Introduction

​Post-ERCP pancreatitis (PEP) is still the most common major complication of ERCP despite technical advancements and meticulous patient selection. The efficacy of the existing techniques is conflicting.

Aims & Methods

We aimed to compare the efficacy of peripapillary epinephrine injection in combination with rectal diclofenac for the prevention of PEP in high-risk patients .
Methods Between January 2023 and August 2023, a total of 378 patients were enrolled. We calculated that 189 patients in each group (rectal diclofenac – Group A and peripapillary epinephrine injection plus rectal indomethacin – Group B) would suffice based on a previous study by our group (α:0.05, 80% power). Patients with a non-naive papillae, ampulla of Vater cancer, biliary pancreatitis, altered anatomy, pregnancy, and pancreatic diseases such as chronic pancreatitis were excluded. Patients were assigned in a 1:1 simple randomized fashion. The primary outcome was the rate of PEP. Secondary outcomes were the rate of hyperamylasemia and rates of other adverse events.

Results

​Demographic characteristics, indications, and procedure-related risk factors were similar between the groups. The overall success rate of selective cannulation was 99.2% in Group A and 99.3% in Group B (p=0.997). PEP occurred in 9 of the 189 (4.8%) patients in Group A and 2 of the 189 (0.5%) patients in Group B. All cases were mild and managed conservatively. The rate of post-procedure 4th-hour hyperamylasemia was significantly higher in Group A (19% vs 5%, p<0.001). Postsphincterotomy-related bleeding developed in 5 patients in Group A (2.64%) but none of the patients had bleeding in Group B. Stapfer type-II perforation occurred in two patients in each group. No major cardiac adverse events-related to epinephrine injection were detected in Group B.

Conclusion

Compared to rectal diclofenac, peripapillary epinephrine injection significantly reduced the incidence of PEP, post-procedure hyperamylasemia, and sphincterotomy-related bleeding.

Clinical Case Summary

Aim: Abdominal Cocoon syndrome is the complete or partial wrapping of the abdominal organs with a membrane structure. Diagnosis can be made by laparoscopy. Patients mostly present with acute abdomen symptoms due to intestinal obstruction.
Case: 27-year-old male patient had recurrent abdominal pain for 12 years and was diagnosed with Behçet's disease and started on treatment. The patient’s abdominal pain increased in the last 6 months. He was followed up 4 months ago with suspected ileus, recovered with symptomatic treatments. A colonoscopy was performed and aphthous ulcers were detected in the terminal ileum and linear ulcers in the sigmoid colon. Tuberculosis,vasculitis and amyloid was excluded in the biopsies .With the preliminary diagnosis of Crohn's disease, 5-ASA and Azathioprine were started, and when no clinical response was obtained, Adalimumab was switched. The patient, who had no history of alcohol, cigarette use or any surgery, stopped all of her medications because she had not had symptomatic improvement for a long time, and was relieved by vomiting voluntarily. Her family history included rheumatoid arthritis in her sister and ulcerative colitis in her cousin. In the physical examination, there was no pathology other than widespread tenderness in the abdomen. In the ultrasonography; the small intestine walls were seem to be slightly edematous and retracted. Enteroscopy was completely normal. In the CT-Enterography, it was thought that it could be an "abdominal cocoon", so a laparotomy was performed and the diagnosis. The small intestines were freed from the fibrotic bands. The patient did not develop any post-operative complications, and her abdominal pain completely resolved after the operation.
Conclusion: Abdominal cocoon syndrome should be kept in mind as a very rare disease that can cause diagnostic confusion, remain undiagnosed for a long time, and cause unnecessary treatments, and can be fixed totally with surgical treatment.

Introduction

Endoscopic resection (ER) of duodenal tumors carries a high risk of intraoperative or delayed perforation because of the thin duodenal wall and exposure to bile and pancreatic juice. Delayed perforation can particularly cause serious condition due to the leakage of the digestive fluids. The detailed management and clinical course following duodenal perforation remains unclear. This study aimed to clarify the optimal management of duodenal perforation following ER.

