Introduction

The success rate of endoscopic retrograde cholangiopancreatography (ERCP) is suboptimal in patients with complex surgically altered anatomy (e.g. Roux-en-Y anastomosis, pancreaticoduodenectomy) due to difficulty in advancement of scope to the target site and selective biliopancreatic duct cannulation. Although balloon-assisted enteroscopy can achieve a higher rate of intubation, its clinical application is limited by its small working channel and few compatible accessories.

Aims & Methods

We aimed to explore the feasibility and effectiveness of a novel endoscopic approach in patients with complex surgically altered anatomy.
This is a retrospective study of patients who underwent ERCP with complex surgically altered anatomy at our center with an annual ERCP volume of approximately 3000, between January 2018 and November 2022. The endoscopic procedures were performed by three senior endoscopists who had ERCP experience for at least 5 years. Long colonoscopy (measuring 168cm)-assisted ERCP was adopted as a first-line intervention, and selective biliopancreatic duct cannulation was performed after the target site (native papilla or the surgical anastomosis) was reached. For patients with failed cannulation, a plastic guide tube measuring 250 cm was inserted via the working channel of the colonoscope and its distal end was placed near the target site. The colonoscope was then withdrawn while the guide tube was left in-situ. By following the guide tube, a conventional side-viewing duodenoscope was cautiously advanced to the target site and biliopancreatic duct cannulation re-attempted.

Results

A total of 58 patients were recruited (mean age:56.7 years [standard deviation [SD]:14.4; male:36 [62.1%]]. The reconstruction methods were as follows – Roux-en-Y hepaticojejunostomy:32 (55.2%), Billroth-II gastrectomy with Braun anastomosis:11 (19.0%), pancreaticoduodenectomy:10 (17.2%) and Roux-en Y gastrectomy:5 (8.6%). Common bile duct stone was the most common indication for ERCP (n=30; 51.7%), followed by bilioenteric anastomotic stenosis (n=15; 25.9%), pancreaticojejunal anastomotic stenosis (n=7; 12.1%) and chronic pancreatitis (n=6; 10.3%). 55 (94.8%) of 58 had successful intubation by long colonoscope with a mean procedure time of 57.7minutes (SD:23.4). The mean time to reach target site was 19.1minutes (SD:9.0). The target site could not be identified in two patients and intestinal perforation occurred during endoscopic intubation in one patient. Among those with successful endoscopic intubation, biliopancreatic duct cannulation was achieved in 35 (63.6%) patients. For the remaining 20 patients with initial failure of biliopancreatic duct cannulation, intubation rate by duodenoscope was 100% by tracing the guide tube to target site. The success rate of biliopancreatic duct cannulation by duodenoscope was 85% (17/20) with a mean procedure time of 83.5 minutes (SD:21.1). The mean time to reach target site was 17.0minutes (SD:6.1). Notably, 90% (18/20) had either native papilla or pancreaticojejunostomy, in which selective biliopancreatic duct cannulation is known to be technically difficult with any type of forward-viewing scope due to unfavorable cannulation trajectory. For those with failed cannulation, two had anatomical stricture and one had impacted pancreatic stone.

Conclusion

ERCP by conventional duodenoscope with colonoscopy-assisted pre-placement of guide tube is a feasible, effective and safe alternative for patients with complex surgically altered anatomy in experienced endoscopists.

Introduction

It is unclear whether the insertion of an axis-orienting double-pigtail plastic stent (DPS) through biliary lumen-apposing metal stents (LAMS) in EUS-guided choledochoduodenostomy (CDS) improves the stent patency.

Aims & Methods

The aim is to determine whether this technical variant offers a clinical benefit in EUS-guided biliary drainage (CDS-type) for the management of distal malignant biliary obstruction. This is a multicentre, open-label, randomised controlled trial with two parallel groups. The primary endpoint was the rate of recurrent biliary obstruction (RBO), as a stent dysfunction parameter, detected during follow-up. Secondary endpoints: technical and clinical success (reduction in bilirubin >50% within 14days), adverse events, and others.

Results

Between November-2020 and October-2022, 123 patients (pancreatic cancer 85%, palliative status 80%) were screened and 84 with malignant biliary obstruction, and underwent EUS-CDS (rescue after failed ERCP, 62%), were randomised: 44 patients in LAMS group and 40 in LAMS-DPS group. The rate of RBO (29.5 vs 10%; OR 0.26 [IC95% 0.07–0.83],p=0.04) was lower, but with a longer procedure time (30 vs 20-min, p=0.02), in LAMS-DPS-group. Furthermore, less biliary reinterventions (12.5 vs 20.5%, p=0.38), longer time-to-RBO (155.5 vs 51.5 days, p=0.10), and shorter hospital stay (6 vs. 8.5,p=0.06) were encountered in LAMS-DPS group. No differences were found between technical (97 vs. 88%), clinical success (92 vs. 88.8%) and AEs (22.5 vs.11.4%). NCT04595058 ClinicalTrials.gov

Table1: Outcomes (RBO, recurrent biliary obstruction; BRI, biliary reinterventions).

