Endoscopic ultrasound-guided gastroenterostomy with lumen-apposing metal stents: a retrospective multicentric comparison of wireless and over-the-wire techniques

BACKGROUND

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMSs) appears to be effective and safe in gastric outlet obstruction (GOO); however, the EUS-GE procedure is not standardized, with the use of assisted or direct methods still debated. The aim of this study was to compare the outcomes of EUS-GE techniques focusing on an assisted with orointestinal drain wireless endoscopic simplified technique (WEST) and the nonassisted direct technique over a guidewire (DTOG).

METHOD

This was a multicenter European retrospective study involving four tertiary centers. Consecutive patients who underwent EUS-GE for GOO between August 2017 and May 2022 were included. The primary aim was to compare the technical success and adverse event (AE) rates of the different EUS-GE techniques. Clinical success was also analyzed.

RESULTS

71 patients (mean [SD] age 66.2 10 years; 42.3 % men; 80.3 % malignant etiology) were included. Technical success was higher in the WEST group (95.1 % vs. 73.3 %; estimate of relative risk from odds ratio (eRR) 3.2, 95 %CI 0.94-10.9; P = 0.01). The rate of AEs was lower in the WEST group (14.6 % vs. 46.7 %; eRR 2.3, 95 %CI 1.2-4.5; P = 0.007). Clinical success was comparable between the two groups at 1 month (97.5 % vs. 89.3 %). The median follow-up was 5 months (range 1-57).

CONCLUSION

The WEST resulted in a higher technical success rate with fewer AEs, with clinical success comparable with the DTOG. Therefore, the WEST (with an orointestinal drain) should be preferred when performing EUS-GE.

Infections caused by hypervirulent Klebsiella pneumoniae in non-endemic countries: three case reports and review of the literature

OBJECTIVES

Spontaneous liver abscess caused by a hypervirulent Klebsiella pneumoniae strain was first described several decades ago in Taiwan and has been an emerging clinical entity worldwide ever since. We aimed to describe the clinical and microbiological characteristics of this infection in a non-endemic setting.

METHODS

A narrative literature review was conducted in PubMed for European case reports of hypervirulent Klebsiella pneumoniae from 2016 to 2021.

RESULTS

Forty case reports were retrieved. Mean age of the patients was 59 years and 72% were male. Diabetes mellitus was present in 33%. Twenty percent of the patients originated from an endemic region. A liver abscess and bacteremia were observed in, respectively, 83% and 80% of the cases. The most frequent metastatic infections were found in the eye (28%) and the lungs (28%). The sensitivity of molecular capsular antigen detection and the string test was 87% and 92%, respectively. Sixty-three percent of the strains had a wildtype resistance.

CONCLUSION

Hypervirulent Klebsiella pneumoniae infections in non-endemic countries are most frequently observed in middle-aged males. Clinicians should be vigilant for metastatic infections.

Is Lugol necessary for endoscopic resection of esophageal squamous cell neoplasia?

Background and study aims  Recent evidence suggests that lugol chromoendoscopy (LCE) and narrow-band imaging (NBI) have comparable sensitivity for detection of superficial esophageal squamous cell carcinoma (SCC). However, LCE is time-consuming and associated with side effects. The aim of this study was to compare the effectiveness of NBI and LCE in defining resection margins of esophageal SCC. Patients and methods  This was a retrospective observational cohort study of patients with esophageal SCC and dysplasia who underwent en-bloc resection between 1999 and 2017 at the Cliniques universitaires Saint-Luc, Brussels. Two groups were defined: 1) inspection with NBI only; and 2) inspection with LCE (with or without NBI). The primary endpoint was complete lateral resection rate. Multivariate regression was used to adjust for potential confounders. Results  A total of 102 patients with 132 lesions were included. Lesions were inspected with LCE in 52 % (n = 68) and with NBI only in 48 % (n = 64). Lesions 0-IIa were more frequent in the NBI group (37 %) and 0-IIb (60 %) in LCE. Lesion location, size, and histology and resection technique (endoscopic submucosal dissection in 122/132 cases, 92 %) were similar between the groups. The rate of complete lateral resection for invasive carcinoma was 90 % in LCE group and 94 % in NBI group ( P  = 0.498) and 65 % and 67 % ( P  = 0.813), respectively, for dysplasia complete lateral resection. These results remained non-significant after adjusting for potential confounders. Conclusions  Mucosal inspection and delineation of tumors with lugol chromoendoscopy before endoscopic resection of esophageal squamous cell lesions was not associated with increased complete lateral resection rate when compared to NBI.

