Clinical Case Summary

A 61-year-old Malay male, without significant past medical history, presented with cough and fever for 4 days. He denied any retrosternal chest pain, dysphagia, odynophagia, or other constitutional symptoms. On examination, he was afebrile, hemodynamically stable, but required high-flow nasal cannula at 60L/40%. Crepitations were heard over the left lower lobe of lung. Initial chest X-ray revealed an air-fluid level in the right retrocardiac region. Computed tomography (CT) scan of the thorax revealed hydropneumopericardium with pockets of air at the upper mediastinum, clusters of nodules in both upper lobes and multiple calcified lymph nodes. No obvious lung mass was identified. The upper oesophagus appeared distended with a transition around the level of T5, where a calcific density was found in the posterior mediastinum adjacent to the oesophagus. The patient underwent oesophagogastroduodenoscopy (OGD) after an urgent pericardiocentesis. A 2cm fistula opening was identified at 22 cm from the upper incisors, with pus emerging from it. The rest of the oesophagus was normal. The fistula opening was initially closed using 4 endoscopic clips but a repeat OGD 9 days later revealed failure of sustained closure. A 12mm over-the-scope clip (OTSC) was subsequently attempted but encountered difficulty to suction up the fibrotic fistula edges. The OTSC was deployed eventually with the assistance of a twin-grasper device which enabled better apposition of the fibrotic fistula edge, closing the fistula opening successfully. Sputum acid-fast bacilli culture subsequently grew pan-sensitive Mycobacterium tuberculosis (TB) complex for which anti-TB treatment was commenced. Soluble contrast swallow performed 4 weeks after OTSC deployment did not demonstrate any oesophageal leak. OGD performed 6 weeks after OTSC deployment showed persistent closure of the fistula with a pseudopolyp observed at the upper oesophagus. The patient made a successful recovery and resumed oral feeding.

References

1.CXR
2.CT thorax
3.Endoscopic finding of fistula
4.Endoscopic closure with OTSC

Introduction

Focal cryoballoon ablation (FCBA) is a relatively new ablation modality for the treatment of Barrett’s esophagus (BE) related neoplasia. This prospective, European multicenter study (Euro-Coldplay, NTR NL7253) aimed to evaluate the efficacy and safety of FCBA for the treatment of limited BE.

Aims & Methods

In eight European Barrett referral centers, patients with C≤2M≤5 BE with an indication for ablation therapy were eligible for inclusion. Before entry, any visible lesion had to be removed by endoscopic resection (max. 2cm in length and 50% of circumference). FCBA was performed by experienced and trained endoscopists at 3 month intervals until complete endoscopic eradication of BE (max. 5 sessions). During every session, the esophagogastric junction was treated circumferentially followed by all visible BE using side-by-side ablations with a dose of 8 seconds per ablation. After at least two FCBA sessions, add-on treatment was allowed with either argon plasma coagulation (APC) for BE lesions of <5mm (max. 2 sessions) or a single endoscopic mucosal resection for lesions of >5mm. Outcomes included complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D), and adverse event rate.

Results

107 patients (91 males; mean age 65) with a median BE length of C0M2 were included, containing low-grade dysplasia (32%), high-grade dysplasia (32%) or early cancer (39%) as worst baseline histology. Currently, 5/107 patients are still under treatment and therefore excluded from further analysis. Of the remaining patients, 97 (97/102; 95%) patients have finished the treatment phase per protocol, while four (4/102; 4%) patients left the study prematurely. Only one (1/102; 1%) patient could not be treated with FCBA due to a device malfunction requiring a switch to radiofrequency ablation. Overall, 65/102 (64%) patients underwent endoscopic resection at entry followed by a median of 2 (IQR 2-2) FCBA treatments with a median of 7 (IQR 5-9) ablations per treatment session. During the treatment phase, 3/102 (3%) patients developed a new visible, neoplastic lesion amenable for endoscopic resection (high-grade dysplasia n = 2, low-risk T1 cancer n = 1). Add-on treatment after at least two FCBA sessions was performed in 38/102 (37%) patients, of whom the most were treated with APC for small remaining Barrett islands (37/38; 97%). CE-D was achieved in 95% (97/102) and CE-IM in 91% (93/102), per intention-to-treat analysis. Per-protocol analysis, CE-D and CE-IM were achieved in 100% (97/97) and 96% (93/97), respectively. Esophageal stricture was the most common adverse event in 13/102 (13%) patients, which resolved after a median of 2 (IQR 1-4) dilations. Only three (3/102; 3%) patients suffered a severe stricture requiring >3 dilations. No perforation or bleeding were observed, while buried BE glands were seen in 1/102 (1%).