Conclusion

This trial confirms that CDS with LAMS is an effective technique. The technical strategy of placing a pigtail within the LAMS is associated with a lower risk of RBO, and a non-significant trend of shorter hospital stay.

References

1-Garcia-Sumalla, A., Loras, C., Sanchiz, V. et al. Multicenter study of lumen-apposing metal stents with or without pigtail in endoscopic ultrasound-guided biliary drainage for malignant obstruction—BAMPI TRIAL: an open-label, randomized controlled trial protocol. Trials 2022; 23:181
2-Gornals JB, Consiglieri CF, Bergamino MA. Double pigtail for preventing ascending cholangitis after endoscopic ultrasonography-guided choledochoduodenostomy with lumen-apposing metal stent. Dig Endosc. 2016;28:100.
3-Garcia-Sumalla A, Loras C, Guarner-Argente C, et al. Is a coaxial plastic stent within a lumen-apposing metal stent useful for the management of distal malignant biliary obstruction? Surg Endosc. 2021;35:4873 –81

Disclosure

- A Garcia-Sumalla is a PhD student at the Faculty of Medicine and Health Sciences, University of Barcelona, and this paper is part of his doctoral project.
- Joan B Gornals acts as a PhD Director; is a consultant for Boston Scientific and has received a research grant from this company.
- Manuel Pérez-Miranda is a consultant and speaker for Medtronic, Olympus, Taewoong, and M.I.Tech.
- Enrique Vazquez-Sequeiros is a consultant for Boston Scientific.
Jose Ramon Aparicio is a consultant for Boston Scientific

Introduction

Sarcopenia defined as having low muscle mass, muscle strength and if combined with low performance indicate severe sarcopenia¹. It is associated with adverse outcomes in cirrhosis, including hepatic encephalopathy, ascites, infection, and increased hospitalisation. Prevalence of sarcopenia has been reported between 40 to 70% and are more common with alcoholic liver disease².

Aims & Methods

We aim to assess relationship between nutritional status/assessment, muscle quality and sarcopenia. Cirrhotic patients were recruited from a tertiary-hepatology-clinic for this prospective cross-sectional study. BIA was performed as the standard (SECA mBCA-525) for nutritional status and sarcopenia assessment. Appendicular skeletal muscle mass (ASM) calculated through sum of limb muscle masses in kg. sarcopenia was diagnosed with ASM/height²<7.0 kg/m² and <5.5 kg/m² for male and female respectively. Muscle quality was measured by mean handgrip strength in kg divided by ASM (HGS/ASM). Validated functional muscle metrics (handgrip and sit-to-stand), liver-frailty-index (LFI)³, Chronic Liver Disease Questionnaire (CLD-Q)⁴ and food-frequency-questionnaire (FFQ) were also analysed.

Results

49 patients, 57% (28) alcohol-liver-disease, 18% (9) non-alcoholic steatohepatitis, 5% (4) viral, 4% (3) autoimmune and 7% (5) mixed aetiologies, were included. 44 healthy controls (HC) were recruited as well. Most patients were male (n=28, 57%), with mean age 56yrs (SD=9), mean Child-Pugh score 6 (IQR= 5-7) and MELD 10 (IQR= 7-12). 35% (n=17) were actively drinking alcohol. 9 (18%) of patients were frail and 34 (69%) were pre-frail. 25 (89%) cirrhotic male and 14 (66%) cirrhotic female had sarcopenia diagnosed via BIA. 24/42 (57%) had lower total daily energy intake than is recommended by EASL guidelines⁵. Of those, 11 (44%) male and 6 (42%) had diagnosis of sarcopenia.
There was positive correlation between nutritional status measured with BIA as Phase angle analysis (PhA) with total skeletal muscle mass adjusted for height, SMM/H², (r=0.51, p<0.0001) and ASM/H² (r=0.04,p=0.7). There was strong correlation between PhA and HGS (r=0.71, p=<0.001). Higher PhA score predicts lower MELD score therefore longer survivals (β = -0.092, p=0.004).
Healthy control has significantly better muscle quality (HGS/ASM) compared to cirrhotic patient (mean 2.52 vs 1.85 kg, SD 0.6 and 0.4 respectively, p<0.001).
Using functional testing, sit-to-stand time was lower in HCs (13.35 vs 8.94 secs, p=0.0001) and hand-grip strength higher in HC (p< 0.001). QoL was negatively correlate with sarcopenia (r=-0.06,p=0.6), LFI (r=-0.2,p=0.1), MELD (r=-0.15,p=0.3) and Child-Pugh score (r= -0.08, p=0.6) although they were not statically significant.