BSGIE survey on COVID-19 and gastrointestinal endoscopy in Belgium : results and recommendations

BACKGROUND AND AIMS

With the first wave of the COVID-19 pandemic declining, activities in the gastrointestinal clinic are being recommenced after a period of stringent measures. Since a second COVID-19 wave is not entirely ruled out health care professionals might remain faced with the need to perform endoscopic procedures in patients with a confirmed positive or unknown COVID-19 status. With this report we aim to provide a practical relevant overview of preparation and protective measures for gastroenterologists based on the currently available guidelines and our local experience and results of a national Belgian survey, to guarantee a fast recall of an adequate infection prevention if COVID-19 reoccurs.

METHODS

From the 23rd of March 2020 and the 13th of May 2020 we performed a Pubmed, Embase and Medline search, resulting in 37 papers on COVID-19 and endoscopy. Additionally, we combined these data with data acquired from the national BSGIE survey amongst Belgian gastroenterologists.

RESULTS

Based on 72 completed surveys in both university and non-university hospitals, the results show (1) a dramatic (<20%) or substantial (<50%) decrease of normal daily endoscopy in 74% and 22% of the units respectively, (2) a difference in screening and protective measures between university and non-university hospitals. These findings were subsequently compared with the current guidelines.

CONCLUSION

Based on new data from the BSGIE survey and current guidelines we tried to realistically represent the current COVID-19 trends in protective measures, screening and indications for endoscopy and to provide a practical overview as preparation for a possible second wave.

Risk factors for conversion to snare resection during colorectal endoscopic submucosal dissection in an expert Western center

BACKGROUND

There are limited data regarding the risk factors and consequences of conversion to endoscopic mucosal resection (rescue EMR) during colorectal endoscopic submucosal dissection (ESD) in Western centers.

METHODS

This was a retrospective analysis of a prospectively collected database, from which 225 consecutive ESDs performed between 2013 and 2017 were selected. Of the included patients, 39 (18.6 %) required rescue EMR. Pre- and per-procedure characteristics were evaluated to determine the features associated with the need for rescue EMR. Outcomes and complications were also assessed.

RESULTS

210 patients were included, with median tumor size of 40 mm (range 20 - 110) and most tumors being in a non-rectal location (66.2 %). When compared with full ESD, rescue EMR was significantly associated with lower rates of en bloc resection (43.6 % vs. 100 %) and complete resection (R0 status; 28.2 % vs. 88.9 %), and with a higher rate of recurrence (5.1 % vs. 0 %) and more need for surgery (15.4 % vs. 3.5 %). In multivariable analysis, non-lifting (adjusted odds ratio [OR^a] 3.06, 95 % confidence interval [CI] 1.23 - 7.66; P = 0.02), nongranular-type laterally spreading tumor (LST-NG; OR^a 2.56, 95 %CI 1.10 - 5.99; P = 0.03), and difficult retroflexion (OR 3.22, 95 %CI 1.01 - 10.28; P = 0.049) were independent risk factors associated with conversion to rescue EMR, while tumor size and location were not.

CONCLUSIONS

During ESD, the presence of poor lifting, LST-NG morphology, and a difficult retroflexed approach were factors associated with the need to convert to rescue EMR. Conversion to rescue EMR remains a valuable strategy.

