days.

CONCLUSIONS

The Instinct clip, when used for UGIB, seems to be safe and effective with similar rebleeding rates compared with other modalities.

Outcomes of Different Methods for Analysis of Biliary Brush Cytology and of Factors Associated with Positive Diagnosis in an Age-Dependent Retrospective Review

Background and Aims

Brush cytology during endoscopic retrograde cholangiopancreatography (ERCP) is the most frequently used strategy for obtaining a tissue sample from an indeterminate biliary stricture. A recent study reported that age is a factor associated with positive yields, but further analysis of how age influences the results was lacking. We aimed to evaluate clinical effectiveness of biliary cytology and prognostic factors for a positive outcome, especially age.

Methods

This study was a single-center, retrospective, clinical study of 77 consecutive patients who underwent brush cytology during ERCP to obtain a diagnosis of an indeterminate biliary stricture. We compared 2 routine cytology techniques: A (smear); B (centrifugation of the cytological material collected and the cut-off brush + cell block when sufficient amount of material was available). The data were collected aiming to compare the accuracy of the different techniques used and the prognostic factors affecting the outcome, with a particular focus on age. The yield for brush cytology was compared with the gold standard defined as either definitive histology or the long-term clinical course.

Results

The overall accuracy of the 2 used methods was 75.3%. Sensitivity was 52.5%, specificity was 100%, positive predictive value was 100%, and negative predictive value was 66.1%. Although not statistically significant, there was a trend toward accuracy for method B compared with method A (80.4 vs. 65.4%; p = 0.153). Multiple logistic regression analysis showed that younger age was the only independent prognostic factor associated with a positive diagnosis (OR 0.95; 95% CI 0.90-0.99; p = 0.039). Receiver operating characteristic curves for age yielded an area under the curve value of 68.2%. On the basis of the Youden index, 69 years was found to be the optimal cutoff for age.

Conclusions

In this series, the accuracy of routine biliary brush cytology was not equal for all methods and ages; in particular, younger patients (below 69 years) tended to have a higher probability of a correct diagnosis.

Diagnostic usefulness of KL-6 concentration of bile in biliary tract cancer

The sensitivity of bile cytology for biliary tract cancer varies from 6-64%, and hence remains unsatisfactory. Sialylated carbohydrate antigen KL-6 mucin is positive in biliary tract cancer tissues and serum KL-6 levels are significantly increased in intrahepatic ductal adenocarcinoma patients compared with healthy individuals. The aim of the present study was to evaluate the usefulness of the KL-6 concentration of bile for the diagnosis of biliary tract cancer. Bile cytology and measurements of bile KL-6 concentration were conducted for 43 patients (25 biliary tract cancers and 18 benign biliary disease). The concentration of KL-6 in the bile of the biliary tract cancer group was compared with the benign biliary disease group. The diagnostic ability was assessed by using receiver operating characteristic curves (ROC). The mean KL-6 concentration of bile for biliary tract cancer (34.6±51.6 U/ml) was increased compared with benign biliary disease (5.2±3.9 U/ml, P<0.001). The area under the ROC for diagnosis of biliary tract cancer was 0.84 for benign biliary disease. When the cut-off level of the KL-6 concentration of bile was 8.6 U/ml, the sensitivity, specificity, and accuracy of the KL-6 concentration of bile alone for the diagnosis of biliary tract cancer were 72, 89, and 79%, respectively. Adding the bile KL-6 concentration to bile cytology measurements, the sensitivity for the diagnosis of biliary tract cancer was increased significantly (100%, P=0.0184). The KL-6 concentration of bile may strengthen the sensitivity of bile cytology for biliary tract cancer.

Risk Factors for Lymph Node Metastasis in Western Early Gastric Cancer After Optimal Surgical Treatment

BACKGROUND

Lymph node metastasis (LNM) has a strong influence on the prognosis of patients with early gastric cancer (EGC). As minimally invasive treatments are considered appropriate for EGC, and lymphadenectomy may be restricted or even eliminated in some cases; it is imperative to identify the main risk factors for LNM to individualize the therapeutic approach. This study aims to evaluate the risk factors for LNM in EGC and to determine the adequacy of the endoscopic resection criteria in a western population.

METHODS

EGC patients who underwent gastrectomy with lymphadenectomy were retrospectively analyzed utilizing a prospective database. The clinicopathological variables were assessed to determine which factors were associated to LNM.

RESULTS

Among 474 enrolled patients, 105 had EGC (22.1%). LNM occurred in 13.3% of all EGC (10% T1a; 15.4% T1b). Tumor size, venous, lymphatic, and perineural invasions were confirmed as independent predictors of LNM by multivariate analysis. Expanded criteria were safely adopted only in selected cases, and 13.6% of patients who matched expanded indication had LNM.

CONCLUSIONS

Tumor size, venous, lymphatic, and perineural invasions were associated with LNM and should be considered as surrogate markers for surgical treatment of EGC. Expanded criteria for endoscopic resection can be safely adopted only in selected cases.

