Introduction

Chronic portal thrombosis and/or portal cavernoma is a cavo-portal collateral venous pathway secondary to chronic thrombotic obstruction. The etiologies are numerous and must be systematically investigated. Our work aimed to study the profile of patients with portal cavernoma secondary to a local cause.

Aims & Methods

We conducted a 6-year retrospective, descriptive and monocentric study (2016-2022) including all patients followed for portal cavernoma and who have in their history a notion of abdominopelvic surgery or local non-surgical cause. All patients underwent a comprehensive etiologic workup for thrombosis.

Results

Out of the 56 patients diagnosed with portal cavernoma, 20 had a history of surgery or a local cause, indicating a prevalence of 35.71%. The mean age of the patients was 43.68 years with a range of 20 to 69 years and there was a clear female predominance with a sex ratio F/M of 19.
The clinical presentation of patients with portal cavernoma included acute abdominal pain in 83.3% of cases, digestive haemorrhage in 33.3%, ascites in 33.3% and asthenia in 16.7%. Biologically, cholestasis was observed in 40% of cases, cytolysis in 26.6%, hepatocellular insufficiency in 6.6%, and pancytopenia in 6.6%. Abdominal ultrasound coupled with Doppler was performed in all patients, revealing a dysmorphic liver in 40% and heterogeneous liver in 26.6%. Furthermore, angiography demonstrated extensive portal thrombosis in 20% of patients, and upper endoscopy found esophageal varices in 60%, gastroesophageal varices in 26.6%, and congestive gastropathy in 16.6% of patients.
Local causes of portal thrombosis included abdominal surgery (50%), pelvic surgery (25%), and non-surgical causes (25%). The abdominal surgeries included cholecystectomy (30%), appendectomy (30%), Porto-azygos shunt (20%), cholecystectomy followed by splenectomy (10%), and cholecystectomy followed by liver surgery: resection of the protruding dome for a hydatid cyst (10%). An exhaustive etiological work-up was performed in all patients, revealing various underlying prothrombotic causes such as protein C and/or S deficiency (25%), celiac disease (10%), polycythemia vera (10%), chronic inflammatory bowel diseases (5%), Biermer disease (5%), and Paroxysmal Nocturnal Hemoglobinuria clone mutation (5%). whereas no associated prothrombotic pathology was found in 40% of the patients. In the 40% where no underlying prothrombotic cause was found, the only cause of portal thrombosis was local: pelvic surgery in 20% of all cases, two abdominal surgeries in 10%, and main bile duct stent in 10% of patients.
As for the complications, 4 patients were complicated by portal biliopathy objectified by Cholangio-MRI and one patient died of hepatorenal syndrome.

Conclusion

The local cause of portal cavernoma is rare in the literature and is 4 % in our series. The most frequent surgery found in history is cholecystectomy, but these patients often have another associated prothrombotic factor. In the rare cases where no underlying prothrombotic factor was found, it was most often pelvic surgery followed by the association of 2 abdominal surgeries and a main bile duct stent.

Introduction

Zenker’s diverticulum (ZD) is an acquired herniation of the posterior hypopharyngeal wall through the Killian’s triangle. ZD may be cause of dysphagia, regurgitation, cough and potentially life-threatening conditions, such as aspiration pneumonia. Peroral Endoscopic Myotomy (Z-POEM) has been recently used for the management of ZD as an alternative to flexible endoscope septotomy and to the open or transoral surgery. We report on the results of Z-POEM in a consecutive series of patients treated in a single referral centre.

Aims & Methods

All the patients who underwent Z-POEM between October 2020 and March 2023 were retrospectively identified. Demographics, clinical and technical aspects were retrieved from a prospectively collected database. After treatment, patients underwent a close clinical and endoscopic follow-up: technical success, incidence of adverse events and symptoms recurrence were calculated 1, 6 and 12 months after treatment.
All procedures were performed under general anaesthesia with endotracheal intubation. An high-definition endoscope with a transparent distal hood was used. Low-flow carbon dioxide insufflation was used instead of room air. A triangle-tip knife (TT-knife; Olympus Co.) and swift coagulation mode were used for both submucosal dissection and myotomy. The procedure included: 1) identification of cricopharyngeal muscle and the septum of the ZD; 2) submucosal lifting directly on the septum of the ZD and mucosal incision on the septum of the diverticulum; 3) dissection of the submucosa , on the diverticular and esophageal side; 4) myotomy of cricopharyngeal muscle and of the proximal part of the esophageal muscularis propria until the bottom of the diverticulum; 5) closure of the mucosal entry with clips.

