Introduction

The safety and efficacy of endoscopic haemostasis in patients with upper gastrointestinal (UGI) bleeding has been widely assessed over the years. However, to date no study addressed the management of UGI bleeding specifically in the setting of patients with surgically altered anatomy.

Aims & Methods

Our study is focused on the evaluation of the endoscopic management of UGI bleeding in these patients with specific concern about the techniques used to achieve haemostasis, the management of technical failure and the rate of adverse events. We conducted a multicentre retrospective- prospective observational study in 13 endoscopy units in Italy. All consecutive patients with UGI bleeding and surgically altered anatomy managed endoscopically were collected from January 2023 to November 2024.

Results

We enrolled 162 patients (73% males) with a mean age of 69 years. 45% of patients had history of oncologic surgery while 20% underwent bariatric surgery. The most common clinical manifestations were melena (59%) followed by hematemesis (22%). At bleeding event patients were taking anticoagulants and antiplatelet in 32% and 16% of cases, respectively. In 43% of cases from 1 to 4 blood units were needed, in 15% more than 4 blood units, while in 42% of patients no transfusions ware required. 42% of endoscopic procedures were performed with anesthesiologist assistance. Bleeding was located at anastomotic site in 70% of cases and ulcer was the most common source of bleeding (54% of patients). The most frequently used treatments were adrenaline combined with TTSC (40 %) and TTSC alone (24%). Haemostatic powder or gel and adrenaline combined with thermal treatment were used only in 6 and 4% of cases respectively while OTSC was used in 1 patient alone after failure of adrenaline combined with TTSC. Bleeding control during endoscopy was achieved in 94% of patients. In 12 patients rebleeding occurred, which was managed with surgery in 2 patients, interventional radiology in 1 case and with new endoscopic treatment in 4 cases. No serious adverse events linked to endoscopy were reported.

Conclusion

Our preliminary results showed that patients with altered anatomy often had severe bleeding requiring a large amount of blood transfusions. The standard endoscopic homeostatic techniques seemed to be effective for the management of bleeding, although a not negligible rate of patients needed additional treatments. However, further data are needed to better assess clinical outcomes in this setting and to better define possible predictive predictors of clinical success and therefore which technique should be preferred to achieve haemostasis.

References

1. S. G. Lim et al., “Endoscopic Approach for Postoperative Complications Following Laparoscopic-Assisted Gastrectomy in Early Gastric Cancer: Literature Review,” Hepatogastroenterology., vol. 59, pp. 1308–1312, 2012.
2. J.-H. Park et al., “Safety and efficacy of post-anastomotic intraoperative endoscopy to avoid early anastomotic complications during gastrectomy for gastric cancer.,” Surg. Endosc., vol. 34, no. 12, pp. 5312–5319, Dec. 2020.
3. K.-H. Kim, M.-C. Kim, G.-J. Jung, J.-S. Jang, and S.-R. Choi, “Endoscopic treatment and risk factors of postoperative anastomotic bleeding after gastrectomy for gastric cancer.,” Int. J. Surg., vol. 10, no. 10, pp. 593–597, 2012.
4. Shen, Y.; Xiao, M.; Weng, J.; Yang, L.; Feng, Y.; Ye, Y.; Zheng, P. Diagnosis and treatment of postoperative bleeding in patients after gastrectomy: A retrospective case series study. J. Gastrointest. Oncol. 2023, 14, 110–118.
5. Wichmann, D.; Fusco, S.; Werner, C.R.; Voesch, S.; Duckworth-Mothes, B.; Schweizer, U.; Stüker, D.; Königsrainer, A.; Thiel, K.; Quante, M. Endoscopic Management for Post-Surgical Complications after Resection of Esophageal Cancer. Cancers 2022, 14, 980.

Introduction

Endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell carcinoma (SESCC) involving the entire circumference carries the extremely high risk of stricture and also raises concerns about curative resection. Therefore, the current Japanese guidelines weakly recommend ESD only for circumferential SESCCs diagnosed as cEP/LPM and sized ≤ 50 mm, while surgery or chemoradiotherapy (CRT) is recommended for circumferential SESCCs other than the above. ¹ However, in clinical practice, ESD is implemented on a case-by-case basis through the discussion in a multi-disciplinary cancer board at each institution because the outcomes of each treatment for circumferential SESCCs remain unclear.²

Aims & Methods

This multicenter prospective observational study aimed to reveal the outcomes of each treatment for circumferential SESCCs. Patients with cT1a-EP/LPM or cT1a-MM/T1b-SM1 N0M0 SESCCs involving the entire circumference were enrolled in this study. At this stage, short-term outcomes, such as the proportion of curative resection after ESD, complete response (CR) after CRT/radiotherapy (RT), and adverse events including esophageal stricture, were evaluated. Curative resection in ESD was defined as pT1a without lymphovascular invasion (LVI). Esophageal stricture was defined as inability to pass the ordinary-sized endoscope thorough the treated site, and refractory stricture was defined as stricture requiring ≥ 6 endoscopic balloon dilation procedures.