Eikenella corrodens perirenal abscess resulting from a pancreatic fistula in a patient with chronic pancreatitis. Case report and literature review

We present a case of a right perirenal Eikenella corrodens abscess in a patient with chronic pancreatitis and poor dental hygiene. Endoscopic Retrograde CholangioPancreaticography (ERCP) revealed a pancreatic fistula draining to the right perirenal loge. The patient was treated with broad-spectrum antibiotics, percutaneous drainage and endoscopic stenting of the duct of Wirsung, stopping the supply of the fistula. A full recovery in our patient was observed. Considering the uncommon location of the abscess, a review of the different aetiologies of perirenal abscesses and their distrubution patterns, and the endoscopic treatment of symptomatic pancreatic fistulas seemed worthwhile.

The predictive value of negative capsule endoscopy for the indication of Obscure Gastrointestinal Bleeding: no reassurance in the long term

BACKGROUND

Capsule Endoscopy (CE) has become the first-line tool to identify an underlying etiology for Obscure Gastrointestinal Bleeding (OGIB) in the small bowel (SB). This study aims to investigate the long-term outcome of patients with a negative CE.

METHODS

Retrospective review of standardized application forms of all patients who underwent CE for OGIB at the Ghent University Hospital between 2002 and 2013. Follow-up data on patients with a negative CE result (n=263) were collected by contacting the referring physician.

RESULTS

Follow-up was available for 211 patients (Male, n=107 ; Female, n=104 ; Overt bleeding, n=76 ; Occult bleeding, n=135). Median follow-up time was 51.7 months (range 1.4-139.6 months). Ninety-six patients underwent further diagnostics, showing a cause for OGIB in 57 (59.4%). Final outcome for the complete cohort of negative CEs was : 139 (65.9%) true negative (i.e. non-SB cause of bleeding/ resolved OGIB), 19 (9%) false negative (i.e. SB cause of OGIB) and 53 (25.1%) ongoing bleeding without cause. Missed SB lesions were : angiodysplasia (n=11), Meckel's diverticulum (n=3), SB malignancy (n=3), jejunal erosions (n=1) and NSAID-induced SB ulcerations (n=1). Bleeding resolved in 138/209 patients (66%) of which 79 underwent non-specific therapy.

CONCLUSIONS

Negative CEs in patients with OGIB do not reassure the treating physician, but warrant close monitoring. In suspicious cases, alternative diagnostic modalities are recommended, showing a high diagnostic yield. (Acta gastroenterol. belg., 2016, 79, 405-413).

New devices for the bariatric patient

Over the past years, the global prevalence of obesity has risen dramatically. This generates enormous costs for the health care system, since obesity is associated with hypertension, diabetes mellitus type 2, coronary heart diseases, stroke, dyslipidemia, psychological problems, and cancer. Bariatric surgery has demonstrated to be the most effective and durable treatment option in the morbidly obese patient. Despite its evidence based efficacy, less than 1% of obese patients will undergo surgery. The role of new, less-invasive devices for the bariatric patient needs to be defined. Are they situated in the gap between lifestyle modification and surgery for the obese patient, in the preoperative work-up of the super-obese patient, in patient groups that are currently excluded for surgery, and/or in the routine treatment of obesity as a chronic disease? This review will focus on emerging technologies for the bariatric patient that are currently in clinical practice or in an advanced development stage, with different modes of action: inducing stretch on the gastric wall (space-occupying or stitching devices), vagal neuromodulation, altering the absorption, or exclusion of the duodenum and proximal jejunum. Exploring the evidence and the indication of different therapeutic approaches and innovations will be an interesting field of research in the near future.

Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography in bariatric Roux-en-Y gastric bypass patients

BACKGROUND

Performing endoscopic retrograde cholangiopancreatography in bariatric patients who underwent Roux-en-Y gastric bypass surgery is challenging due to the long anatomical route required to reach the biliopancreatic limb.

AIM

Assessment of the feasibility and performance of laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography.

METHODS

A retrospective multicenter observational consecutive-patient cohort study of all patients in the period May 2008 to September 2014 with a history of Roux-en-Y gastric bypass who presented with complicated biliary disease and who underwent a laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography. The laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography procedure was similar in all centers and was performed through a 15 mm or 18 mm trocar that was inserted in the gastric remnant. Cholecystectomy was performed concomitantly when indicated.

