Introduction

First-line approach for complicated acute diverticulitis is conservative treatment with bowel rest and systemic antibiotics. The presence of pericolic, mesocolic, or distant (usually deep pelvic) abscess ≥4 cm (1a or II stages according to Hinchey classification) represents an indication for drainage, either trans-abdominal, trans-gluteal, trans-rectal, or trans-vaginal. Endoscopic-ultrasound-guided pelvic abscess drainage (EUS-PAD) with lumen-apposing metal stents (LAMS) has been reported as a safe and effective alternative approach for complicated diverticular disease.

Aims & Methods

We aimed to assess the safety and efficacy of EUS-PAD with LAMS in a homogeneous population of patients with acute diverticulitis complicated by a pericolic, mesocolic, or pelvic abscess. A multicenter study was conducted from 2019-2023 retrieving all consecutive patients who underwent EUS drainage attempts for complicated acute diverticulitis in three referral centers. All cases have been considered suitable for EUS-PAD by local multidisciplinary teams. Continuous variables are expressed as median [interquartile range].

Results

Sixty-six patients underwent EUS assessment with interventional intent; however, in 13 cases, no sign (no. 5) or a small abscess (no. 8) was found. Finally, 53 patients (29 female 54.7%) with a median age of 74 [62-83] year-old were considered. Most cases (no. 40, 75.5%) had a pelvic abscess (Hinchey stage II) while 13 (24.5%) had a para-colonic abscess (stage 1b); thirty-one (58.5%) did not receive any antiplatelet or anticoagulant agent, while 10 (18.9%) were on low molecular weight heparin, and 12 (22.6%) on antiplatelet agents. No patient had fecal diversion. The median abscess size was 50 [40-60] mm. EUS-PAD have been conducted under conscious sedation in 14 (26.4%), deep sedation in 12 cases (22.6%), or general anesthesia in 27 cases (50.9%) with electrocautery-enhanced LAMS (Hot Axios, Boston Scientific, US). Six patients (11.3%) underwent concomitant percutaneous drainage, while in one case (1.9%) two LAMS have been used. In 34 cases (64.2%) trans-rectal EUS-PAD was performed, in 19 (35.8%) a trans-colonic route was required. Technical success was achieved in 49 (92.5%). A trend toward a higher technical success rate was observed for the trans-rectal route (odd ratio 6.19; 95% C.I 0.60 - 64.3; P 0.13); abscess size ≥50 mm was independently related to a higher technical success rate (OR 18.0 [1.63 - 198]; P 0.02). Stent size was 6x8mm (no. 2), 8x8 mm (no. 11), 10x10mm (no. 20), 15x10mm (no. 15), and 15x15mm (no. 1). Clinical success rate was 88.7%. The incidence of adverse events was 3.8%, with 1 minor procedural bleeding (AGREE II) and one late proximal migration (AGREE IIIa). LAMS were removed after a median of 19 [14-28] days and substituted with a double pigtail plastic stent in 9 cases. Patients were followed for 12 [8-12] months. Four (7.5%) patients underwent urgent Hartmann sigmoidectomy; during follow-up 12 (22.6%) patients required elective surgery; finally, 2 (3.8%) patients presented recurrent diverticular abscesses. No procedure-related or disease-specific mortality was observed during follow-up.

Conclusion

EUS-guided pelvic abscess drainage (EUS-PAD) with LAMS could be considered a safe and effective approach among conservative treatments for complicated acute diverticulitis.
EUS drainage with LAMS was confirmed as an effective treatment modality for encapsulated collections larger than 5 cm and close to colonic wall; trans-rectal approach seems safer while no difference in stent size were observed in terms of safety and efficacy.

