EUS-guided gastroenterostomy with a lumen apposing self-expandable metallic stent relieves gastric outlet obstruction - a Scandinavian case series

BACKGROUND

EUS-guided gastroenterostomy (EUS-GE) with lumen-apposing metallic stents (LAMS) in patients with gastric outlet obstruction (GOO) has proven to be an alternative to luminal stenting in the duodenum and surgical gastroenterostomy. In severely ill patients, the method can provide improved quality of life (QoL) and symptom relief by restoration of the luminal passage of fluid and nutrients to the small intestine.

AIM

To assess the technical and clinical success and safety of EUS-GE.

MATERIAL AND METHODS

A dual center retrospective case series of 33 consecutive patients with GOO due to malignant (n = 28) or non-malignant conditions (n = 5). The patients were treated with EUS-GE using cautery enhanced LAMS. Procedures were performed guided by EUS and fluoroscopy in general anesthesia or conscious sedation.

RESULTS

Technical success was achieved in all patients. The median procedure time was 71 min and the median hospital stay was three days. Thirty (91%) patients were able to resume oral nutrition after the procedure. Ten patients (30%) experienced adverse events (AEs), including migration of the stent, bleeding, and infection. Four patients had fatal AEs (12%). All stent-related AEs were handled endoscopically. Five patients (15%) needed re-intervention. The median survival time for patients with malignant obstruction was 8.5 weeks (0.5-76), and 13 patients with obstructing malignancies lived 12 weeks or longer.

CONCLUSION

EUS-GE is a minimally invasive and efficient method for restoration of the gastrointestinal passage and may improve palliative care for patients with GOO. The method has potential hazards and should only be offered in expert centers that regularly perform the procedure.

Correlation between faecal excretion of indium-111-labelled granulocytes and calprotectin, a granulocyte marker protein, in patients with inflammatory bowel disease

BACKGROUND

Several studies have suggested that clinical indices of disease activity in inflammatory bowel disease (IBD) do not adequately reflect the degree of inflammation in most such patients. Faecal excretion of indium-111-labelled neutrophilic granulocytes has been suggested as the gold standard of disease activity, but its complexity and high cost and the exposure of patients to ionizing irradiation have limited the use of this technique. The aim of this study was to investigate the correlation between the faecal excretion of the granulocyte marker protein calprotectin and that of 111In-labelled granulocytes.

METHODS

Calprotectin in stool extracts from 19 patients with Crohn's disease (CD), 10 with ulcerative colitis (UC), and 9 presumably healthy controls was assessed with a simple enzyme-linked immunosorbent assay. Simultaneously, the faecal excretion of autologous 111In-labelled granulocytes was measured.

RESULTS

There was a strong correlation between the average daily excretion of calprotectin and that of the total 3-day excretion of 111In-labelled granulocytes (r = 0.87, P < 0.0001). Furthermore, the concentration of calprotectin, assessed in a small stool sample on day 1, also correlated well with the excretion 111In-labelled granulocytes (r = 0.80, P < 0.0001).

CONCLUSION

The results suggest that faecal calprotectin reflects the granulocyte migration through the gut wall in patients with IBD and hence might serve as a simple, inexpensive alternative to the indium-111 technique.

Characterization and quantification of plasma proteins excreted in faeces from healthy humans

Faecal plasma protein loss was studied in 38 healthy adults. Using crossed immunoelectrophoresis and single radial immunodiffusion the most frequently found proteins were alpha 1-antitrypsin, IgA, alpha 1-antichymotrypsin (found in 97, 92, and 84% of subjects), prealbumin and IgM (both found in 55%). The major plasma proteins, albumin and IgG, were found in 37 and 13% of subjects, respectively, and in trace amounts only. alpha 2-macroglobulin could not be detected. There was no relation between the presence of proteins in faeces and their plasma concentration. When added to faeces, alpha 1-antitrypsin, alpha 1-antichymotrypsin, and prealbumin were resistant to incubation (37 degrees C, 48 h), whereas albumin, IgG, IgM, and IgA were rapidly degraded (within 8-24 h). Some IgA was bound to secretory component, indicating enteric secretion. alpha 2-macroglobulin was semi-resistant to degradation, but its passage to the intestinal lumen may have been prevented by its molecular size. In conclusion, resistance to degradation, enteric secretion, and low molecular weight are the primary factors which favour the excretion of plasma proteins in faeces. The technique used in this study allows further studies in patients with inflammatory changes and protein-losing enteropathy.

Treatment of active distal ulcerative colitis with immunoglobulin G enemas

Seven patients with active distal ulcerative colitis were treated with IgG enemas given as a daily bedtime retention enema for two weeks. Evaluation of effect was assessed by means of sigmoidoscopy with biopsy, measuring acute phase reactants in peripheral blood, and measuring the faecal protein loss. Clinical signs of active disease were registered by the patients on a diary chart. Five patients completed the treatment period, two patients were withdrawn after 7 and 10 days due to deterioration of disease. Four patients did not register any effect, whereas one patient improved clinically. In conclusion, rectally administered IgG did not exert any effect on rectal ulcerative colitis in our study.