Conclusion

Cirrhotic patients had lower muscle quality and functional status compared to HC. FFQ and PhA are good assessment tool to establish nutritional status. PhA correlated much better with SMM/H2 than ASM/H2 and is a good predictor for disease severity. QoL is multifactorial and couldn’t be explained with frailty scores or clinical severity scores.

References

1. Alfonso J Cruz-Jentoft et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019 Jan 1;48(1):16-31
2. Xinxing Tantai et al. Effect of sarcopenia on survival in patients with cirrhosis: A meta-analysis Journal of Hepatology 2022 vol. 76 j 588–599
3. Jennifer C Lai et al. Development of a novel frailty index to predict mortality in patients with end-stage liver disease. Hepatology 2017 Aug;66(2):564-574
4. Z M Younossi et al. Development of a disease specific questionnaire to measure health related quality of life in patients with chronic liver disease. Gut 1999;45:295–300
5. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol. 2019 Jan;70(1):172-193.

Introduction

Aims & Methods

Results

Conclusion

References

Introduction

Esophageal food bolus obstruction (FBO) is a common presentation to Emergency Departments worldwide¹. There remains a paucity of data relating to efficacy of pre-endoscopic and endoscopic management resulting in a wide variety of clinical practice. Consensus guidelines do not advocate strongly for pre-endoscopic medications however they remain commonly used^2,3. This study evaluated the safety and efficacy of pre-endoscopic and endoscopic treatment in successful clearance of FBO and assessed the prevalence of underlying esophageal pathology.

Aims & Methods

ICD-10 codes retrospectively identified adult patients ≥18 years admitted to the Monash Health network (Melbourne, Australia) with esophageal FBO from 2010 to 2021. Medical records were reviewed to determine baseline characteristics, medical and endoscopic treatments and outcomes. Pre-endoscopic therapies included glucagon, glyceryl trinitrate (GTN), buscopan and Coca Cola. Multivariable analysis was performed to determine factors associated with pre-endoscopic clearance of FBO.

Results

608 patients were included. The median age was 56 years (IQR 39 – 71) and 405 (66.6%) were male. A prior history of FBO was noted in 228 (37.5%) patients, 110 (18.1%) had gastro-oesophageal reflux disease, 71 (11.7%) had dysphagia and 51 (8.4%) had a history of esophageal strictures. Inability to swallow saliva was noted in 296 (49.7%) patients at presentation.
Pre-endoscopic therapy was administered to 389 (64.0%) patients with a mean of 2 medications prescribed. Glucagon (47.4%), GTN (37.2%) and Coca Cola (36.3%) were most commonly administered. Successful FBO clearance was documented in 36.8% patients receiving medical therapy (glucagon 35.1%, GTN 36.2%, Coca Cola 38.0%); no individual medication significantly reduced the need for endoscopic intervention. Multi-variable analysis demonstrated that tolerating saliva (OR 1.95, p=0.025) and liquids (OR 2.28, p=0.001) significantly predicted spontaneous resolution of the EFBO without endoscopy.
474 (78.0%) patients proceeded to endoscopy. Median time to endoscopy was 14 hours (IQR 6 – 16) with 36.1% patients intubated for the procedure. The FBO was most commonly located in the lower esophagus (32.7%). The most common endoscopic findings were esophagitis (30.2%) and peptic ulcer disease (18.8%), with 3 (0.6%) malignancies identified. Endoscopic complications occurred in 35 (7.4%) patients (partial esophageal tear (n=24), aspiration pneumonia (n=5)). At endoscopy, a cause for the FBO was found in 130 (27.4%) patients, most commonly due to esophageal strictures (13.9%), eosinophilic esophagitis (11.2%) and Schatzki rings (9.1%). Esophageal biopsies were taken in 155 (32.7%) patients, of which 34.2% reached the diagnostic criteria for eosinophilic esophagitis.

Conclusion

Despite limited evidence, pre-endoscopic medical treatment of FBO is safe, commonly utilised, and results in spontaneous clearance in 36.8% patients. Patients’ clinical symptoms, in particular the ability to tolerate saliva or liquids, is the best predictor for spontaneous FBO clearance. Endoscopy remains highly effective and has a low complication rate.

References

1. Longstreth GF, Longstreth KJ, Yao JF. Esophageal food impaction: Epidemiology and therapy. A retrospective, observational study. Gastrointest Endosc. 2001;53(2):193-198. doi:10.1067/mge.2001.112709
2. Ikenberry SO, Jue TL, Anderson MA, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091. doi:10.1016/j.gie.2010.11.010
3. Birk M, Bauerfeind P, Deprez P, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(05):489-496. doi:10.1055/s-0042-100456