Results

Fifty Z-POEM were performed on 49 patients. Thirty patients were males (73.2%), with a mean age of 71.3±9.8 years. The mean length of ZD was 15.3±8.6 mm. The mean length of myotomy was 18.2±7.4 mm, the mucosal entry site was closed with 3.3±0.6 clips. Mean procedure time was 16.6±6.3 minutes. Technical success rate was 96% (48/50). Intraprocedural, mild, complications occurred in two patients (one bleeding and one mucosal perforation) and were treated intraoperatively. A severe complication (oesophageal perforation) occurred in one patient (2%) and required surgery. A substantial decrease in Kothari-Haber score was observed 1 month (6.3±2.2 vs 1±1.3 P < 0.0001), 6 months (6.3±2.2 vs 1.6±1.6 P < 0.0001) and 12 months (6.3±2.2 vs 2±1.6 P = 0.0004) after treatment. Clinical success was achieved in 89.6% of patients. Three patients underwent a successful endoscopic retreatment (2 flexible endoscope septotomies and 1 Z-POEM) after 1, 6 and 7 months, respectively.

Conclusion

Z-POEM is a promising technique for the treatment of ZD. Larger studies with a long follow-up and comparative trials are necessary to assess its role in the management of ZD.

Introduction

Experimental data have shown increased expression of angiogenic factors in portal hypertension and disruption of endothelial integrity in small intestinal mucosal vessels that is possibly correlated with antigen translocation to the portal circulation. ZO-1 is a tight junction structural protein of the intestinal epithelium. Recent data revealed that ΖΟ-1 is also expressed by endothelial and mesenchymal cells and plays a dominant role in mucosal healing. Decreased ZO-1 expression may unsettle epithelial restorative capacity following mucosal damage and contribute to the impaired endothelial integrity and bacterial translocation.

Aims & Methods

We therefore aimed to assess changes in mucosal vascular density and evaluate intestinal vessel endothelial integrity in cirrhotic patients by assessing the immunohistochemical expression of ZO-1 in small intestinal biopsy samples. Sixty-three cirrhotic patients were enrolled (M/F:35/28, mean age ±SD: 62±13) during an 18-month period. Nine non-cirrhotic patients served as controls. Patients with current or recent alcohol consumption, porto-splenic vein thrombosis, non-cirrhotic portal hypertension, hepatocellular carcinoma, transjugular intrahepatic portosystemic shunt, chronic kidney disease, celiac disease, acute infection, or any other chronic intestinal disease were excluded. Small intestine biopsy samples were taken during endoscopy and endothelial ZO-1 expression was assessed by immunohistochemistry using the indirect streptavidin biotin peroxidase method. Mucosal vascular density was evaluated by counting the number of mucosal vessels per x20 optical field. Serum lipopolysaccharide-binding protein (LBP) levels were measured by ELISA.

Results

Thirty-four patients (54%) had compensated and 29(46%) had decompensated cirrhosis. Child-Turcotte-Pugh (CTP) classification was: A 46 (73%)/B 14 (22%)/ C 3 (5%). The mean MELD score was 10.5±3.7. Mean LBP levels were 7511.97±2868.90 μg/ml. The mean number of mucosal vessels per x20 optical field did not differ between cirrhotic patients and controls (3.7±1.1 vs 3.2±0.9, p=0.238) but patients with CTP-A class had increased number of mucosal vessels compared to controls (3.8±1.1 vs 3.2±0.9, p=0.048) and CTP-B class patients (3.8±1.1 vs 3.2±0.7, p=0.045). A negative correlation was observed between the number of mucosal vessels and CTP score (r: -0.428, p=0.016). In cirrhotic patients, ZO-1 immunostaining was detected in the whole perimeter of all counted vessels per optical field in only 10/63 (16.4%) samples. Loss of endothelial ZO-1 immunostaining in more than 50% of the vessel perimeter or total loss of ZO-1 in more than 50% of counted vessels was observed more frequently in cirrhotic patient samples (42/63, 66.6%) compared to controls (1/9, 11.1%, p=0.001). Mean (±SD) LBP levels were numerically, albeit not significantly, higher in patients with than without significant loss of ZO-1 endothelial expression (7801±3698 vs 6761±1032 μg/ml, p=0.342).

