Introduction

We previously reported short-term outcomes at 3 months after cold forceps biopsy (CFB) using jumbo biopsy forceps (Boston Scientific or Olympus Medical Systems) for micro-pharyngeal neoplasms¹.

Aims & Methods

We extended the follow-up and present here outcomes at 12 months after the CFB (UMIN registry number: 000037980). One hundred twenty-five lesions in 101 patients endoscopically diagnosed with narrow-band imaging of dilated intrapapillary capillary loops with clear demarcation as micro-pharyngeal tumors of 3 mm or less and excised with CFB were prospectively registered. After excluding 28 lesions with benign pathology, 97 lesions (13 lesions of squamous cell carcinoma, 4 of high-grade dysplasia, and 80 of low-grade dysplasia) were endoscopically followed up 3 and 12 months after the first CFB. Additional CFB was performed if lesions with endoscopically determined local remnant/recurrence (ER, narrow-band imaging of dilated intrapapillary capillary loops with clear demarcation) were found. The primary outcome was ER rate. The secondary outcome was composite remnant/recurrence (CR) (ER with pathological recurrence, ER without pathological assessment, and non-ER scars but with pathological recurrence) rate.

Results

Endoscopy at 3 months after CFB was performed in 56 lesions in 47 patients, and CFB scars were identified in 25 lesions (44.6%). Additional CFB was performed in all scars judged as ER, and regular biopsy was obtained in some scars without ER. ER rate at 3 months was 23.2% (13/56, 95% confidence interval 13 - 36.4%), and CR rate was also 23.2% (13/56, 13 -36.4%) (one ER scar with negative pathology, and one non-ER scar with positive pathology). Endoscopy at 12 months was performed in 84 lesions in 71 patients. CFB scars were identified in 20 lesions (23.8%); ER rate at 12 months was 11.9% (10/84, 5.9 -20.8%), and CR rate was 8.3% (7/84, 3.4-16.4%) (3 ER scars with negative pathology, no non-ER scar with positive pathology). Regarding safety of the procedure, no intraoperative or postoperative adverse event was observed in all the 125 lesions including 24 lesions excised under continued antithrombotic therapy.

Conclusion

About 10% remnant or recurrence rates at 12 months after the procedure suggest that CFB may be minimally invasive therapeutic option for micro-pharyngeal neoplasms of 3 mm or smaller. Further follow-up study is continuing.

References

1: Shimodate Y et al. Efficacy and safety of cold forceps biopsy for diminutive pharyngeal neoplasms: Single-center, prospective pilot study. Dig Endosc 2021; 33: 761-769.

Introduction

Thyroidectomy is one of the most common surgical procedures worldwide, yet its potential effects on esophageal function remain inadequately characterized. While post-thyroidectomy issues such as voice changes have been well-documented, alterations in esophageal motility following this procedure have received limited attention in scientific literature.

Aims & Methods

This study aims to evaluate the impact of thyroidectomy on esophageal motility parameters using High-resolution manometry (HRM), with particular attention to upper esophageal sphincter (UES) function. Seventeen patients (11 females), who were to undergo total thyroidectomy or hemithyroidectomy, were prospectively recruited between the months of February and May 2023. Ten of them had goiters, while seven had thyroid nodules. Exclusion criteria were having an age under 30 or over 70 years old, having to also undergo a parathyroid surgery and taking medications that could alter the esophageal sphincter. All of them underwent a pre-operative HRM and a second one thirty days after surgery. HRM were performed according to the Chicago Classification 4.0 and the data were analyzed using the online analysis platform “Swallow Gateway”. Gastrointestinal (GI) symptoms were assessed using a standardized questionnaire, before the first and the second HRM. No after procedural complication was reported.