References

Fugazzola P, Ceresoli M, Coccolini F, et al. The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly. World J Emerg Surg. 2022;17: 5.
Nagata N, Ishii N, Manabe N, et al. Guidelines for Colonic Diverticular Bleeding and Colonic Diverticulitis: Japan Gastroenterological Association. Digestion. 2019; 99 (Suppl 1): 1-26.
Kruis W, Germer CT, Böhm S, et al. German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) and the German Society of General and Visceral Surgery (DGAV). German guideline diverticular disease/diverticulitis: Part II: Conservative, interventional and surgical management. United European Gastroenterol J. 2022; 10: 940-957.
Donatelli G, Cereatti F, Fazi M, et al. Endoscopic ultrasound-guided drainage of intra-abdominal diverticular abscess. A case series. J Minim Access Surg. 2021; 17: 513-518.
Poincloux L, Caillol F, Allimant C, et al. Long-term outcome of endoscopic ultrasound-guided pelvic abscess drainage: a two-center series. Endoscopy. 2017; 49: 484-490.
Lisotti A, Cominardi A, Bacchilega I, et al. EUS-guided transrectal drainage of pelvic fluid collections using electrocautery-enhanced lumen-apposing metal stents: a case series. VideoGIE. 2020; 5: 380-385.

Disclosure

Andrea Lisotti had a proctorship contract with Boston Scientific in 2021 and 2022.

Introduction

The underwater immersion technique has so far been used for the resection of sessile polyps, with satisfactory results in terms of efficacy and complications (due to the use of water instead of medical air (CO2) and the absence of fluid substances in the submucosa.

Aims & Methods

The aim of this work is to demonstrate the effectiveness of the underwater technique for diagnostic purposes, in patients suffering from diverticular disease with insurmountable stenosis at traditional colonoscopy.A cohort of 50 patients (20 D and 30 U - mean age 72 years) with incomplete colonoscopy due to stenosing diverticular disease ( DICA 4) confirmed by CT colon ( virtual colonoscopy) examination was enrolled. Previously, all the patients had been evaluated at other endoscopy centers , and studied at the Gastroenterology and Digestive Endoscopy Center of the Benevento ASL, subsequently for the detection, in at least 15 patients, of lesions compatible with polyps > 6 mm on the colon CT scan. All patients underwent colonoscopy under conscious sedation with a thin colonoscope (Olympus PTH PF 190), filling the stenotic lumen with water instead.

Results

In 41 patients, the use of the UW technique allowed the stenotic section to be overcome, allowing the examination to be completed; in the remaining 9 the stenosis was insurmountable. In the 15 patients with lesions compatible with polyps > 6 mm on colon CT, only 5 pts were positive, 2 of which with the finding of polypoid formations > 1 cm in sections other than those reported on colon CT. No complications were recorded both in the diagnostic phase and in the operative phase.

Conclusion

The UNDERWATER technique can represent an alternative method in the diagnosis of certain pathological and inflammatory conditions with a high risk of perforation. The irrigation of the colonic lumen with water also allows the magnification of the mucosa, improving the identification and treatment of polypoid lesions (particularly the sessile ones).

References

A.Tursi et al Dica endoscopic class. for diverticular disease shows a significant interobserver agreement among community endoscopist . J Gastroint Liver Dos 2019 : 28 (1) 23-27.
A.Tursi et Al Prognostic value of Dica score J . Clin. Gastroenterology 2016
Y.Takeuchi et al Underwater endoscopic mucosal resection for colonrectal polyps lesions: can it be an underwater revolution?DEN Open 2022, 2 e84

Introduction

Direct oral anticoagulants (DOACs), particularly rivaroxaban and apixaban, are increasingly utilized to manage thromboembolic conditions due to their favorable efficacy and safety profiles. However, gastrointestinal bleeding (GIB) remains a significant concern associated with these medications, particularly considering pharmacogenetic variations among populations. This study aims to evaluate the frequency and identify risk factors associated with GIB in patients using rivaroxaban and apixaban in a Mexican healthcare setting.