Conclusion

Cirrhotic patients show increased loss of small intestinal endothelial ZO-1 expression compared to control patients. Intestinal mucosal vessel number is increased in CTP-A patients compared to control and CTP-B patients. These findings are in agreement with novel theories proposing that mechanisms leading to bacterial translocation in cirrhosis are not confined to the small intestinal lumen and merit further investigation.

Introduction

Overweight and obesity present global health challenges, often managed through lifestyle changes and medications like glucagon-like peptide-1 receptor agonists (GLP-1 RAs), which can cause gastrointestinal (GI) adverse events. However, research on their effects in non-diabetic populations is lacking.

Aims & Methods

This review addresses this gap by examining the impact of GLP-1 RAs on GI adverse events in non-diabetic overweight or obese individuals. We systematically reviewed the literature by conducting a search using PubMed and EMBASE, adhering to predefined inclusion and exclusion criteria, to assess GI adverse events linked with GLP-1 RAs in non-diabetic overweight or obese populations. We conducted a dose response meta-analysis to evaluate each adverse event associated with different GLP-1 RAs. The quality of the included studies was appraised utilizing the Cochrane Collaboration's assessment tool.

Results

Our systematic review and meta-analysis encompassed thirty-eight articles, incorporating data from a total cohort of 32,882 individuals. Predominant GI adverse effects observed included nausea, vomiting, diarrhea, constipation, and abdominal pain. Across all evaluated GLP-1 RAs, a notable elevation in nausea risk was noted, with orforglipron exhibiting the highest risk, succeeded by exenatide, tirzepatide, semaglutide, and liraglutide. Moreover, liraglutide, orforglipron, semaglutide, and tirzepatide were associated with heightened vomiting risk, while cagrilinitide and exenatide displayed no significant increase. Exenatide, cagrilinitide, and orforglipron demonstrated no significant association with diarrhea risk. Conversely, semaglutide and liraglutide correlated with an elevated risk of constipation, while cagrilinitide and exenatide did not exhibit a significant increase. Notably, certain GLP-1 RAs were linked to a heightened risk of abdominal pain, with liraglutide, semaglutide, and tirzepatide displaying significant increases, whereas orforglipron showed no significant elevation in abdominal pain risk.

Conclusion

In conclusion, GLP-1 RAs are associated with an increased risk of GI adverse effects, including nausea, vomiting, diarrhea, constipation, and abdominal pain. Importantly, distinct GLP-1 RAs exhibited varying degrees of risk for these adverse effects, underscoring the importance of tailored risk assessment and management strategies in clinical practice.

Disclosure

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Introduction

Among the diagnostic methods for EHCC, cell brush is the conventional method for EHCC diagnosis, but the sensitivity of cell brush and routine biopsy is low. The sensitivity and accuracy of EHCC diagnosis can be improved by single oral choledochoscopy. Radiofrequency ablation is a common and effective treatment for unresectable EHCC, providing local tumor control. Single oral choledochoscopy combined with radiofrequency ablation can improve the positive rate of pathological diagnosis.

Aims & Methods

To investigate the feasibility and safety of treating nonresectable extrahepatic cholangiocarcinoma (EHCC) with single resection combined with radiofrequency ablation (RFA).
A total of 149 patients with suspected extrahepatic cholangiocarcinoma treated in Hangzhou First People's Hospital from January 2013 to January 2023 were reviewed. According to the treatment process, 114 patients were eventually included and divided into two groups (n=48 cases) : Single oral choledochoscopy was performed by ERCP and the lesion tissue was biopsied under direct vision. Intraoperative rapid pathologic examination was performed on the same stage RFA for the patients who were pathologically identified as malignant tumors. Regular times group (n = 66) : first by endoscopic retrograde pancreatic angiography (endoscopic retrograde cholangiopancreatography, ERCP) + cells brush or a single biopsy samples by mouth choledochoscope examination, pathological results to obtain positive line of ERCP + RFA again; The operation success rate, postoperative liver function recovery, average ERCP number, postoperative adverse event incidence, length of hospitalization and cost were compared between the two groups.