Results

UES function significatively changed after thyroidectomy, as it is shown by HRM metrics such as Pharyngeal Contractile Integral (CI), Velopharyngeal CI, Hypopharyngeal CI, UES-CI, UES Integrated Relaxation Pressure (UES-IRP), Post-Deglutitive UES CI, Proximal Contractile Integral (PCI), which all significatively decreased (p < 0.05) at the HRM performed after surgery. Compared to Swallow Gateway normal values, there was an important increase of pathological HRM metrics after thyroidectomy. No significant HRM difference was found between the two categories of patients (goiter and thyroid nodules) and no significant correlation was registered between GI symptoms pre- and post-surgery and between GI symptoms and HRM metrics.

Conclusion

Thyroidectomy may significantly affect esophageal motility, especially the function of the upper esophageal sphincter. This finding could be useful in the diagnostic and therapeutic pathway of these patients, although further and larger studies are required to confirm this result.

Introduction

Duodenal Neuroendocrine Neoplasms (dNENs) are rare neoplasms (2.7% of all NENs) (1), but their incidence is on the rise. Most of them are smaller, low-grade neoplasms with an indolent course. The role of endoscopic resection and active surveillance of dNENs needs to be reviewed (2). The term neuroendocrine tumor (NET) generally refers to well-differentiated disease, neuroendocrine carcinoma (NEC) refers to poorly differentiated disease, and NEN is an umbrella term inclusive of both.

Aims & Methods

This is a single-center observational retrospective study of duodenal Endoscopic Band Ligation (dEBL) done between June 2020 and February 2023 at the Asian Institute of Gastroenterology (AIG Hospitals), Hyderabad, India. The primary aim was to study the therapeutic efficacy of dEBL for dNENs. All patients having histological or molecular radiology (Gallium 68 DOTATEC) confirmation of a neuroendocrine neoplasm either at our center or outside were included. The size, number, and location of lesions were recorded. On histopathology examination, the grade and Ki 67 index were noted (3). The presence of lymph node, hepatic, and skeletal metastasis was assessed at the time of diagnosis through cross-sectional imaging and Gallium 68 DOTATEC scans (4). All patients underwent follow-up endoscopies 3–12 months after dEBL, and those who were indicated underwent repeat imaging.

Results

During the study period, n = 138 (M: F: 107:31, age: 53.92±11.95 years) patients underwent dEBL. Most lesions (90%) were non-functional and were incidentally diagnosed on endoscopy. The most common site was the first part of the duodenum and duodenal bulb (n = 123, 89%), with the majority of patients having single lesions (n = 118, 85%). The size of lesions (endoscopic or radiologic) was <1cm in n=110 (80%) patients. Diagnostic endoscopic ultrasound was done in n=82 (59%) patients and showed lesions arising from the 2^nd layer of the duodenum. Biopsy showed Well differentiated NENs (with or without duodenitis) in n = 108 (78%) patients, with a Ki67 index less than 3% in 61/92 (67%) patients. A DOTATEC scan done in n = 77 (56%) patients showed uptake in n = 37/77 (48%) patients. The mean SUV max was 23.61. Follow-up endoscopies were done in n = 104 (76%) patients at 3–12 months post-procedure, which showed complete clearance of the lesion in n = 92 (95%) patients (therapeutic efficacy). Twelve patients had residual lesions on endoscopic evaluation and underwent repeat DOTATEC scans, of which four showed residual lesions for which a repeat dEBL was done. Eleven patients (8%) had post-procedure upper abdominal pain, which subsided with conservative management.

Conclusion

Endoscopic duodenal banding should be considered a safe and effective treatment modality for all well-differentiated, low-grade dNENs after excluding metastases. Further prospective studies should be done to establish this modality as the gold standard of treatment and include it in the algorithm for the management of dNENs.

