A Successful 12-Month Trial of a Lumen-Apposing Self-Expandable Metallic Stent on a Benign Recalcitrant After Surgical Stricture

Gastrojejunal anastomotic strictures are common postsurgical complications that may be treated endoscopically. In some cases, conventional endoscopic dilations may prove ineffective, prompting consideration of covered self-expandable metal stents as the next step. However, the efficacy of these stents may be limited by their risk of migration. Lumen-apposing self-expandable metallic stents pose a lower migration risk because of their unique design and offer a possible off-label solution for recalcitrant strictures. We describe a patient with a postsurgical, gastrojejunal anastomotic stricture refractory to several interventions, who achieved long-lasting remission of symptoms after a 12-month trial of lumen-apposing self-expandable metallic stent placement.

Increased Prevalence of Alcohol-Related Gastrointestinal and Liver Diseases During the COVID-19 Pandemic

BACKGROUND

Higher prevalence of alcohol-related gastrointestinal (GI) and liver diseases (ARGLDs) were anecdotally reported during the COVID-19 pandemic, but little published evidence exists.

METHODS

A healthcare system audit of inpatient GI consults was performed during the pandemic's lockdown phase (3/23/2020-5/10/2020, n=558) and reopening phase (6/1/2020-7/19/2020, n=711) with comparison to those timeframes in 2019.

RESULTS

Consult volume decreased by 27.7% during the lockdown, but the proportion of ARGLDs increased by 59.6% (p=0.03). This trend continued during reopening, with potentially more severe disease as more patients required endoscopic intervention. Patients with alcoholic hepatitis during reopening were younger compared to the lockdown.

CONCLUSIONS

Our study demonstrates increased prevalence and severity of ARGLDs amongst younger individuals during the COVID-19 pandemic. This increase started during the lockdown but worsened despite relaxation of restrictions. Systems to increase screening for and treatment of alcohol use disorder as society recovers from the pandemic remain imperative.

Effect of Proton Pump Inhibitor Therapy on NOX5, mPGES1 and iNOS expression in Barrett's Esophagus

Acid reflux may contribute to the progression from Barrett’s esophagus (BE) to esophageal adenocarcinoma (EA). However, it is not clear whether the molecular changes present in BE patients are reversible after proton pump inhibitor (PPI) treatment. In this study we examined whether PPI treatment affects NOX5, microsomal prostaglandin E synthase (mPGES)-1 and inducible nitric oxide synthase (iNOS) expression. We found that NADPH oxidase 5 (NOX5), mPGES-1 and iNOS were significantly increased in BE mucosa. One-month PPI treatment significantly decreased NOX5, mPGES1 and iNOS. In BAR-T cells, NOX5 mRNA and p16 promoter methylation increased after pulsed acid treatment in a time-dependent manner. Four or eight-week-acid induced increase in NOX5 mRNA, NOX5 protein and p16 methylation may be reversible. Twelve-week acid treatment also significantly increased NOX5, mPGES1 and iNOS mRNA expression. However, twelve-week-acid-induced changes only partially restored or did not recover at all after the cells were cultured at pH 7.2 for 8 weeks. We conclude that NOX5, mPGES1 and iNOS may be reversible after PPI treatment. Short-term acid-induced increase in NOX5 expression and p16 methylation might be reversible, whereas long-term acid-induced changes only partially recovered 8 weeks after removal of acid treatment.