RESULTS

In total, 23 patients underwent a laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography procedure. Two patients required a mini-laparotomy for transgastric access because of a complex surgical history resulting in multiple adhesions. Indications included ascending cholangitis, choledocholithiasis, and biliary pancreatitis. Of the 23 patients, 13 underwent concomitant cholecystectomy. All patients successfully underwent biliary cannulation and sphincterotomy. No endoscopic procedure-related complications (i. e. bleeding, pancreatitis or retroperitoneal perforation) occurred. Mean hospital stay was 2.8 days (range 2 - 4).

CONCLUSIONS

Transgastric endoscopic retrograde cholangiopancreatography is a feasible approach in the treatment of pancreaticobiliary disease in Roux-en-Y gastric bypass patients, without major complications in our series and allows endoscopic treatment and cholecystectomy to be performed consecutively in a single procedure. In Roux-en-Y gastric bypass patients without a history of prior cholecystectomy presenting with complicated gallstone disease, combining cholecystectomy and transgastric endoscopic retrograde cholangiopancreatography as a first-line approach may be a valid treatment strategy.

Ascites: not always the usual suspects

A case report of a 44-year-old woman with an infrequent cause of ascites, i.e. intraperitoneal urine leakage, is presented. Urinary ascites due to spontaneous bladder rupture or fistula after radiation therapy for cervical cancer is not a rare complication and can develop several years after initial treatment. Diagnosis of urinary ascites should be suspected in patients with ascites and a history of radiation therapy for a bladder or a gynaecological disease. Measurement of urea and creatinine levels in urine, ascites and plasma is a simple and non-invasive diagnostic test. In physiological conditions, the ascites/plasma creatinine ratio approximates a ratio of one to one. This ratio is elevated to a value of 5/1 in case of urinary ascites. Although cystoscopy and imaging techniques such as cystography and computed tomography (with or without cystography) are extremely helpful, definitive diagnosis is frequently based on intraoperative findings, because of the lack of pathognomonic symptoms or signs. Surgery is the treatment of choice.

Reclassification of Lactobacillus thermotolerans Niamsup et al. 2003 as a later synonym of Lactobacillus ingluviei Baele et al. 2003

The relatedness of the speciesLactobacillus ingluvieiandLactobacillus thermotoleranswas investigated by comparing partial sequences of the 16S rRNA gene (99·9 % similarity over 1504 bp), thehsp60gene (98·8 % similarity over 954 bp) and therecAgene (98·5 % similarity over 452 bp) and by determining DNA–DNA binding levels (79±3 %) and genomic DNA G+C contents (50 and 49 mol%, respectively). These data, in addition to their similar biochemical characteristics, suggest that the two taxa constitute a single species. According to Rules 38 and 42 of theBacteriological Code, they should be united under the nameLactobacillus ingluviei, with the nameLactobacillus thermotoleransas a later heterotypic synonym.

Lactobacillus acidifarinae sp. nov. and Lactobacillus zymae sp. nov., from wheat sourdoughs

Three heterofermentative lactic acid bacteria, obtained from Greek and Belgian artisanal wheat sourdoughs, were preliminarily identified as Lactobacillus brevis-like after screening using whole-cell protein fingerprinting and 16S rRNA gene sequence analysis. The three sourdough isolates showed nearly identical sequences (>99·7 % sequence similarity), and highest similarities of 98·2 and 97·6 % were obtained to the species Lactobacillus spicheri and Lactobacillus brevis, respectively. Growth characteristics, biochemical features, amplified fragment length polymorphism fingerprinting, DNA–DNA hybridizations and DNA G+C contents demonstrated that the isolates represent two novel Lactobacillus species. The names Lactobacillus acidifarinae sp. nov. and Lactobacillus zymae sp. nov. are proposed and the type strains are LMG 22200T (=R-19065T=CCM 7240T) and LMG 22198T (=R-18615T=CCM 7241T), respectively.

