Introduction

Endoscopic ultrasound-guided gallbladder drainage is usually reserved for high surgical risk patients. The procedure was usually performed under deep sedation to ensure the best tolerability for the patient and facilitate the endoscopist’s performance.
However, many of them showed a high-risk even for deep sedation.

Aims & Methods

Our aim was to evaluate the safety and efficacy of EUS-GBD under conscious sedation (CS).
All consecutive EUS-GBD under CS performed in our hospital were prospectively enrolled from January 2020 to December 2022.
Patient characteristics, type and dosage of anesthetic drug administered (Fentanyl (FNT), Pethidine (PTD) or Benzodiazepine (BZD)), size of lumen-apposing-metal-stent (LAMS), gallbladder (GB) access, technical success, clinical success, early and late adverse events (AEs) rate were evaluated. Safety was defined as AEs occurrence. The efficacy of EUS-GBD was expressed as technical and clinical success. We defined as “conscious sedation” a drug-induced depression of consciousness during which patients respond to verbal commands or react to touch. Breathing remains intact and no support is needed.

Results

A total of 49 patients (41.7% male, mean age 82,9±10 years-old) underwent EUS-GBD under in our Unit. Among all the 49 EUS-GBD in CS, 47 (95.9%) were indicated as treatment for acute cholecystitis in high-surgical-risk patients and 2 (4.1%) as rescue-strategy after ERCP fail.
In 45 (91.8%) EUS-GBD a 10x10mm LAMS was deployed, in 3 (6.2%) procedures a 15x10mm and in 1 (2%) an 8x8mm LAMS. GB was accessed from the duodenum in 68.8% of cases.
A combination of PTD+BZD was administered in 29 (59.2%) EUS-GBD, while 18 (36.7%) procedures were performed under FNT+BZD. Only 2 (4.1%) EUS-GBD were performed only under BZD.
Mean FNT, PTD, BZD dose were 50(±11.5) mcg, 38.4(±25.6) mg and 4(±1.5) mg, respectively.
Technical success of EUS-GBD under CS was 97.9%. In one procedure the distal flange of the LAMS did not open due to LAMS malfunction. The clinical success of EUS-GBD under CS was 97.9% since in one procedure there was not a decrease of inflammatory, cytolysis and cholestasis indices. Only in 1 (2%) EUS-GBD an early AE was reported. No late AEs were described.
The statistical analysis showed that the administration of a combination of fentanyl and benzodiazepine or a combination of pethidine and benzodiazepines or the administration of only benzodiazepines affected neither technical nor clinical success, nor AEs rate (Table 1).

Conclusion

EUS-GBD under CS was a safe procedure with a low AEs rate.
The administration of FNT+BZD, PTD+BZD or BZD alone did not affect procedure outcome.

Introduction

Eosinophilic esophagitis (EoE) is a complex disease that often coexists with different conditions. Given the complexity of this pathology, a multidisciplinary approach, with gastroenterologist, allergist, dietitian, psychologist, and endoscopist may benefit to diagnosis and management of patients, reducing time to diagnosis as well.

Aims & Methods

To evaluate impact of multidisciplinary team in diagnosis and management of eosinophilic esophagitis disease. A retrospective study was conducted to include all patients referred to Fondazione Policlinico Universitario A. Gemelli between September 2016 and April 2023. Prevalence of allergic, nutritional, and psychological disturbs was evaluated. Referral for each patient was reviewed. Diagnostic delay (time interval between first occurrence of EoE symptoms and confirmed diagnosis with endoscopy) was analyzed in patients with suspected eosinophilic esophagitis and diagnosis made in our center, compared to data reported in literature. Publications from 2014 to 2023 were reviewed.

Results

A total of 98 patients, 76 males and 22 females, with a mean age at diagnosis of 25 years, were included in the study. For all patients, each visit was conducted in team with gastroenterologist, allergist, dietitian, and psychologist. 81 patients presented allergic diseases (82 %), 51 patients (52 %) needed nutritional support by a dietitian and 63 patients (64 %) presented psychological implication by the disease to necessitate clinical support. 42 patients (43%) were referred by team members. 13 patients (13%) presented to our center with suspect eosinophilic esophagitis. For these patients, ab initio evaluated with multidisciplinary approach, mean time to diagnosis was 2.25 months. Diagnostic delay reported in literature was 3 years.

Conclusion

Multidisciplinary team is needed to manage patients with eosinophilic esophagitis because its several associated diseases. In fact, most of our patients presented allergic, nutritional, and psychological disturbs. This approach assures more appropriate medical management through shared decision making. Almost half of patients was referred by team members. Thank to awareness of each physician of the team and his early referral, we assisted in a reduction of diagnostic delay in our center compared to data reported in literature.