Safety and efficacy of endoscopic spray cryotherapy for esophageal cancer

Although surgery is traditionally the standard of care for esophageal cancer, esophagectomy carries significant morbidity. Alternative endoscopic therapies are needed for patients who are not candidates for conventional treatment. The objective of this study is to assess the safety, efficacy, and tolerability of spray cryotherapy of esophageal adenocarcinoma. This study includes patients with esophageal adenocarcinoma who had failed or were not candidates for conventional therapy enrolled retrospectively and prospectively in an open-label registry and patients in a retrospective cohort from 11 academic and community practices. Endoscopic spray cryotherapy was performed until biopsy proven local tumor eradication or until treatment was halted due to progression of disease, patient withdrawal or comorbidities. Eighty-eight patients with esophageal adenocarcinoma (median age 76, 80.7% male, mean length 5.1 cm) underwent 359 treatments (mean 4.4 per patient). Tumor stages included 39 with T1a, 25 with T1b, 9 with unspecified T1, and 15 with T2. Eighty-six patients completed treatment with complete response of intraluminal disease in 55.8%, including complete response in 76.3% for T1a, 45.8% for T1b, 66.2% for all T1, and 6.7% for T2. Mean follow-up was 18.4 months. There were no deaths or perforations related to spray cryotherapy. Strictures developed in 12 of 88 patients (13.6%) but were present before spray cryotherapy in 3 of 12. This study suggests that endoscopic spray cryotherapy is a safe, well-tolerated, and effective treatment option for early esophageal adenocarcinoma.

Safety and efficacy of endoscopic spray cryotherapy for Barrett's dysplasia: results of the National Cryospray Registry

Retrospective series have shown the efficacy of endoscopic spray cryotherapy in eradicating high-grade dysplasia (HGD) in Barrett's esophagus (BE); however, prospective data are lacking, and efficacy for low-grade dysplasia (LGD) is unclear. The aim of this study was to assess the efficacy and safety of spray cryotherapy in patients with LGD or HGD. A multicenter, prospective open-label registry enrolled patients with dysplastic BE. Spray cryotherapy was performed every 2-3 months until there was no endoscopic evidence of BE and no histological evidence of dysplasia, followed by surveillance endoscopies up to 2 years. Primary outcome measures were complete eradication of dysplasia (CE-D) and complete eradication of all intestinal metaplasia (CE-IM). Ninety-six subjects with Barrett's dysplasia (67% HGD; 65% long-segment BE; mean length 4.5 cm) underwent 321 treatments (mean 3.3 per subject). Mean age was 67 years, 83% were male. Eighty patients (83%) completed treatment with follow-up endoscopy (mean duration 21 months). In patients with LGD, rate of CE-D was 91% (21/23) and rate of CE-IM was 61% (14/23). In HGD, CE-D rate was 81% (46/57) and CE-IM was 65% (37/57). In patients with short-segment BE (SSBE) with any dysplasia, CE-D was achieved in 97% (30/31) and CE-IM in 77% (24/31). There were no esophageal perforations or related deaths. One subject developed a stricture, which did not require dilation. One patient was hospitalized for bleeding in the setting of non-steroidal anti-inflammatory drug use. In the largest prospective cohort to date, data suggest endoscopic spray cryotherapy is a safe and effective modality for eradication of BE with LGD or HGD, particularly with SSBE.

Safety and efficacy of endoscopic spray cryotherapy for esophageal cancer

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Background: Although surgery is traditionally the standard of care for esophageal cancer, esophagectomy carries significant morbidity and mortality. Alternative endoscopic therapies are needed for patients who are not candidates for conventional treatment. The objective of this study was to assess the safety, efficacy, and tolerability of spray cryotherapy of esophageal cancer. Methods: This study includes patients enrolled retrospectively and prospectively in an open-label registry and patients in a retrospective cohort from twelve academic and community practices. Endoscopic spray cryotherapy was performed until local tumor eradication was confirmed by biopsy or until treatment was halted due to progression of disease, patient withdrawal or co-morbidities. Results: One-hundred and eight patients (median age 75.5, 79.6% male, 93.5% adenocarcinoma, mean length 5.2 cm) underwent 442 treatments (mean 4.2 per patient). Tumor stages included 40 with T1a, 27 with T1b, 10 with unspecified T1, 15 with T2, and 16 with no T stage reported. One-hundred and six patients completed treatment with complete response of intraluminal disease in 54.7%, including complete response in 74.4% for T1a, 50% for T1b, 65.3% for all T1, 6.7% for T2, and 50% for those with no T stage reported. Mean follow-up was 17.3 months. There were no deaths or perforations related to spray cryotherapy. Strictures developed in 11 of 108 patients (10.2%) but were present before spray cryotherapy in 3 of 11. Conclusions: This study suggests that endoscopic spray cryotherapy is safe, well tolerated and effective for early esophageal cancer in patients who are not candidates for conventional therapy.

