Introduction

With accumulating evidence on endoscopic ultrasonography-guided hepaticogastrostomy (EUS‑HGS) as a salvage treatment for malignant biliary obstruction (MBO), EUS-HGS has now recognized as one of the primary options even in patients with possible ERCP. However, recurrent biliary obstruction (RBO) occasionally occurs after EUS-HGS and it might impose a heavy burden on patients.

Aims & Methods

This study aimed to investigate the safety and effectiveness of reintervention for RBO after EUS-HGS.
Between August 2011 and February 2023, 177 patients with MBO underwent EUS-HGS using self-expandable metal stent (SEMS), and among them a total of 45 patients who required reintervention for RBO after EUS-HGS were enrolled in this study. Technical success (defined as successful reintervention through the HGS stent), clinical success (defined as successful management of cholangitis and/or a 50% decrease or normalization of the bilirubin level within 14 days after any reintervention), adverse events (AEs), time to RBO (TRBO) and overall survival (OS) were investigated. Potential factors associated with technical success were also explored.

Results

MBO was located at distal in 26 (57.8%) and at proximal in 19 (42.2%), with major underlying disease of biliary tract cancer (n = 21, 46.7%) and pancreatic cancer (n = 18, 40.0%). Five patients with proximal MBO underwent EUS-HGS combined with bridging stenting across the hepatic hilum, while all of the remaining had EUS-HGS alone. Median time to reintervention after EUS-HGS was 80 days (95% CI, 62-131 days) and the major causes of reintervention were hyperplasia at uncover portion of the EUS-HGS stent (n = 24, 53.3%) followed by food impaction or sludge formation (n = 8, 17.8%), stent migration (n = 5, 11.1%) and additional biliary obstruction (n = 4, 8.9%). Technical success was achieved in 39 (88.9%). In 6 cases with technical failure, salvage procedures including ERCP (n = 3), PTBD (n = 2) and additional HGS (n = 1) were performed, which eventually resulted in clinical success in 43 patients (95.5%). Although a mild transit fever was developed in one patient, no severe AEs or procedure-related deaths were observed. Median TRBO and OS after reintervention were 168 days and 161 days, respectively. Notably, patients with distal MBO had a longer TRBO while a shorter OS as compared to those with proximal MBO (median TRBO of 168 days vs. 118 days, p = 0.041 and median OS of 113 days vs. 345 days, p = 0.025). Proximal MBO was associated with technical failure of reintervention in multivariable analysis (odds ratio of 7.26, 95% confidence interval, 0.18-0.98, p = 0.046).

Conclusion

Reintervention for RBO after EUS‑HGS was technically feasible and clinically effective, without any severe AEs, especially in patients with distal MBO.

Introduction

Endoscopic submucosal dissection (ESD) is one of the effective treatments for superficial non-ampullary duodenal epithelial tumors (SNADETs). To avoid postoperative perforation and bleeding, our hospital had introduced D-LECS with ESD for SNADETs. From 2021, D-LECS was divided into D-LECS with FTR, which is a full-thickness resection, and D-LECS with ESD, which is intended for post-ESD reinforcement (1). D-LECS with ESD is considered to be a therapeutic procedure that not only ensures safety but also contributes to the improvement of endoscopic skills.

Aims & Methods

The aim of this study is to evaluate the impact of D-LECS with ESD on the skill development of endoscopists. The subjects were 17 cases in which D-LECS was performed among 79cases diagnosed with SNADA by biopsy at our hospital between January 2000 and October 2023. 5 cases in which D-LECS with ESD was performed. The ESD assessment score was defined using a ladder chart based on muscle layer exposure, perforation, ESD time, and pathological examination results. The scoring for points each item is as follows. (Exposure of muscle layer none: 0, <3mm: 1pt, 3~10mm: 2pt, 10mm<: 3pt, Perforation of the muscle none: 0, <3mm: 1pt, 3~10mm: 5pt, 10mm<: 10pt, ESD time <60min.: 0pt, 60~120min.: 5pt, 120min.<: 10pt, Pathological examination result pR0: 0pt, cR0+pRX: 5pt, pR1:10pt) Images and videos were used in combination to evaluate the muscle layer.

