Propensity score-matched retrospective cohort study of endoscopic ultrasound-guided gastroenterostomy and enteral stenting for malignant gastric outlet

BACKGROUND

Symptomatic malignant gastric outlet obstruction (GOO) significantly reduce patients' quality of life. Endoscopic treatment involves enteral stenting or endoscopic ultrasonography to perform gastroenterostomy (EUS-GE). Aim was to compare enteral stenting with EUS-GE for endoscopic treatment of malignant GOO.

METHODS

We retrospectively compared enteral stenting with EUS-GE for the treatment of malignant GOO. Patients treated at our institution were identified and a propensity score matching analysis was performed. Treatment failure was the primary outcome, while the secondary endpoints were time until treatment failure, technical and clinical success rates, and adverse event rates.

RESULTS

Eighty-eight patients were included in the final analysis. Of whom, 44 were included in each of the two treatment groups. Treatment failure occurred significantly more frequently in the enteral stenting group (13/44) compared with the EUS-GE group (4/44; hazard ratio: 4,9; 95% CI 1.6-15.1). A Kaplan-Meier analysis revealed a median time until treatment failure of 22.0 weeks (95% CI 4.6-39.4) in the enteral stenting group compared with 76.0 weeks (95% CI 55.9-96.1) in the EUS-GE group (P = .002). No difference in technical success and clinical success was detected. Technical success was achieved in 43/44 patients (97.7%) in the enteral stenting group compared with 41/44 patients (93.2%) in the EUS-GE group, while clinical success was achieved in 32/44 (72.7%) and 35/44 (79.5%) patients, respectively. Nine adverse events were observed (9/44, 10.2%). There were no differences in 30-day adverse event rate and 30-day mortality rate.

CONCLUSION

EUS-GE was superior to enteral stenting in the treatment of malignant GOO in terms of treatment failure and time until treatment failure in a propensity score-matched cohort.

Efficacy and safety of combined EMR and endoscopic full-thickness resection (hybrid EFTR) for large nonlifting colorectal adenomas

BACKGROUND AND AIMS

Endoscopic full-thickness resection (EFTR) with a full-thickness resection device (FTRD) has become the standard technique for selected nonlifting colorectal adenomas, but tumor size is the major limitation. However, large lesions might be approached in combination with EMR. Herein, we report the largest single-center experience to date of combined EMR and EFTR (hybrid EFTR) in patients with large (≥25 mm) nonlifting colorectal adenomas not amenable to EMR or EFTR alone.

METHODS

This is a single-center retrospective analysis of consecutive patients who underwent hybrid EFTR of large (≥25 mm) nonlifting colorectal adenomas. Outcomes of technical success (successful advancement of the FTRD with consecutive successful clip deployment and snare resection), macroscopic complete resection, adverse events, and endoscopic follow-up were evaluated.

RESULTS

Seventy-five patients with nonlifting colorectal adenomas were included. Mean lesion size was 36.5 mm (range, 25-60 mm), and 66.6% were located in the right side of the colon. Technical success was 100% with macroscopic complete resection in 97.3%. Mean procedure time was 83.6 minutes. Adverse events occurred in 6.7%, leading to surgical therapy in 1.3%. Histology revealed T1 carcinoma in 16%. Endoscopic follow-up was available in 93.3% (mean follow-up time, 8.1 months; range, 3-36) and showed no signs of residual or recurrent adenoma in 88.6%. Recurrence (11.4%) was treated endoscopically.

CONCLUSIONS

Hybrid EFTR is safe and effective for advanced colorectal adenoma that cannot be approached by EMR or EFTR alone. Hybrid EFTR expands the indication of EFTR substantially in selected patients.

Substance use disorder and the baby boomers: Does German outpatient addiction care face a change?

Background

The aging of baby boomers is expected to confront addiction care with new challenges. This study aims to investigate if German addiction care is confronted with a sustained change in its clientele that was initiated by the baby boomers.

Methods

Using data from Berlin outpatient addiction care facilities, we contrasted type of primary substance use disorder and number of comorbid substance use disorders in baby boomers with an older (n = 6524) as well as a younger cohort (n = 15677). To isolate cohort effects, two-level random-intercept regression models were applied in the overlapping age groups of the baby boomer cohort with each other cohort.

Results

Compared to the older cohort, alcohol use disorder lost importance while illicit substances use disorder gained importance in the baby boomers. Baby boomers presented a higher number of comorbid substance use disorders than the older cohort. Comparing baby boomers with the younger cohort, these relationships pointed in the opposite direction.

Conclusions

Outpatient addiction care faces a sustained change to more illicit and comorbid substance use disorders. The addiction care system ought to adapt its services to address the changing needs of its clientele.

Key messages

Baby boomers differed in comparison to the older cohort regarding type of substance use disorder and comorbid substance use disorders. The changes set off by the baby boomers continued in the younger cohort.

The dependence of calcium efflux from cardiac muscle on temperature and external ion composition

1. Exchangeable Ca in guinea-pig auricles and ventricular trabeculae of sheep and calf hearts was labelled with (45)Ca and the loss of radioactivity into inactive rinsing solutions of different ion composition was measured for periods up to 6 hr. At no time did the decrease of radioactivity in the muscle follow a single exponential course, while the rate coefficient k (= fraction of (45)Ca lost per minute from muscle into rinsing solution) decreased slightly with time.2. On the basis of the temperature-sensitivity of Ca efflux from auricles the activation energy has been calculated to have a value of 5900 cal/mole, corresponding to a Q(10) of 1.35. 2,4-Dinitrophenol (5.5 x 10(-5) - 5.5 x 10(-4)M) had either no effect on Ca efflux or increased it slightly.3. Compared to control efflux in 1.8 mM [Ca](o) Ca efflux decreased to 70% in Ca-free solution, to 20% in Ca-free, Na-free solution and to 65% in Ca-containing, Na-free solution, NaCl being replaced by either sucrose or LiCl. Quantitatively, Ca efflux from auricles has been shown to depend to a large extent on the ratio [Ca(2+)](o)/[Na(+)](o) (2). The affinity for Na of the activation site for Ca efflux (carrier) is much less than for Ca.4. The efflux from muscles soaked for about 2 hr in Ca-free solution was not linearly related to Ca-concentration in the tissue but followed a square law.5. While Ca content in auricles increased in Ca-containing, Na-poor solution it decreased again when Tyrode solution was readmitted indicating a Na-sensitive Ca net transport in cardiac muscle.6. The results are interpreted in terms of a modified exchange diffusion mechanism (Ussing, 1947) which is responsible for Ca extrusion from mammalian cardiac muscle.