Obesity management in Prader-Willi syndrome: current perspectives

Prader-Willi syndrome (PWS) is a complex multisystem disorder due to the absent expression of the paternally active genes in the PWS critical region on chromosome 15 (15q11.2-q13). The syndrome is considered the most common genetic cause of obesity, occurring in 1:10,000-1:30,000 live births. Its main characteristics include neonatal hypotonia, poor feeding, and lack of appetite in infancy, followed by weight gain, lack of satiety, and uncontrolled appetite, frequently after the age of 2-3 years. The clinical picture includes short stature, multiple endocrine abnormalities (hypogonadism, growth hormone/insulin-like growth factor-I axis dysfunction, hypothyroidism, central adrenal insufficiency), dysmorphic features, scoliosis, osteoporosis, mental retardation, and behavioral and psychiatric problems. Subjects with PWS will become severely obese unless their food intake is strictly controlled. Constant and obsessive food seeking behavior can make life very difficult for both the family and caretakers. Prevention of obesity is mandatory in these patients from the first years of life, because once obesity develops it is difficult to maintain the control of food intake. In fact, PWS subjects die prematurely from complications conventionally related to obesity, including diabetes mellitus, metabolic syndrome, sleep apnea, respiratory insufficiency, and cardiovascular disease. The mechanisms underlying hyperphagia in PWS are not completely known, and to date no drugs have proven their efficacy in controlling appetite. Consequently, dietary restriction, physical activity, and behavior management are fundamental in the prevention and management of obesity in PWS. In spite of all available therapeutic tools, however, successful weight loss and maintenance are hardly accomplished. In this context, clinical trials with new drugs have been initiated in order to find new possibilities of a therapy for obesity in these patients. The preliminary results of these studies seem to be encouraging. On the other hand, until well-proven medical treatments are available, bariatric surgery can be taken into consideration, especially in PWS patients with life-threatening comorbidities.

Rare Tumors and Lesions of the Pancreas

There are a few entities that account for most solid and cystic masses of the pancreas. The pancreas harbors a wide array of diseases, including adenocarcinoma, and its variants, such as anaplastic and adenosquamous carcinoma. Other neoplasms include acinar cell carcinoma, solid pseudopapillary tumor, and sarcomas. Benign lesions include hamartomas, hemangiomas, lymphangioma, and plasmacytoma. Isolated metastases include renal cell carcinoma, melanoma, and other carcinomas. Benign inflammatory conditions, such as autoimmune pancreatitis and groove pancreatitis can also mimic solid neoplasms of the pancreas.

Percutaneous endoscopic gastrostomy under conscious sedation in patients with amyotrophic lateral sclerosis is safe: an observational study

OBJECTIVES

Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disease that causes muscle weakness with respiratory and swallowing dysfunction, eventually leading to death. Permanent enteral feeding is indicated in almost all patients. A percutaneous endoscopic gastrostomy (PEG) tube is considered the first choice, usually performed under conscious sedation (intravenous midazolam). Guidelines are very cautious with respect to sedation in ALS because of the risk for respiratory complications. In our tertiary referral hospital, conscious sedation has been used for many years.Our aim was to review 30-day complications in PEG performed under conscious sedation in ALS patients (without noninvasive positive pressure ventilation during the procedure).

PATIENTS AND METHODS

A retrospective review, including all ALS patients undergoing PEG under conscious sedation from October 2009 to April 2016, was performed.

RESULTS

Analysis included 45 (44% men) patients receiving intravenous midazolam sedation (mean dose 5 mg) during PEG placement, age 36-91 years (mean: 68.7 years). Forced vital capacity (FVC) was 24-116% (mean 68%), of which mild to moderate dysfunction (FVC 50-69%) was present in 42.2% of patients and (very) severe dysfunction (FVC <50%) in 8.8%. No respiratory complications (e.g. aspiration pneumonia) were observed. Other complications, for example, infection, bleeding and peritonitis occurred in, respectively, 8.9, 2.2 and 0%. Mean survival after PEG placement was 13.4 months (range: 1-45 months).

CONCLUSION

Conscious sedation during PEG insertion in ALS patients did not lead to respiratory complications or to an increase in other complications. Our data indicate that conscious sedation can be used safely in ALS patients with mild to moderate pulmonary dysfunction.

Clinical Outcomes of Upper Gastrointestinal Stents and Review of Current Literature

BACKGROUND AND OBJECTIVES

The self-expandable metal stent (SEMS) is an alternative for several possible surgical and palliative treatments of upper gastrointestinal obstructions that occur in several disease states. The present study was performed to describe a single-center experience with upper gastrointestinal stents.

METHODS

All patients at a single center who had an SEMS placed for the treatment of obstruction over a 3-year period were retrospectively evaluated. Pre- and postoperative dysphagia scoring was calculated and used to evaluate postprocedure improvement in quality of life. Procedural success and early and late complication rates were investigated.