References

1. Modlin IM, Lye KD, Kidd M. A 5‐decade analysis of 13,715 carcinoid tumors. Cancer: Interdisciplinary International Journal of the American Cancer Society. 2003 Feb 15;97(4):934-59.
2. Delle Fave G, Sundin A, Taal B, Ferolla P, Ramage JK, Ferone D, Ito T, Weber W, Zheng-Pei Z, De Herder WW, Pascher A. ENETS consensus guidelines update for gastroduodenal neuroendocrine neoplasms. Neuroendocrinology. 2016;103(2):119-24.
3. Zhang JY, Kunz PL. Making sense of a complex disease: A practical approach to managing neuroendocrine tumors. JCO Oncology Practice. 2022 Apr;18(4):258-64.
4. Pavel M, Öberg K, Falconi M, Krenning EP, Sundin A, Perren A, Berruti A. Gastroenteropancreatic neuroendocrine neoplasms: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology. 2020 Jul 1;31(7):844-60.

Introduction

Long-term outcomes of gastric subepithelial lesions have not been elucidated. To reveal the natural history, we initiated a prospective, 10-year follow-up of patients with small (≤20 mm) gastric subepithelial lesions in September 2014. Here, we report the results of an interim analysis of a prospective observational study.

Aims & Methods

In total, 567 patients with 609 lesions were prospectively registered between September 2014 and August 2016. The location, size, morphology, and number of subepithelial lesions were recorded on a web-based case report form.

Results

The endoscopic follow-up period was 4.60 ± 1.73 years (mean ± SD), and survival data were investigated for 5.28 ± 1.68 years. This interim analysis revealed that the estimated cumulative incidence of a size increase ≥5 mm, after accounting for patients’ death and resection of the tumor as competing risk events, was 4.5%. In addition, the estimated cumulative incidence of lesion size increase ≥5 mm or resection of lesions was 7.7% at 5 years, and that of size increase ≥10 mm or resection of lesions was 4.3% at 5 years.

Conclusion

These results indicate that approximately one in 13 patients with small (≤20 mm) gastric subepithelial lesions may require resection or further investigation for increased tumor size (≥5 mm) within five years under active surveillance.

References

Nishida T, Hirota S, Yanagisawa A et al. Clinical practice guidelines for gastrointestinal stromal tumor (GIST) in Japan: English version. Int J Clin Oncol 2008; 13: 416-30.

Disclosure

This study has been conducted as an Academic Committee Working Group of the Japan Gastroenterological Endoscopy Society.

Introduction

Some patients undergoing Capsule Endoscopy (CE) are at risk of retention and require Patency Capsule (PC). Due to limited CT scan access, most Irish CE units consider a visible PC on abdominal x-ray, 26-28 hours after ingestion as a failed test. Some patients with delayed GI transit may falsely fail their PC. Prokinetincs; Prucalopride and Gastrograffin is widely used in CE units as booster medications but their effect on PC has yet to be established.

Aims & Methods

To evaluate the role of Gastrografin, Prucalopride, and fasting in improving the pass rates of PC
Retrospective, observational comparative study between two PC regimens in Beaumont Hospital, Ireland: Group A (Non-fasting and Prucalopride 2mg ingested with PC alone) vs Group B (Fasting, Prucalopride 2mg and Gastrografin 50mls ingested with PC and 2mg Prucalopride on day of x-ray). Data was collected from electronic records. Student t-test was used to compare pass rates and p<0.05 considered significant.

Results

Demographics: Group A, n= 59, mean age 50.3 (18-82), 47.5% (n=28) males. Group B, n=30, mean age 50.6 (21-85), 53% (n=16) males.
Pass rates: Group A 61% (n=36) vs Group B 92%(n=27), p=0.002.
No PC adverse events and no medication side effects were noted in both groups.

Conclusion

This pilot study shows that Gastrografin, fasting and Prucalopride is a promising regimen with a high pass rates in patients undergoing PC. This strategy is lucarative in centers which has limited access to CT post PC. Fasting then ingesting PC promotes the gastro-ileal reflex increasing GI motility. Prucalopride and Gastrografin both have pro-motility effects. Furthermore, Gastrografin has the advantage of delineating the colonic wall on abdominal x-ray and improving pass rates. Further prospective multi-center studies will be needed to confirm our findings.