Results

1. Patients in both groups successfully completed the RFA, the operation success rate was 100% (114/114).
2. There was no significant difference in the overall incidence of postoperative adverse events between the two groups [39.58% (19/48) vs. 39.40% (26/66),χ2=0.00, P=0.984].
3. There was no significant difference in the proportion of patients with total bilirubin improvement between the two groups [41.67% (20/48) vs. 42.42% (28/66), χ2= 0.32, P=0.750].
4. The average number of ERCP in the same group was significantly lower than that in the conventional group, and the difference was statistically significant (1.00±0.00 times/person vs. 2.64±0.49 times/person, t=0.77, P<0.001).
5. The average length of hospital stay in the same group was significantly longer than that in the conventional group, with statistical significance (8.40±3.63 days vs. 17.47±9.82 days, t=6.21, P<0.001).
6. The average hospitalization cost in the same group was significantly higher than that in the conventional group, and the difference was statistically significant (27718.31±9142.02 yuan versus 49112.76±16153.14 yuan, t=7.38, P<0.001).

Conclusion

Single oral choledochoscopy combined with biopsy and RFA in the diagnosis and treatment of unresectable EHCC can reduce the number of operations and does not increase the incidence of postoperative adverse events, which is a safe and effective method with a high cost-benefit ratio.

References

[1] Le V H, O'Connor V V, Li D, et al. Outcomes of Neoadjuvant Therapy for Cholangiocarcinoma: A Review of Existing Evidence Assessing Treatment Response and R0 Resection Rate [J]. J Surg Oncol, 2021, 123(1): 164-71.
[2] Chen R, Zheng D, Li Q, et al. Immunotherapy of Cholangiocarcinoma: Therapeutic Strategies and Predictive Biomarkers [J]. Cancer Lett, 2022, 546: 215853.
[3] Rizzo A, Ricci A D, Brandi G. Durvalumab: An Investigational Anti-Pd-L1 Antibody for the Treatment of Biliary Tract Cancer [J]. Expert Opin Investig Drugs, 2021, 30(4): 343-50.
[4] Sadeghi S. Infigratinib for Cholangiocarcinoma [J]. Drugs Today (Barc), 2022, 58(7): 327-34.
[5] Vignone A, Biancaniello F, Casadio M, et al. Emerging Therapies for Advanced Cholangiocarcinoma: An Updated Literature Review [J]. J Clin Med, 2021, 10(21).
[6] Jang D K, Kim J, Paik C N, et al. Endoscopic Retrograde Cholangiopancreatography-Related Adverse Events in Korea: A Nationwide Assessment [J]. United European Gastroenterol J, 2022, 10(1): 73-9.
[7] Hollenbach M, Hoffmeister A. Adverse Events in Endoscopic Retrograde Cholangiopancreaticography (Ercp): Focus on Post-Ercp-Pancreatitis [J]. United European Gastroenterol J, 2022, 10(1): 10-1.

Disclosure

The authors declare that there are no conflicts of interest.

Introduction

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is an important diagnostic tool for suspected parenchymal lesions within the gastrointestinal tract and adjacent organs. However, the amount of literature on EUS-FNA for sampling focal liver lesions (FLLs) is limited.

Aims & Methods

This study aims at evaluating the safety and effectiveness of EUS-FNA in FLLs. Data from 88 patients who were diagnosed with FLLs by imaging and underwent EUS-FNA was reviewed in this retrospective study at the Second Affiliated Hospital of Soochow University and Ruijin Hospital of School of Medicine of Shanghai Jiao Tong University from 1 January 2017 to 31 August 2022.The EUS-FNA biopsy results were compared with the final diagnosis to evaluate the diagnostic value. Meanwhile, the relevant factors were analyzed to determine their influences on the EUS-FNA biopsy results.

Results

A final diagnosis was obtained (86 malignant and 2 benign) from the 88 cases. The overall diagnostic accuracy of EUS-FNA in FLLs was 93.18% (82／88; 95% confidence interval [CI ],87.9–98.5), with a sensitivity, specificity, positive predictive value, and negative predictive value of 93.02% (80／86; 95%CI, 87.6–98.4), 100% (2／2; 95%CI, 100–100), 100% (80／80; 95%CI, 100–100), and 25% (2／8; 95%CI, -5–55.0), respectively . The parameters related to lesion and procedure were not statistically significant between these two groups (p> 0.05) (Table 1). The number of puncture needles in the groups showed a statistically significant difference between multiple and single punctures (p = 0.001).

Conclusion

It is revealed in this study that EUS-FNA is a safe and excellent diagnostic method for FLLs with high accuracy.