Continued evidence for safety of endoscopic retrograde cholangiopancreatography during pregnancy

AIM: To report the safety of continued use of endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy at various maternal ages.

METHODS: A retrospective chart review of pregnant patients who underwent ERCP at a tertiary academic center was undertaken between 2002 and 2012. Pertinent past medical history and initial presenting laboratory data were collected. Review of the procedure note for each ERCP performed provided documentation of lead shielding, type of sedation, fluoroscopy time, and post-procedure complications. Patients’ clinical courses were reviewed until the time of delivery and pregnancy complications with fetal outcomes were examined. Data was stratified based upon the mother’s age at the time of ERCP: 18-21, 22-29, and ≥ 30 years of age.

RESULTS: Twenty pregnant patients who underwent ERCP between 2002 and 2012 were identified. The mean age at the time of ERCP was 26.4 years (18-38 years) and the average trimester was the second. The indications for ERCP were choledocholithiasis in 17 patients, gallstone pancreatitis in 2 patients, and cholangitis in 1 patient. The mean fluoroscopy time of ERCP was 3.8 min (0.3-23.6 min). Sphincterotomy was performed in 18 patients with therapeutic intent and not as a prophylactic measure to prevent recurrences. Clinical documentation of use of protective shielding was found in only 8 notes (40%). Post procedure complications were limited to two cases of post-ERCP pancreatitis (10%). Elective cholecystectomy was performed shortly after ERCP in 11 of the pregnant patients. Birth records were available for 16 patients, of which 15 had full-term pregnancies. Cesarean sections were performed in 5 (31%) patients. Term birth weight was greater than 2500 g in all cases except one in which the mother had a known hypercoagulable state.

CONCLUSION: ERCP during pregnancy is both safe and efficacious regardless of maternal age or trimester.

Predictors of gastroesophageal reflux symptoms in pregnant women screened for sleep disordered breathing: a secondary analysis

BACKGROUND

Gastroesophageal reflux disease (GERD) is common in pregnancy. The cause is multifactorial, including a decreased or transient lower esophageal sphincter relaxation, increased intra-abdominal pressure, and gastrointestinal motility disturbances.

AIMS

Evaluate the incidence of GERD in pregnancy and assess predictors and predisposing factors.

METHOD

This is a secondary analysis of a survey of postpartum women regarding symptoms of sleep disordered breathing (SDB) and GERD performed at a large tertiary care center. Patients rated heartburn frequency during pregnancy as either never, occasionally/sometimes, or frequently/always. Pregnancy outcomes and newborn information was collected. Categorical variables were compared by Fisher's exact test and continuous variables were compared by Anova or Kruskal-Wallis test. Multinominal logistic regression was also performed.

RESULTS

Information regarding 1000 mothers and 1025 newborns was reviewed. The majority of mothers were Caucasian (68.8%) with mean age 29 ± 6.1 years. A total of 56.7% had GERD frequently/always; and 25.5% had none. GERD symptoms correlated with pre-pregnancy body mass index (BMI), BMI at delivery, maternal age, smoking and symptoms of SDB. There was no significant correlation between fetal weight and maternal weight gain with GERD symptoms. Symptoms were more frequent in white non-Hispanic women than in other racial groups.

CONCLUSIONS

This study suggests that GERD symptoms correlate with pre-pregnancy BMI and BMI at delivery, but not with the amount of weight gain during pregnancy. Maternal age, smoking, race, and SDB are also associated with GERD. Interestingly, fetal weight/uterine size did not seem predictive of developing GERD in pregnancy.

Current state of endoscopic therapies in Barrett's esophagus and esophageal cancer

Barrett's esophagus (BE) is a premalignant condition that predisposes patients to esophageal adenocarcinoma. This risk increases with increasing dysplasia, especially in patients with BE and high-grade dysplasia. Radical esophagectomy had long been the only option for these patients; however, it has been associated with significant morbidity and mortality. Endoscopic therapies have been increasingly used as an alternative to radical esophagectomy given the minimally invasive nature and tolerability of the procedure relative to surgery. Currently, the most widely used endoscopic therapies include endoscopic mucosal resection, photodynamic therapy, CryoSpray ablation, and radiofrequency ablation. Retrospective and prospective studies on the use of each of these modalities in patients with nondysplastic BE, dysplastic BE, and early esophageal cancer have demonstrated their effectiveness in eradication of dysplasia with or without reversion of Barrett's epithelium to normal squamous epithelium of the esophagus. These modalities are well tolerated, safe, and have few side effects. Ultimately, more research is needed regarding their ability to fully displace surgical intervention as the gold standard, although at this point their role in poor operative candidates or patients seeking conservative approaches remains promising.