Streptococcus minor sp. nov., from faecal samples and tonsils of domestic animals

Nine isolates, which were obtained from tonsils, anal swabs and faeces of dogs and from tonsils of a cat and a calf, constituted a homogeneous but unidentified taxon after screening with tRNA intergenic length polymorphism analysis and whole-cell protein fingerprinting. 16S rDNA sequence analysis classified representative strains in the genus Streptococcus. Highest sequence similarity (95·9 %) was obtained with Streptococcus ovis. Growth characteristics, biochemical features, DNA–DNA hybridization and DNA G+C contents of selected strains demonstrated that they represent a single, novel streptococcal species. The name Streptococcus minor sp. nov. is proposed for the novel species; the type strain (ON59T=LMG 21734T=CCUG 47487T) was isolated from a dog tonsil.

Phylogeny of Maricaulis Abraham et al. 1999 and proposal of Maricaulis virginensis sp. nov., M. parjimensis sp. nov., M. washingtonensis sp. nov. and M. salignorans sp. nov

Thirteen marine bacteria isolated from different locations, belonging to the genus Maricaulis, were characterized by 16S rRNA gene sequencing, DNA-DNA hybridizations and analysis of the internally transcribed 16S-23S rDNA spacer (ITS1) region, analysis of fatty acids from total lipids, mass spectrometry of polar lipids and determination of temperature and NaCl tolerances. The data obtained led to the identification of five new sulfoquinovosyl diacylglycerols, using tandem mass spectrometry, and the fragmentation patterns of the individual compounds. Four novel species were identified and described as Maricaulis virginensis sp. nov. (type strain VKM B-1 5139T)), Maricaulis parjimensis sp. nov. (type strain MCS 25(T)), Maricaulis washingtonensis sp. nov. (type strain MCS 6(T)) and Maricaulis salignorans sp. nov. (type strain MCS 18(T)). They differ in their temperature and salt tolerances and can be differentiated by their polar lipids and fatty acid patterns, as well as their ITS1 and 16S rRNA gene sequences.

Globicatella sulfidifaciens sp. nov., isolated from purulent infections in domestic animals

DNA-DNA hybridization experiments and comparative 165 rDNA sequence analysis revealed that six isolates from purulent joint and lung infections in calves, from a lung lesion in a sheep, and from a joint infection of a pig represented a novel species belonging to the genus Globicatella. Whole-cell protein electrophoresis and biochemical activity testing revealed that the isolates formed a homogeneous group differing from Globicatella sanguinis, the only species of this genus described to date. These animal isolates were classified as Globicatella sulfidifaciens sp. nov. with LMG 188441 (= CCUG 44365T), isolated from the lung of a calf, as the type strain. A detailed description of its phenotypic characteristics is presented. Hydrogen sulphide production was found to be a very useful diagnostic feature.

Enterococcus villorum sp. nov., an enteroadherent bacterium associated with diarrhoea in piglets

The taxonomic positions of five enteroadherent bacterial pig isolates, showing phenotypic characteristics most similar to those of Enterococcus durans and Enterococcus hirae, were investigated in a polyphasic study that included 16S rDNA sequence analysis, DNA-DNA hybridizations, DNA base-ratio determinations, whole-cell protein fingerprinting, D11344-primed PCR typing and an extensive examination of phenotypic properties. The results demonstrated that the organisms represent a new species in the Enterococcus faecium species group, for which the name Enterococcus villorum sp. nov. is proposed. The type strain is LMG 12287T (= CCM 4887T).

Sphingomonas alaskensis sp. nov., a dominant bacterium from a marine oligotrophic environment

Seven Gram-negative strains, isolated in 1990 from a 10(6)-fold dilution series of seawater from Resurrection Bay, a deep fjord of the Gulf of Alaska, were identified in a polyphasic taxonomic study. Analysis of 16S rDNA sequences and DNA-homology studies confirmed the phylogenetic position of all strains in the genus Sphingomonas and further indicated that all of the strains constitute a single homogeneous genomic species, distinct from all validly described Sphingomonas species. The ability to differentiate the species, both phenotypically and chemotaxonomically, from its nearest neighbours justifies the proposal of a new species name, Sphingomonas alaskensis sp. nov., for this taxon. Strain LMG 18877T (= RB2256T = DSM 13593T) was selected as the type strain.