Results

ESD assessment scores of cases undergoing D-LECS with ESD were presented. The state of exposure of the muscle layer had a median of 5 (1-7), a mean of 4.8, and a standard deviation (SD) of 2.3. The state of perforation of the muscle layer had a median of 0 (0-10), a mean of 2.6, and a SD of 4.3. The median ESD time was 170 minutes, the mean was 146 minutes (41-198). The state of pathological examination had a median of 0 (0-10), a mean of 2.0, and a SD of 4.5. The ESD assessment scores are presented as follows: (Exposure of muscle layer, Perforation of muscles layer, ESD, Pathological examination result). The results of each score are as shown on the right, Case1: (7, 0,10, 0), Case2: (5,10, 10, 0), Case3: (5, 0, 10, 0), Case4: (6, 3, 10, 10), Case5: (1, 0, 1, 0). Although the number of cases was small, the time required for ESD was shortened and the degree of perforation tended to improve with experience. 2 examples revealed some important points. Case 1: This case had many blood vessels, and the ST hood was needed because it is difficult to perform ESD. When the endoscope was extended, perforation occurred. Once the perforation was made, it was difficult to move the patient to other bed, so the muscle layer was sutured with OTSC, and a PGA sheet. Case 2: The endoscopic strategy and device were improved, and the lesion could be dissected within 1 hour. ESD was performed with Dual Knife J 1.5. Pulling the lesion with an S-O clip. The RDI function was used during hemostasis to avoid the burn effect on the muscle layer.

Conclusion

D-LECS with ESD will lead to improvements of duodenal ESD techniques. But to ensure safety, laparoscopic closure is preferable until reliable suturing via endoscope becomes possible.

References

(1) Souya Nunobe, Motonari Ri, Naoki Hiki et al: Safety and Feasibility of laparoscopic and endoscopic cooperative surgery for duodenal neoplasm: a retrospective multicenter study. Endoscopy 53: 1065-1068, 2021

Introduction

ESD has become the standard treatment for early gastric cancer. Recently, the number of patients taking antithrombotic agents (ATAs) has increased, and the prevention of post-ESD bleeding is a main concern. EHS after gastric ESD has been developed to solve these problems, but the effectiveness and procedural success rate of EHS is not known. Here we investigate the successful introduction of EHS and evaluate the safety and effectiveness of the EHS.

Aims & Methods

11 patients who underwent EHS after gastric ESD from December 2022 to April 2024 were included in this study. Patient and lesion background, endoscopic findings, and treatment outcomes were reviewed retrospectively. A V-loc 180 available barbed suture (VLOCL0604; Covidien, Mansfield, Mass, USA) and through-the scope flexible needle holder (SutuArt, Olympus, Tokyo, Japan) were used for EHS. The same endoscopist and the assistant performed Ex vivo training model prior to clinical introduction.

Results

Mean age was 74.8±7.3 years, 9 males and 2 females, and 4 with and 7 without ATAs. The lesion locations were as follows: upper/middle/lower = 4/0/7. Mean tumor size was 15.4±5.3 mm, mean defect size was 30.3±5.4 mm, and mean resection time was 46.6±26.4 minutes. The mean time needed for suturing was 30.6±9.6 minutes, and a mean of 4.7±0.4 stitches were placed. Suturing speed （resection area/suturing time) was 20.9±7.5 mm²/min. Complete suture was achieved in all patients, and they began clear fluid on POD1. There were no adverse events during EHS such as bleeding or perforation.

Conclusion

In EHS, complete suture was achieved in all cases, with no post-ESD bleeding or delayed perforation. Further data is needed to confirm its effectiveness.

References

1) O. Goto et al. Endoscopic hand-suturing is feasible, safe, and may reduce bleeding risk after gastric endoscopic submucosal dissection: a multicenter pilot study (with video). Gastrointest Endosc 2020 ; 91(5): 1195-1202.

Introduction

Hepatocellular carcinoma (HCC) is the leading cause of death in patients with cirrhosis. Indeed, several risk stratification scores have been developed to anticipate early detection in order to better codify their management, including the Toronto Hepatocellular Carcinoma Risk Index (THRI). It is a simple and validated tool that has been developed to predict the risk of HCC in patients with cirrhosis and is mainly based on the following parameters: etiology, age, sex and platelet count.
The objective of this study was to evaluate the reliability of the THRI score in predicting the occurrence of hepatocellular carcinoma.