Conclusion

In expert hands, endoscopic eradication therapy with FCBA seems to be highly effective with an acceptable safety profile for patients with limited BE. Long-term follow-up is warranted to evaluate the durability of the treatment response.

Disclosure

C.N. Frederiks have received speaker's fee and reimbursement of study-related travel costs from Pentax Medical. A. Overwater has received reimbursement of study-related travel costs from Pentax Medical. J.J.G.H.M. Bergman is a consultant for Medtronic, Cook Medical, and Boston Scientific, and has received research funding from Pentax Medical, C2 Therapeutics, Medtronic, Aqua Medical, Olympus Endoscopy, and Fuji-film. R.E. Pouw is a consultant for MicroTech, and has received speaker’s fee from Medtronic. R. Bisschops is a consultant for Pentax Medical, Medtronic, and Erbe Medical, and has received research funding and speaker’s fees from Pentax Medical, Medtronic, and Erbe Medical. T. Beyna is consultant for Medtronic, Erbe Medical, Microtech Endoscopy, Olympus Endoscopy, and Boston Scientific. B.L.A.M. Weusten has received research funding from Pentax Medical, C2 Therapeutics, and Aqua Medical. The remaining authors declare to have no disclosures relevant to this manuscript.

Introduction

Esophageal or gastric perforation is associated with systemic inflammatory response syndrome (SIRS), which can lead to multi-organ dysfunction and mortality in up to 50% of cases. Endoscopic vacuum therapy involves the use of a catheter with a sponge attached to its distal end, connected to a machine that applies negative pressure, allowing for continuous drainage of the perforation site and potentially promoting healing of the transmural defect. Previous series have reported promising results, indicating the potential effectiveness of this therapy in managing esophageal perforations. To evaluate the efficacy of endoscopic vacuum treatment in patients with primary or secondary gastroesophageal perforations.

Aims & Methods

Single-center retrospective cohort study on patients treated for gastroesophageal perforation between March 2019 and September 2022. The inclusion criteria for the study were patients with gastroesophageal perforation resulting from spontaneous rupture or iatrogenic damage (post-surgical or post-endoscopic treatment). The primary outcomes of the study were the success rate of endoscopic therapy, the length of hospital stay, and the specific survival at 30 and 90 days. The success rate of endoscopic therapy was assessed by considering the treatment successful if it led to the resolution of the fistula following vacuum endoscopic therapy. Secondary endpoints included the need for intensive care unit (ICU) stay between the start of vacuum endoscopic therapy and the patient's discharge.

Results

27 patients, with a mean age of 69.8 years (95% CI 65.4-74.3), including 9 (33.3%) women, underwent endoscopic treatment with vacuum therapy for esophageal perforation. The causes of perforation were as follows: 6 (22.2%) cases were primary (Boerhaave syndrome), 15 (55.5%) cases were post-surgical (post-surgical anastomosis), and 6 (22.2%) cases were post-endoscopic treatment (endoscopic dilatation). Among the patients, 13 (48.1%) had previously undergone surgery for cancer, with 69.2% of them receiving intrathoracic stomach interposition reconstruction and the remaining patients undergoing reconstruction according to Roux-en-Y procedure. The treatment was successful in 21 (77.7%) patients, with a 14 days (9.0-24.4, 95% CI) median duration of treatment, and 4 (3-7, 95% CI) median number of endoscopic devices used per patient. One patient (3.7%) died within 30 days, and another one (3.7%) within 90 days. A total of 10 (38.4%) patients required an ICU stay, and there were no readmissions within 30 days. No procedure-related complication was reported.