Aims & Methods

This single-center retrospective study included cases of perforation among patients who underwent ER for duodenal tumors at our institution between April 2013 and October 2024. The study endpoint was the clinical course after perforation, including the hospitalization period after ER for duodenal tumors. Perforation was defined as the presence of extraluminal gas on computed tomography (CT) scan. Delayed perforation was defined as a perforation that was not endoscopically recognized during the procedure but was diagnosed postoperatively. In contrast, intraoperative perforation was defined as a case in which a perforation was endoscopically identified during the endoscopic procedure. Long hospitalization was defined as a hospital stay of 20 days or longer.

Results

Of the 1,475 cases with duodenal tumors underwent ER during the study period, intraoperative perforation occurred in 8 cases (0.5%) and delayed perforation in 10 cases (0.7%). The median age of patients with perforation was 62 (range: 47–80) years, and 50% (9 patients) were male. The 18 cases included 6 cases of endoscopic papillectomy (EP), 7 cases of endoscopic mucosal resection (EMR), 2 cases of endoscopic submucosal dissection, and 3 cases of endoscopic submucosal resection with a ligation device. Among the cases of intraoperative perforations, long hospitalization, 61 days of conservative treatment, was required in one case who developed a large perforation during scope insertion of single‑balloon enteroscopy for duodenal adenoma resection. The remaining 7 cases achieved successful endoscopic closure intraoperatively and hospitalization periods were within 17 days. Of the 10 delayed perforation cases, 2 occurred after EP and 8 after EMR for non-ampullary tumors. The median time from the end of endoscopic resection to the diagnosis of perforation was 24 hours (4–46 hours). The median hospitalization period of the cases with delayed perforations was 32 days (9–81 days), and significantly longer than that of intraoperative perforation (13 days) (p<0.05). Long hospitalization was required in 8 cases (80%) of delayed perforation. None of the delayed perforation cases required surgical intervention, and endoscopic nasobiliary and nasopancreatic duct drainage (ENBPD) was performed in 7 cases (70%). Ascites was observed on CT scan at the time of diagnosis of delayed perforation in 7 of the 8 patients who required long hospitalization. One case without ascites at the diagnosis of delayed perforation still required long hospitalization, possibly due to the 10-hour delay from the diagnosis to ENBPD. On the other hand, two cases who did not need long hospitalization showed no ascites at the diagnosis of delayed perforation.

Conclusion

Compared to intraoperative perforation, delayed perforation was associated with significantly prolonged hospitalization, particularly in cases with ascites. Early detection of ascites and prompt initiation of ENBPD may help mitigate the clinical burden. Establishing an emergent backup system for ENBPD is essential for the safe management of delayed perforation after duodenal ER.

Introduction

The STRIDE II guidelines recognize endoscopic healing as one of the main therapeutic targets in Crohn's disease (CD). Nevertheless, transmural healing could reduce the risk of long-term complications. The aim of this study was to assess the risk of long-term complications in CD according to the degree of endoscopic and ultrasound healing.

Aims & Methods

We conducted a prospective study that included all patients with CD in clinical remission who underwent colonoscopy with endoscopic healing (CDEIS <4) and intestinal ultrasound (IUS) within 4 weeks between September 2019 and September 2022. IUS transmural healing was defined by a parietal thickness < 3 mm on all digestive segments (colonic and ileal) without color doppler signal.
The primary endpoint was CD relapse, defined as the need for drug intensification, initiation of corticosteroid therapy, CD-related hospitalization, development of a perianal and luminal fistula or abscess, or the need CD-related bowel surgery. Patients were followed up at least every 6 months for two years.

Results

A total of 93 patients were included, the majority of whom were women (53%) with ileocolonic location (43%). The median disease duration was 12 years (IQR, 4-19) and 71% patients were treated with anti-TNF. Ultrasound transmural healing was observed in 73% (68/93) of patients. After a median follow-up of 22.5 months [IQR, 19.3-23.7] 26% of patients have relapsed. The risk of relapse was significantly higher among patients IUS activity at 6 and 12 months (13% vs. 5% and 24% vs 8 % p = 0.007). In multivariate analysis, the risk of relapse was 3 times higher without IUS transmural healing (HR 3.07 (1.35-9.97); p = 0.007). Among patients with a complete endoscopic healing (CDEIS 0) the relapse rate were also significantly higher among patients with IUS activity compared to those with IUS healing (HR 3.65 (1.06-12.8); p =0.040).

Conclusion

IUS transmural healing was associated with a lower risk of relapse among patients with endoscopic healing and could be considered as a non-invasive therapeutic target in CD.