Results

A total of 126 patients with circumferential SESCCs were enrolled from 16 Japanese tertiary institutions between May 2021 and November 2024. ESD was performed for 90 (71.4%) patients including 6 undergoing stepwise ESD, surgery for 18 (14.3%), CRT for 16 (12.7%), and RT alone for 2 (1.6%). Median longitudinal length of tumor was 55 (range: 30–140) mm in the ESD group, 80 (50–150) mm in the surgery group, and 70 (30–100) mm in the CRT/RT group. Tumor depth was diagnosed as cEP/LPM in 65.4% (55/84) of the ESD group, 38.9% (7/18) of the surgery group, and 50.0% (9/18) of the CRT/RT group, and the others were diagnosed as cMM/SM1. As stricture prevention method after ESD, local injection or filling of triamcinolone (TA) alone was used in 9 patients (10.7%), and both local injection of TA and oral steroid of prednisolone were used in 75 (89.3%). Among the 63 patients who did not receive additional treatment after ESD, the proportion of stricture and refractory stricture were 46.0% (29/63) and 27.0% (17/63), respectively. Curative resection after ESD was achieved in 58 patients (69.0%), including 46 (83.6%) with cEP/LPM and 12 (41.4%) with cMM/SM1. Of 26 patients with non-curative resection after ESD, 20 (76.9%) received additional treatment of either surgery, CRT, or RT, while the remaining 6 opted for follow-up. Of 18 patients in the surgery group, 7 with cEP/LPM and 4 with cMM/SM1 were diagnosed as pT1aN0 without LVI, while the remaining 7 with cMM/SM1 were diagnosed as pT1b, 3 of whom had lymph node metastasis. Anastomotic stricture was observed in 11.1% (2/18) of patients treated with surgery. Of 18 patients in the CRT/RT group, CR was confirmed in all patients without forming stricture.

Conclusion

Considering the high curative resection rate, ESD could be indicated for circumferential SESCCs diagnosed as cEP/LPM. In contrast, the careful consideration may be required in indicating ESD for circumferential SESCCs diagnosed as cMM/SM1 due to its low curative resection rate. Long-term outcome needs to be confirmed for further treatment comparisons.

References

1. Ishihara R, Arima M, Iizuka T, et al. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer. Dig Endosc. 2020; 32: 452–93.
2. Kadota T, Ishihara R, Hatta W, et al. Multi-institutional questionnaire on treatment strategies for superficial entire circumferential esophageal squamous cell carcinoma. DEN Open. 2023; 3: e206.

Introduction

The prevalence of obesity in inflammatory bowel disease (IBD) has risen, with 15–40% of adults classified as obese and an additional 20–40% as overweight ¹. Poor dietary habits and sedentary lifestyles contribute to overweight and sarcopenia, potentially worsening IBD-related disability.

Aims & Methods

This cross-sectional study aimed to evaluate the relationships between nutritional status, adherence to the Mediterranean diet, sarcopenia and disability in IBD patients. Patients with IBD attending the outpatient clinic or infusion unit of an academic tertiary center between 2023 and 2024 were consecutively enrolled. Bioelectrical impedance analysis (BIA) was used to estimate the fat-free mass index (FFMI), a recognized measure of skeletal muscle mass. Physical function was assessed via gait speed (time to walk 6 meters), and handgrip strength (HGS) measured using a Jamar dynamometer. Sarcopenia was diagnosed based on FFMI, HGS, and walking speed. Disability was evaluated using the IBD-Disk questionnaire, with scores ≥40 indicating moderate-to-severe disability. Adherence to the Mediterranean diet was assessed using the Medi-Lite score, with scores <9 reflecting low adherence. Demographic, clinical, and disease related data were collected.