Conclusion

In the current pilot study, the findings support the feasibility and safety of endoscopic vacuum therapy as a treatment modality for both primary and secondary gastro-esophageal perforations.

References

• Kuehn F, Schiffmann L, Rau BM, Klar E. Surgical endoscopic vacuum therapy for anastomotic leakage and perforation of the upper gastrointestinal tract. J Gastrointest Surg 2012
• Pattynama LMD, Eshuis WJ, van Berge Henegouwen MI, Bergman J, Pouw RE. Vacuum-stent: A combination of endoscopic vacuum therapy and an intraluminal stent for treatment of esophageal transmural defects. Front Surg 2023
• Luttikhold J, Pattynama LMD, Seewald S, et al. Endoscopic vacuum therapy for esophageal perforation: a multicenter retrospective cohort study. Endoscopy 2023

Disclosure

Dr Valente and Dr Arnelo are consultant to Boston Scientific. Dr Arnelo is Consultant to Ambu

Introduction

In the treatment of bleeding from GI vascular malformations, the priority of endoscopic hemostasis methods, particularly argon plasma coagulation (APC), is unquestionable. Until now, no effective medication-based therapy has been available as an alternative or supplemental method. Previous studies have reported on the ineffectiveness of steroids, estrogens, and progestogens. In the past decade, several promising clinical trials have been conducted regarding the use of thalidomide and long-acting-release (LAR) octreotide to reduce bleeding from vascular malformations.

Aims & Methods

At the Department of Internal Medicine-Gastroenterology of the Petz Aladár University Teaching Hospital in Győr-Moson-Sopron County, in patients who did not respond to endoscopic treatment, either.
1. Investigate the efficacy and side effects of thalidomide,
2. Investigate the efficacy and side effects of LAR octreotide in patients resistant to thalidomide treatment.

From July 2021 to February 2024, 25 patients were treated for bleeding and anemia from GI vascular malformations. In 20 patients, bleeding was stopped with 35 (1-2) APC treatments. 5 polymorbid patients (male:female= 1:4, average age ~64.6 years) required regular transfusions despite previous ~7.2 APC treatments. Their predominant underlying diseases included Banti's syndrome, autoimmune hemolytic anemia, ischemic cardiomyopathy, atrial fibrillation, Osler's disease, and autoimmune hepatitis. These 5 patients underwent a 3-month course of 100mg thalidomide per day. In patients where thalidomide was ineffective or caused side effects, LAR octreotide intramuscular injections were indicated once every four weeks at a 30mg dose. Visits, blood counts, and lab tests were conducted monthly.

Results

With thalidomide treatment, the transfusion requirement ceased in 2/5 patients. In 2/5 patients, the treatment was suspended due to ineffectiveness and side effects (deep vein thrombosis, emesis). Treatment was ineffective in 1/5 patients. In the last 3 patients, LAR octreotide treatment was also ineffective. Mild side effects (meteorism, nausea, exanthemas) were observed in these patients.

Conclusion

In the care of patients bleeding from vascular malformations resistant to endoscopic therapy,
1. Thalidomide may be an effective medication,
2. Close patient monitoring is important to filter out side effects,
3. The effectiveness of LAR octreotide cannot be determined based on the study,
4. Further follow-up studies are necessary.

Introduction

Currently, endoscopic retrograde appendicitis therapy (ERAT) is indicated only for acute uncomplicated appendicitis, though its utility can be extended to patients who are poor surgical candidates in more complex appendiceal disease such as those with periappendiceal abscess. Current treatments of periappendiceal abscess include emergency surgery, nonsurgical management with or without percutaneous drainage, and interval appendectomy after nonsurgical management. Herein, we highlight the utility of ERAT, which allows for interventional, noninvasive management of periappendiceal abscess without surgery.