RESULTS

A total of 171 endoscopic procedures were performed in 73 patients. Procedural success was 95.8% (n = 69) and dilatation was performed in 80 patients. The rate of perioperative complication was 26% (n = 19). After 1 month, stents were patent in all patients (n = 73). Stent obstruction was noted in 6 patients: 2 each at 2, 7, and 10 months.

CONCLUSION

SEMS usage for palliative and curative purposes in benign or malignant upper gastrointestinal system obstructions is an efficient and reliable treatment method with advantages, such as shortening hospital stay, decreased pain, cost-effectiveness, and low mortality-morbidity rates when compared to surgical procedures, and a high rate of clinical success.

Energy metabolism during the perioperative period of gastric endoscopic submucosal dissection

The aim of this study was to investigate the change in the energy metabolism and invasiveness in the perioperative period of endoscopic submucosal dissection for early gastric cancer. Fifty-two consecutive patients were enrolled into the study between July 2013 and May 2014 and examined resting energy expenditure using an indirect calorimeter, body weight and basal energy expenditure using the Harris-Benedict equation before and after endoscopic submucosal dissection. Resting energy expenditure/body weight and resting energy expenditure/basal energy expenditure were 20.2 ± 3.0 kcal/kg/day and 0.96 ± 0.11 on the day of endoscopic submucosal dissection, whereas one day after the endoscopic submucosal dissection they were 21.7 ± 3.2 kcal/kg/day and 1.03 ± 0.14, showing significant increases (p<0.001, respectively). The stress factor on the postoperative day 1 was computed as 1.07. This increase was low in comparison to that experienced for surgery, suggesting that the degree of perioperative invasiveness in patients receiving endoscopic submucosal dissection is lower in comparison to that during surgery (The study of the resting energy metabolism and stress factor using an indirect calorimeter in the perioperative period of endoscopic operation: UMIN000027135).

Brazilian Intragastric Balloon Consensus Statement (BIBC): practical guidelines based on experience of over 40,000 cases

BACKGROUND

Intragastric balloons (IGBs) are a minimally invasive option for obesity treatment, acting as a space-occupying device and leading to weight loss through increased satiety. This device has been growing in popularity owing to its safety profile and good weight loss results. However, there are no published guidelines that standardize the technical aspects of the procedure.

OBJECTIVES

To create a practical guideline for intragastric balloon usage.

SETTING

Private and Academic Settings, Brazil.

METHODS

A consensus meeting was held in São Paulo, Brazil, in June 2016, bringing together 39 Brazilian endoscopists with extensive experience in IGBs from all regions of the country. Topics on patient selection, indications, contraindications, multidisciplinary follow-up, technique, and adverse events were discussed in the form of questions. After electronic voting, a consensus was defined when there was ≥70% agreement. Experts were also requested to provide data on their experience with IGBs.

RESULTS

The selected experts discussed and reached a consensus on 76 questions, mainly concerning specific indications and contraindications for the procedure; technical details, such as patient preparation, minimum balloon-filling volume, techniques for implant and explant; patient follow-up and recommended medication for the adaptation period; and adverse event management. The overall Brazilian expert data encompassed 41,863 IGBs, with a mean percentage total weight loss of 18.4% ± 2.9%. The adverse event rate after the adaptation period was 2.5%, the most common being hyperinflation (.9%) and spontaneous deflation (.8%) of the device. The early removal rate due to intolerance was 2.2%.

CONCLUSIONS

The present consensus represents practical recommendations for performing IGB procedures and reflects Brazil's significant experience with this device. The experience of over 40,000 cases shows that the device leads to satisfactory weight loss with a low rate of adverse events.

A nomogram to predict lymph node metastasis in patients with early gastric cancer

Background

Lymph node status is crucial to determining treatment for early gastric cancer (EGC). We aim to establish a nomogram to predict the possibility of lymph node metastasis (LNM) in EGC patients.

Methods

Medical records of 952 EGC patients with curative resection, from 2002 to 2014, were retrospectively retrieved. Univariate and multivariate analysis were performed to examine risk factors associated with LNM. A nomogram for predicting LNM was established and internally validated.

Results

Five variables significantly associated with LNM were included in our model, these are sex (Odd ratio [OR] = 1.961, 95% confidence index [CI], 1.334 to 2.883; P = 0.001), depth of tumor (OR = 2.875, 95% CI, 1.872 to 4.414; P = 0.000), tumor size (OR = 1.986, 95% CI, 1.265 to 3.118; P = 0.003), histology type (OR = 2.926, 95% CI, 1.854 to 4.617; P = 0.000) and lymphovascular invasion (OR = 4.967, 95% CI, 2.996 to 8.235; P = 0.000). The discrimination of the prediction model was 0.786.

Conclusions

A nomogram for predicting lymph node metastasis in patients with early gastric cancer was successfully established, which was superior to the absolute endoscopic submucosal dissection (ESD) indication in terms of the clinical performance.