Results

A total of 95 IBD patients (58% with Crohn’s disease, CD), 57.8% female, with a median age of 42 years (IQR 26-58) were included. Clinical activity ,measured with the Harvey-Bradshaw index (HBI), had a median score of 6 (IQR 4–7) for CD, while the median pMayo score for ulcerative colitis (UC) was 4 (IQR 2–6).
The median BMI was 23.60 (IQR 21-27). Overweight prevalence was 43.2% (41/95). Low adherence to the Mediterranean diet was significantly more frequent in overweight patients compared to nonoverweight patients (p<0.001). Overweight was also associated with increased age (p < 0.001). Sarcopenia prevalence was 7% (7/95) and was more common in non-overweight patients than in overweight patients (p = 0.002). The median BMI among sarcopenic patients was 20.6 (18.5–25.3). The mean IBD-Disk score was 41 ± 23.2, with 46.3% of patients reporting moderate-to-severe disability. Overweight patients were more likely to experience moderate-to-severe disability compared to non-overweight patients [27 (65.9%) vs. 23 (42.6%), p =0.02]. No significant association was found between sarcopenia and moderate-to-severe disability (p = 0.44).

Conclusion

Overweight is associated with low adherence to the Mediterranean diet and increased disability in IBD patients. Targeted interventions to improve adherence to the Mediterranean diet and manage overweight could potentially reduce disability in IBD patients.

References

1. Singh S et al, Nat Rev Gastro Hepatol. 2017 February ; 14(2): 110–121 10.1038/nrgastro.2016.181

Clinical Case Summary

Joubert Syndrome (JS) is a rare genetic disorder, affecting approximately 1 in 80,000–100,000 live births. It is characterized by hypotonia, developmental delay, cerebellar ataxia, and the hallmark "molar tooth sign" (MTS) on brain imaging. Even rarer is its hepatic manifestation, Joubert Syndrome with hepatic defect (JS-H), which occurs in 6%–14% of cases and is commonly associated with congenital hepatic fibrosis (CHF). This report presents the first genetically confirmed case of JS-H in the Philippines.
A 19-year-old male with developmental delay, dysarthria, and ataxia presented with jaundice, abdominal distention, and upper gastrointestinal bleeding. On admission, he exhibited distinct facial features, neurological deficits, and signs of portal hypertension. Laboratory tests revealed pancytopenia, liver dysfunction, and coagulopathy. Esophagogastroduodenoscopy identified type 1 gastroesophageal varices (GOV1). Cranial imaging confirmed MTS. Whole exome sequencing revealed pathogenic TMEM67 variants, establishing the diagnosis of JS-H. Other potential causes of advanced liver fibrosis were systematically ruled out.
Management focused on hemodynamic stabilization. The patient received blood transfusions, somatostatin analogs, non-selective beta-blockers, antibiotics, and diuretics, along with nutritional support and rehabilitative therapies. Due to resource limitations, medical management was optimized. With a MELD 3.0 score predicting a 96% 90-day survival rate, the patient is a potential liver transplant candidate. He was discharged in stable condition, with ongoing surveillance for multi-organ involvement and malignancy.
This case highlights the diagnostic challenges of JS-H and underscores the critical need for early recognition, genetic testing, and a multidisciplinary approach. Increased awareness can lead to earlier interventions and improved outcomes for affected individuals.

References

Parisi MA, Doherty D, Chance PF, Glass IA. Joubert syndrome (and related disorders). European Journal of Human Genetics. 2007 Mar 21;15(5):511–21. doi:10.1038/sj.ejhg.5201648
Olave MC, Gurung A, Mistry PK, Kakar S, Yeh M, Xu M, et al. Etiology of cirrhosis in the young. Human Pathology. 2020 Feb;96:96–103. doi:10.1016/j.humpath.2019.09.015
Jamandre AJ, Flores MK, Hiyadan JH, Melecio-Jamandre CA. Beyond childhood: Joubert syndrome in a 34-year-old female – A case report. Journal of Health and Medical Sciences. 2023 Mar 30;6(1). doi:10.31014/aior.1994.06.01.261
Ong SR, Viterbo G, Galsim RJ. Joubert Syndrome in a 9-year old Female Presenting with Intellectual, Motor and Ocular Impairment [Internet]. European Society of Radiology; 2022. Available from: https://www.eurorad.org/case/16899
Qiao W, Ren Y, Bai Y, Liu S, Zhang Q, Zhi F. Cyanoacrylate injection versus band ligation in the endoscopic management of Acute Gastric Variceal bleeding. Medicine. 2015 Oct;94(41). doi:10.1097/md.0000000000001725
Bachmann‐Gagescu R, Dempsey JC, Bulgheroni S, Chen ML, D’Arrigo S, Glass IA, et al. Healthcare recommendations for Joubert syndrome. American Journal of Medical Genetics Part A. 2019 Nov 11;182(1):229–49. doi:10.1002/ajmg.a.61399
Wu WK, Ziogas IA, Izzy M, Pai AK, Hafberg ET, Matsuoka LK, et al. Liver transplantation for congenital hepatic fibrosis. Transplant International. 2021 May 30;34(7):1281–92. doi:10.1111/tri.13884

Introduction

Endoscopic biliary drainage for malignant obstruction can be technically challenging, particularly in patients with high-grade hilar strictures or progressive distal lesions that extend beyond the reach of ERCP alone. While ERCP remains the first-line approach, it may prove inadequate in complex scenarios. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an alternative or complementary technique. However, data on outcomes that combine ERCP and EUS-BD in routine clinical practice remain insufficient and limited.