Aims & Methods

This retrospective observational study analyzed data from January 2018 to December 2023 at the Centro Médico Nacional 20 de Noviembre, Mexico City. The cohort consisted of 278 patients: 136 on DOAC therapy (rivaroxaban or apixaban) and 142 controls without anticoagulation. Clinical data, demographic characteristics, comorbidities, and concomitant medications were systematically reviewed. Statistical methods employed included chi-square tests, Student's t-tests, and logistic regression analysis to assess the risk factors and association between anticoagulant type and incidence of GIB.

Results

The study population had a mean age of 67.36 ± 15.05 years, with an equal gender distribution (52.9% male). Rivaroxaban was significantly linked to increased GIB-related hospitalizations compared to controls (OR 1.29, 95% CI: 1.10–1.52, p < 0.001), while apixaban showed no statistically significant increase. NSAID co-administration dramatically raised the risk of GIB in rivaroxaban users (OR 16.1, 95% CI: 1.22–212.6, p = 0.03). Patients treated with DOACs experienced more hospitalizations (average 0.49 ± 0.80) and longer hospital stays (2.19 ± 3.54 days) compared to controls (0.30 ± 0.62 hospitalizations, 0.99 ± 2.68 days, respectively). Mortality rates were not significantly different between groups.

Conclusion

Rivaroxaban and apixaban present similar overall risks of gastrointestinal bleeding, although rivaroxaban is associated with higher hospitalization rates. Concomitant NSAID use substantially elevates the risk in patients on rivaroxaban. This underscores the necessity of individualized anticoagulant management strategies, especially in populations with distinct genetic and clinical characteristics, such as the Mexican demographic.

References

1. Lopes RD, Guimarães PO, Kolls BJ, et al. Gastrointestinal bleeding with novel oral anticoagulants: A systematic review and meta-analysis. BMJ. 2015;350:h1857.
2. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962.
3. Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365:981-992.

Introduction

Endoscopic sleeve gastroplasty (ESG) is a less invasive alternative to surgery for patients with obesity. The post procedure recovery is quicker and patients can be discharged one day after procedure.

Aims & Methods

We aimed to determine the outcome after ESG in patients with obesity and benefit of adding GLP1 agonist after ESG. All patients undergoing ESG at our center from 2017 up to 2020 were retrospectively recruited. Patients with BMI ranging from 30 to 40 kg/m² were eligible for ESG. The baseline demographic and clinical profile and reports of investigations were recorded. The date of procedure and follow up details including weight at various time points were noted. The procedure was done by Apollo^TM overstitch device. The primary outcome was loss of at least 10% weight from baseline after ESG. The secondary outcome was loss of >20% weight after surgery. Multivariate analysis was performed using logistic regression to asses the predictors of weight loss after ESG including use of GLP1 agonist.

Results

	Weight loss >10% (n=28)	Weight loss <10% (n=13)	p
Age (Years)	39.9+9	37.4+9.2	0.3
Gender (Female)	25 (89.3%)	12 (92.3%)	0.98
Weight before ESG (Kg)	90.4+12.8	88.9+8.6	0.76
Use of GLP1 agonist after ESG	11 (39.3%)	8 (61.5%)	0.2

Forty-six patients underwent ESG during the study period. Their mean age was 39.9+8.8 years and 91.3% were females. The mean BMI before ESG was 35.1+2.9 kg/m² and mean weight was 90.2+11.5 kg. Follow-up data was available for 41 patients: the mean duration of follow-up was 29.4+14.8months. The primary outcome (weight loss >10%) was achieved in 68.3% patients. Weight loss >20% was noted in 19.5% subjects. The mean weight 6-12 months after ESG was 80.8+11.2 Kg and after 2 years was 87.6+12.6 Kg. Multivariate analysis was done using age, gender, baseline weight and use of GLP1 agonist as variables for predicting weight loss after ESG (Table 1). We did not find any significant predictors including use of GLP1 agonist (p=0.2).

Conclusion

ESG leads to weight loss in about two-third of patients although the effect is not sustained after 2 years. Use of GLP1 agonist does not have additional impact on weight loss.