Aims & Methods

The aim of this study was to evaluate the safety and efficacy of ERAT for treating periappendiceal abscess.
Twenty-four consecutive periappendiceal abscess patients were evaluated between May 2017 and May 2022 at three tertiary care Hospitals in China. The diagnosis of periappendiceal abscess was confirmed by direct colonoscopy imaging and computed tomography (CT) and/or ultrasonography (US). The baseline characteristics of all the patients, procedure success rate, procedure time, postoperative length of hospital stay, complications, and recurrence rate were recorded.

Results

The success rate of ERAT was 95.8% (intubation failed in one patient due to the closure/blockage of the appendix opening). All the patients (100%) patients had abdominal tenderness, 56. 5% had abdominal rebound pain, 21.7% had fever, and 86.9% patients had elevated white blood cells before the ERAT. The mean procedure time was 33.79 minutes with standard deviation (SD) of 17.1 min. The mean length of postoperative hospital stay was 5.4 (SD 2.6) days. Time to relief of abdominal pain after the ERAT was 28.2±19.4 hours. After the ERAT procedure WBC get back to normal range in 2.2±1.3 days. No complication observed in any of the patient. Antibiotics were routinely administered for 3 days after the ERAT. We followed up the patients at 3, 6, 12, 24 and 36 months respectively. Recurrence occurred in 8.7% of the patents at mean 26.9 (SD 10) months of follow-up.

Conclusion

Preliminary evidence suggests that ERAT is safe and effective alternative option for treating periappendiceal abscess, making it a valuable addition to the armamentarium of interventional endoscopy. The practice of ERAT currently remains predominantly limited to the Eastern world. As the treatment paradigm of appendicitis evolves, it is crucial that novel techniques such as ERAT be evaluated at a global scale alongside the evolving standard of care therapies.

Disclosure

None to declare

Introduction

Endoscopic eradication therapy (EET) is well-established for treatment of Barrett’s Esophagus (BE) related neoplasia. Despite very low risks of neoplasia recurrence, current protocols for endoscopic follow-up (FU) after successful EET are quite strict and do not take into account the significant risk of mortality due to other causes than esophageal cancer. An accurate prediction of the risk for unrelated mortality is key to patient-tailored and cost-effective care.

Aims & Methods

We evaluated the performance of the well-known Charlson Comorbidity Index (CCI) for prediction of unrelated mortality during follow-up in a cohort of patients successfully treated with EET for BE neoplasia. In the Netherlands, EET is centralized in 9 Barrett Expert Centers (BEC) who follow a joint treatment and FU protocol and have a joint registry. This registry is merged with National Statistics for accurate survival outcomes, including date and cause of death. This study included all patients who achieved complete eradication of BE after EET (from 2008-2018) and with at least one year FU. CCI was calculated at the start of EET based on existing medical records. The predictive value of the CCI on the primary outcome mortality during FU was evaluated using C-statistic and calibration plots (predicted vs observed rates).

Results

A total of 1,154 patients were followed for median 59 months (IQR 37-91) per patient after achieving complete eradication of EET. At start of FU, mean age was 64 years (±9). Most common comorbidities were: myocardial infarction (n=165, 14%), diabetes mellitus (n=158, 14%), and chronic obstructive pulmonary disease (n=155, 13%). Median CCI was 3 (IQR 2-4, range 0-10). During FU, 154 (13%) patients died due to unrelated causes. The time to death was median 58 months (IQR 36-90) after start of EET. Baseline CCI score was significantly higher among the patients who died from unrelated causes (4.0 ±1.7) as compared to patients alive (2.9 ±1.6, p<0.05). With increasing baseline CCI, mortality risk increased significantly. For each quartile of CCI (i.e. CCI <2; 2-3; 3-4; and >4), mortality during FU was 7%, 11%, 21% and 27% respectively. Discrimination of CCI was acceptable (C-statistic 0.78 [95% CI 0.72-0.84], with higher scores indicating better ability of the model to distinguish individuals with and without mortality). The calibration plot indicated reasonable calibration, based on comparable predicted and observed risks. Sensitivity analyses showed comparable results, indicating the model is robust.

Conclusion

CCI predicts unrelated mortality well in a population of BE patients after successful EET. This simple-to-calculate score could be used to guide decisions for patient-tailored management such as when to stop follow-up after successful EET.