Introduction

Massive gastrointestinal bleeding (MGB) is a life-threatening condition that requires prompt recognition and resuscitation to increase the chance of good outcomes (1).

Aims & Methods

Aims: Analyze risk factors, comorbidities and outcomes of MGB.
Methods: Retrospective analysis of a prospective registry of upper gastrointestinal bleed (UGIB) patients admitted to ‘Virgen de las Nieves University Hospital’ between 2013-2020.
MGB was defined as UGIB with transfusion of >2 pRBCs in the emergency room or during the first 24h of hospital stay and signs of shock (2). Main outcomes were 30-day mortality, rebleeding, bleeding persistence or severe complication throughout admission and complications within the first 6 months after discharge (including cardiovascular, hemorrhagic or deaths).
Statistical analysis was performed by SPSS.

Results

We included 1213 UGIB patients, 171 with MGB.
Multivariate logistic regression analysis showed that, being admitted for another condition (HR 1.72,95%CI 1.04-2.58,p=0.035), having a systemic disease (HR 2.30,95%CI 1.22-5.32,p=0.045), a disseminated malignancy (HR 2.07,95%CI 1.02-4.21,p=0.045) or suffering a severe comorbidity (HR 2.21,95%CI 1.25-3.91,p=0.009) were independent risk factor for MGB.
Among 171 MGB patients, 21% died, with 10 deaths directly from hypovolemic shock secondary to UGIB, and 11% due to complications.
Table shows significance differences between deaths and survivors.

Relevant Comorbidities ASA 3-4 (%)	Deaths 96.7%	Survivors 78.5%	p 0.0018
Active bleeding (%)	76.3	43.3	0.007
Interventional radiology (%)	13.3	3.7	0.034
SBP (mean±SD mmHg)	79±8	84±9	0.025
Albumin (mean±SD mg/dl)	2.4±0.5	2.8±0.6	0.011
Calcium (mean±SD mg/dl)	7.7±0.6	8.2±0.8	0.032
Platelets (mean±SD /mm3)	158*103±101*103	206*103±106*103	0.027
Severe complications during hospitalization	76.7	22.1	<0.0001
Bleeding persistence (%)	63.3	17.6	<0.0001
Rebleeding (%)	40	17	0.005

Multivariate analysis showed that active bleeding in endoscopy (HR 4.80,95%CI 1.06-21.62,p=0.041) and severe complications (HR 14.03,95%CI 3.30-59.60,p<0.0001) were independent predictors for mortality, being calcium levels a protective factor (HR 0.41,95%CI 0.16-0.94,p=0.045).
Among the survivors after the index episode,14% died after 6 months, being main causes of death recurrent bleeding(5.2%), neoplasms(4.4%), cirrhosis complications(2%), cardiovascular disease(1.5%) and sepsis(1.5%).
Delayed bleeding was caused by recurrent UGIB in 86.6%, lower GIB in 10% and from a non-GI origin in 3.4%. Delayed cardiovascular events were heart failure in 46%, thromboembolic events in 23%, myocardial ischemia in 15.4% and atrial fibrillation in 15.6%.

Conclusion

Our study is a prospectively collected single center registry of patients with massive UGIB, in which we observed that being an inpatient and harboring severe comorbidities, particularly systemic diseases and malignancies, were risk factors for this condition. Mortality among those patients was related to CKD, cirrhosis, severe comorbidities and excessive alcohol consumption. We also found an increased delayed mortality, probably related to a worsening health condition in which GI bleeding heralded poor outcomes, some of them potentially preventable with close follow-up.

References

1. Nagata N, Sakurai T, Shimbo T, et al. Acute Severe Gastrointestinal Tract Bleeding Is Associated With an Increased Risk of Thromboembolism and Death. Clin Gastroenterol Hepatol. 2017;15:1882-1889 e1881.
2. D'Amore K, Swaminathan A. Massive Gastrointestinal Hemorrhage. Emerg Med Clin North Am. 2020;38:871-889.