Aims & Methods

This study aims to evaluate the clinical success, stent patency, and complication rates of combined ERCP and EUS-BD in patients with malignant biliary obstruction while identifying factors associated with complications. We included 40 patients who underwent combined ERCP and EUS-BD for malignant biliary obstruction at a tertiary center from March 2020 to March 2025. The patients were divided into two groups: one-session procedures, in which both techniques were performed during the same session (n=14), and staged procedures, where EUS-BD was followed by at least one prior ERCP (n=26). Clinical success was defined as resolving jaundice and/or cholangitis without additional drainage. The outcomes assessed included clinical success, stent patency, complications, and reintervention. Univariate analysis was employed to identify predictors of complications.

Results

The cohort included 21 (52.5 %) males and 19 (47.5%) females, with a median age of 65.6 years. The distribution of strictures was as follows: 23 (57.5%) high-grade hilar (Bismuth III/IV), 7 (17.5%) Bismuth I/II, and 10 (25%) distal. Underlying malignancies included 12 (30%) hilar cholangiocarcinoma, 8 (20%) pancreatic adenocarcinoma, and 16 (40 %) liver or hilar metastasis from other tumors.
Clinical success was achieved in 90% of patients (36/40), with no significant difference between one-session and staged groups (85.7% vs. 92.3%, p=0.60). The median procedural time was 39.3 minutes. Overall, 12 patients (30%) experienced complications, including stent-related infections in 10 (25%), post-ERCP pancreatitis in 1(2.5%), and bleeding in 1 (2.5%). Complication rates were similar between the one-session and staged groups (28.6% vs. 31.0%, p=1.00). Reintervention was required in 3 patients (7.5%). A significant association was observed between undergoing more than two prior ERCPs and the risk of complications (66.7% vs. 22.6%, p=0.038). Neither the presence of hilar strictures (p=0.56) nor procedural timing (one-session vs. staged; p=1.00) was significantly associated with increased complications.

Conclusion

Combining ERCP and EUS-guided biliary drainage is a safe and effective strategy for managing malignant biliary obstruction, including complex hilar and progressive distal strictures. Performing both procedures in a single session does not increase complication rates and may provide comparable clinical success. The number of prior ERCPs was the only significant predictor of complications, suggesting a potential benefit from earlier use of EUS-BD in selected patients. Further prospective studies are warranted to confirm these findings and guide treatment algorithms for complex biliary obstruction.

Clinical Case Summary

Primary biliary cholangitis (PBC) is a rare disease (19-42 per million) characterized by a T-lymphocyte-mediated attack on small intralobular bile ducts. We are presented with a case of a 46 year old female who came in for generalized pruritis, generalized jaundice and elevated liver enzymes. The patient was completely worked up, and all the most common causes of jaundice turned out negative. Liver biopsy was done and was signed out as a case of PBC which progressed to a decompensated state of liver cirrhosis complicated by portal hypertension. Most of the treatment options were exhausted at this time and the medical team was left with the option to do liver transplantation. During the work-up for the said transplant, there was an incidental finding of a breast cancer which was an absolute contraindication to transplantation. Fortunately, the malignancy was at an early stage (Stage 1) and was managed surgically. A repeat PET CT scan was done for surveillance which revealed no distant metastases. The procedure was tolerated well by the patient and was eligible to be placed back on the transplant list. The patient was in dire need of transplant and having been initially removed from the transplant list pushed her at the back of the list. Fortunately a relative selflessly offered to be a living donor and the patient was for liver transplant. Unfortunately, the patient succumbed to COVID-19 and expired even before the medical team could do the transplant. This case highlights the management of PBC with end-stage liver disease has numerous complications but are manageable. Individualization of patient management is essential when faced with rare and complicated cases which lead to the conclusion that absolute contrainidications are not always absolute as demonstrated in this case that the patient initially thought that she can never undergo liver transplant due to her malignancy but was given another chance at life when she got treated and was declared cancer free.

References

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