Spray cryotherapy for palliation of locally advanced adenocarcinoma in Barrett's esophagus

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Background: Up to 60% of patients with esophageal cancer are deemed inoperable at the time of diagnosis due to either advanced stage or significant co-morbidities. Currently, endoscopic palliative measures include stenting and photodynamic therapy. Although spray cryotherapy has been successfully used in ablating Barrett's esophagus, and different grades of dysplasia, there has been only one published case describing complete remission of squamous cell carcinoma following cryoablation. We present the first case of the use of the CryoSpray Ablation System (CSA Medical, Baltimore, MD) for palliative treatment of an esophageal T3 adenocarcinoma in an elderly woman with dysphagia and weight loss.

Methods: An upper endoscopy was performed with standard monitored anesthesia. A special dual lumen Cryo decompression tube is introduced over an endoscopically placed savary guidewire in the gastric antrum and connected to suction. This tube is used to decompress the stomach when the liquid nitrogen is sprayed. Cryoablation is performed using the CryoSpray Ablation System that uses liquid nitrogen is delivered via a 7 Fr catheter at low pressures (2-3 PSI) at -196°C.The lesion was treated with four freeze cycles of 10-20 seconds each with 60 second interim thaws. Freezing and thawing techniques were monitored by direct visualization. The procedure is repeated every 4-6 weeks. The patient received a total of 7 treatments over 10 months.

Results: The patient did not experience any adverse effects after treatment. After 3 treatments (week 20), complete endoscopic resolution of the lesion was noted, with regression of the Barrett's mucosa and major improvement of her dysphagia. At week 28, a recurrent mass was seen on EGD in the mid-esophagus. This was treated with 3 sessions of spray cryotherapy at 4 week intervals with improvement of dysphagia after each application. 11 months after her initial cryotherapy, the patient opted to have an esophageal stent due to tumor progression.

Conclusions: Spray cryotherapy is a safe and effective endoscopic modality for the ablation of Barrett's esophagus and superficial esophageal cancer, it is a promising new modality for the palliation of advanced esophageal cancer.

No significant financial relationships to disclose.

Role of endoscopic ultrasound in the diagnosis and staging of pancreatic cancer

Endoscopic Ultrasound (EUS) is a relatively new modality. Its high resolution makes it possible to detect tumors of 5mm in diameter otherwise missed by other imaging modalities. It is more accurate than computerized tomography (CT) scan, Transabdominal Ultrasound (US) and Magnetic Resonance Imaging (MRI) in diagnosing pancreatic lesions, especially those less than 20mm in diameter. EUS can be used to obtain pancreatic and nodal tissue using ultrasound- guided fine needle aspiration increasing the diagnostic yield and helping determining further management. It can also determine vascular involvement by pancreatic cancer with a sensitivity of more than 90%. The current indications for EUS in the diagnosis and management of pancreatic cancer will be reviewed.

Acute transverse myelitis in systemic lupus erythematosus: a case of rapid diagnosis and complete recovery

Acute transverse myelitis is a rare and serious complication of systemic lupus erythematosus. Delay in diagnosis and treatment is associated with significant morbidity and mortality. Earlier diagnosis is facilitated by magnetic resonance imaging. Treatment of systemic lupus erythematosus-related acute transverse myelitis remains controversial. The use of steroids alone may result in incomplete recovery. We report a patient who was promptly diagnosed with systemic lupus erythematosus-related acute transverse myelitis by magnetic resonance imaging. The patient had complete resolution of her symptoms following aggressive treatment with steroids and cyclophosphamide. Review of published treatment of systemic lupus erythematosus-related acute transverse myelitis suggests aggressive therapy with steroids and cyclophosphamide may provide the best outcome.