References

Lenti MV, Savarino E, Mauro A, Penagini R, Racca F, Ghisa M, Laserra G, Merli S, Arsiè E, Longoni V, de Bortoli N, Sostilio A, Marabotto E, Ziola S, Vanoli A, Zingone F, Barberio B, Tolone S, Docimo L, Pellegatta G, Paoletti G, Ribolsi M, Repici A, Klersy C, Di Sabatino A. Diagnostic delay and misdiagnosis in eosinophilic oesophagitis. Dig Liver Dis. 2021 Dec;53(12):1632-1639. doi: 10.1016/j.dld.2021.05.017. Epub 2021 Jun 8. PMID: 34116974
Sauer BG, West A, McGowan EC. Multidisciplinary Eosinophilic Esophagitis Care: A Model for Comprehensive Patient-Centered Care Through Shared Decision Making Between Gastroenterology, Allergy, and Nutrition. Clin Gastroenterol Hepatol. 2021 Nov;19(11):2226-2229. doi: 10.1016/j.cgh.2021.07.025. Epub 2021 Jul 16. PMID: 34280551.
Murray FR, Kreienbuehl AS, Greuter T, Nennstiel S, Safroneeva E, Saner C, Schindler V, Schlag C, Schoepfer AM, Schreiner P, Straumann A, Biedermann L. Diagnostic Delay in Patients With Eosinophilic Esophagitis Has Not Changed Since the First Description 30 Years Ago: Diagnostic Delay in Eosinophilic Esophagitis. Am J Gastroenterol. 2022 Nov 1;117(11):1772-1779. doi: 10.14309/ajg.0000000000001950. Epub 2022 Aug 12. PMID: 35971224.

Introduction

There are doubts about the effectiveness of concomitant use of probiotics (PB) in the treatment of Helicobacter pylori infection. Objective: To determine whether the use of PB improves the effectiveness of eradication treatments used in Europe.

Aims & Methods

Prospective, multicentre, non-interventional, prospective registry (Hp-EuReg) of the clinical practice of European gastroenterologists. Data were collected in an e-CRD in AEG-REDCap from 2013 to 2021. All data from countries with at least 30 cases undergoing eradication therapy and at least 1 with associated PB were included, using patients without PB as controls and grouping by geographical region. Modified intention-to-treat (mITT) analyses were performed, as well as multivariate analysis, assessing factors associated with treatment effectiveness.

Results

36,699 patients were included, 8,233 (22%) with PB. Overall, PB use was associated with greater effectiveness (91% vs 86%; p<0.0001). Adjusting for treatment regimen, this significance held for triple (89% vs 83%; p<0.0001), concomitant quadruple (93% vs 89%; p=0.0009), quadruple with bismuth (92% vs 86%; p<0.0001) and sequential (91% vs 78%; p<0.0001) therapies. In the logistic regression model in first-line eradication (adjusted for age, sex, duration of eradication treatment, PPI dose and adherence), PB use maintained the benefit in the triple, bismuth quadruple and sequential treatments. After adjusting such a model by region, significance was maintained in the Eastern region (low rate of resistance to clarithromycin and metronidazole) for triple therapies, and in the Central region (high rate of resistance) for concomitant quadruple and sequential therapies.

Conclusion

In Europe, the use of formulations with PB adjuvant to eradication therapy is associated with increased effectiveness of eradication therapy, with the benefit being superior in triple and sequential therapies.

Disclosure

Nothing to disclosure

Introduction

Endoscopic ultrasound-guided fine needles biopsy (EUS-FNB) is nowadays considered mandatory for the assessment of solid pancreatic lesions (SPLs) in the neoadjuvant era. Even if most recent guidelines suggest that not less than 3 passes are sufficient to obtain adequate histological characterization, the right number of needle passes with the newest generation of FNB needles remains a topic of debate. In our study we aim to evaluate if less than 3 passes are enough to ensure high rates of confirmed histological diagnosis with the newest generation of FNB cutting needles.

Aims & Methods

Consecutive patients with SPLs requiring tissue sampling through EUS-FNB were enrolled in our study between October 2022 and March 2023. Tissue sampling was performed by the same expert endoscopist through a new 22G needle with asymmetric three-prong tip with the slow-pull technique and fanning when possible. The number of needle passes was determined by the macroscopic onsite evaluation (MOSE), and samples, coming from different passes, were divided into different test tubes. Our endpoints were diagnostic accuracy, positive core procurement yield and sample quality considering each test tube separetely.

Results

53 lesions (of which 75% pancreatic ductal adenocarcinoma) were sampled with an average size of 31 mm (SD=12mm). Sampling was performed with 2 or 3 passes, according to MOSE. Regarding the first needle pass, diagnostic accuracy was 97% (51 confirmed histological diagnosis) which reached 98% considering the second needle pass. Sample adequacy reached approximately 99%. Positive core procurement and tissue quality were >95% in all test tubes. No major adverse events were detected.

Conclusion

In patients with SPLs, the newest generation of histology needles for EUS-FNB could ensure a high diagnostic accuracy with only one needle pass, becoming extremely relevant in terms of time-saving, cost-effectiveness and safety, especially in high volume centers. Due to the limited number of patients additional data are needed.