Aims & Methods

We conducted a monocentric retrospective study collecting all cirrhotic patients over an 8-year period [2008-2015]. Clinico-biological data, disease severity, and long-term outcomes were collected.
THRI was calculated for all patients, and were classified according to HCC risk into three levels : low HCC risk (<120), intermediate HCC risk (between 120 and 240), and those with high HCC risk (>240).
A statistical study using the SPSS tool was carried out. The performance of this score was evaluated with the area under the receiver operating characteristics curve (AUROC).

Results

We included 120 cirrhotic patients with an M/F sex ratio equal to 0.5. The mean age was 57 years [14-85]. The most frequent aetiology of cirrhosis were viral C (49%) and viral B (31%). The mean overall survival was approximately 6 years after diagnosis.
Twenty-five patients developed HCC during follow-up (20.8%). Patients who developed HCC had a higher THRI score than those who did not develop HCC : 264.8 ± 48.6 versus 232.3 ± 64.8, respectively with p-value = 0.008
Patients with a low risk of HCC were 5 (4.2%), none of whom had developed HCC. Fifty-eight patients (48.3%) were at intermediate risk, 12% of them (N=7) had developed HCC. The remaining 57 patients (47.5%) were at a high risk and 31.6% of them (N=18) developed HCC during their follow-up.
The AUROC for the THRI to predict HCC was 0.649 ([95% CI 0.533–0.765]. The cutoff THRI value in predicting the occurrence of HCC was 235.5 with a sensitivity of 72% and a specificity of 50%.

Conclusion

According to our study, the THRI score appears to be an effective tool for predicting the occurrence of HCC in cirrhotic patients. Its good sensitivity allows to identify the high-risk HCC population for early screening.

Introduction

Intragastric balloon (IGB) is a minimally invasive intervention used for obese patients who do not achieve adequate weight loss with standard medical therapy (SMT), which includes lifestyle interventions with or without pharmacological treatment. It is also an option for individuals who do not meet the criteria for bariatric surgery or choose not to undergo it. Despite its growing use, there is little data on the short and long-term effectiveness of IGB compared to SMT in randomized controlled trials (RCTs).

Aims & Methods

This systematic review and meta-analysis aimed to compare the efficacy of IGB therapy for at least six months versus SMT in the treatment of obesity, assessing outcomes at 6, 9, and 12 months. A comprehensive literature search was conducted in the MEDLINE, EMBASE, and Cochrane Library databases. The primary outcome was the percentage of excess weight loss (%EWL), while secondary outcomes included absolute weight loss (AWL), percentage of total weight loss (%TWL), and body mass index reduction (BMIR). We calculated mean differences (MD) with 95% confidence intervals (CI) for continuous outcomes. Meta-regression was performed using baseline body mass index (BMI) as a covariate, and subgroup analyses were conducted based on IGB type, baseline BMI, and pharmacological therapy in the SMT group.

Results

A total of 15 RCTs, including 1,961 patients, were included. Compared to SMT, IGB therapy resulted in significantly greater %EWL at 6 months (MD 16.80%; 95% CI [9.22%; 24.38%]), 9 months (MD 14.36%; 95% CI [7.67%; 21.04%]), and 12 months (MD 13.10%; 95% CI [10.43%; 15.77%]). IGB was also superior in AWL, %TWL, and BMIR across all time points (Table 1). Subgroup analyses revealed that results remained consistent regardless of pharmacological therapy use in the SMT group (p=0.77). The Orbera balloon showed superior %TWL at 6 months (p<0.01) and AWL at 6 months (test for subgroup differences with p=0.01), while the Spatz3 balloon demonstrated better %TWL at 9 months (p<0.01). Studies with a baseline BMI >40 kg/m² had significantly greater %TWL at 6 months (p=0.04) and AWL at 6 months (p<0.01) than those with BMI ≤40 kg/m². Meta-regression analysis indicated that higher baseline BMI was associated with greater AWL and BMIR at 6 months.

Conclusion

IGB therapy was significantly more effective than SMT, even when pharmacological therapy was included, leading to superior weight loss outcomes at 6, 9, and 12 months.

Table 1. Summary of findings.

References

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