Introduction

Malignant Gastric Outlet Obstruction (mGOO) has been standardly treated by surgical GastroEnterostomy (S-GE) or Endoscopic Stenting (ES). More recently, EUS GastroEnterostomy (EUS-GE) has emerged as a low-invasive alternative with surgical-range efficacy, supported by guidelines. Nevertheless, its worldwide diffusion is heterogeneous and advantages/disadvantages debated. The aim of this survey is to assess clinical decision-making of international specialists regarding mGOO and to explore current opinion regarding EUS-GE use.

Aims & Methods

An online survey was created exploring centers’ experiences and physicians’ opinions regarding indications, contraindications, benefits and risks of available treatments; 2 case vignettes explored clinical decision-making in different scenarios. The survey was spread through social networks and the EPC newsletter.

Results

Overall, 290 pancreatologists from 44 countries (5 continents) responded, of whom 35% surgeons and 65% gastroenterologists, 44% from centers managing > 20 mGOO/year. The most frequently available treatment for mGOO was ES (91%), followed by S-GE, while EUS-GE was only available to 59% of responders, and only 10% declared proficiency in this technique.
68% referred an established gold-standard in their centers, but this differed by specialty, with ES, EUS-GE and S-GE being advised by 45%, 20% and 10% of gastroenterologists and 24%, 8% and 25% of surgeons.
For 51% of responders, EUS-GE will become the primary treatment for mGOO. This percentage increases among gastroenterologists and high-volume centers. For 14%, EUS-GE spread will be limited in the future, or used only when ES fails (19%), with higher rates among surgeons.
When choosing between alternatives, the main decision driver is life expectancy, followed by disease stage and patient’s frailty, whereas potential future surgical resectability does not contraindicate any treatment for 3/4 of responders. The main perceived advantages of EUS-GE were minimally invasiveness and high clinical efficacy, while the learning curve remains its main disadvantage.

Conclusion

This survey revealed significant differences in the management of mGOO, depending on specialties, local expertise and treatment volume, suggesting the lack of standardized algorithms.
Despite great enthusiasm around EUS-GE, its availability remains suboptimal, with learning curve as the main barrier. Life expectancy and patients’ frailty are likely to remain the main decision factors.

Introduction

Complete excision of upper gastrointestinal sub-epithelial lesions (SELs) eliminates diagnostic uncertainty, obviates the need for surveillance and may be necessary for definitive diagnosis and management. Current guidelines lack precision and cohesion, and surgery is associated with significant morbidity. Herein, we describe and report on the outcomes of our SEL algorithm for endoscopic (SAFE) resection.

Aims & Methods

SELs were enrolled prospectively over 115 months until March 2023. All underwent axial (CT) imaging and endoscopic-ultrasonography (EUS) to exclude a large exophytic component or invasion into local structures, and assess for muscularis propria involvement.

Results

106 SELs were resected (mean age 60.6±13.4, 51.9% male; 41 oesophageal, 65 gastric). Oesophageal SELs underwent ESD (n=22) or STER if MP involvement was suspected (n=19). Gastric SELs underwent STER (n=6 at cardia), ESD (n=47) or exposing-EFTR (n=12). Technical success was 97.6% and 92.3% respectively. Five (7.7%) were completed laparoscopically due to deep and broad full-thickness involvement. Five (7.7%) required laparoscopic gastrotomy and surgical retrieval after successful resection and closure due to a large lesion size (mean 47 mm). There was no delayed bleeding, perforation or recurrence at a median of 13 months.

Conclusion

Upper GI SELs are effectively and safely treated by endoscopic resection. The SAFE approach provides a framework that facilitates structured decision-making. Oesophageal SELs suspected to involve the MP should undergo STER. Gastric SELs can be best managed by ESD with a view to proceed to exposing-EFTR. A laparoscopic UGI surgeon should be available in case surgical retrieval of the specimen or laparoscopic completion is required.

Disclosure

Michael J. Bourke: Research Support: Olympus, Cook Medical, Boston Scientific.

Introduction

Copeptin is a stable surrogate biomarker for the activation of the arginine vasopressin (AVP) system [1] as occurs in patients with cirrhosis and clinically significant portal hypertension (CSPH). Specifically, CSPH-induced haemodynamic alterations characterized by reduced peripheral vascular resistance and splanchnic hyperemia cause subsequent AVP system activation [2]. We aimed to evaluate serum copeptin levels (i) in different stages of cirrhosis and (ii) their prognostic value for clinical events in a cohort of stable outpatients with cirrhosis.

Aims & Methods

Stable outpatients with cirrhosis undergoing hepatic venous pressure gradient (HVPG) measurements and available copeptin levels were included; while patients with liver transplantation, malignacy, vascular liver disease, transjugular intrahepatic portosystemic shunt, heart failure and infection were excluded. Patients were stratified into 6 subgroups (S0-S5) for their clinical stage of cirrhosis, with S0-S2 representing compensated cirrhosis (S0: subclinical portal hypertension (PH) with an HVPG of 6-9 mmHg, S1: CSPH without varices, S2: CSPH with varices) and S3-S5 decompensated cirrhosis (S3: history of variceal bleeding, S4: non-bleeding decompensation, S5: further decompensation). Competing risk regression models were used to evaluate the association between copeptin levels and the risk of acute on chronic liver failure (ACLF) and liver-related death (LRD). Liver transplantation was considered as a competing event. Our previously established serum copeptin cut-off at >11.4 pmol/L [3] was used to stratify the patients into a high vs. low AVP system activation group.

Results

In total, 475 patients (S0: n=49, S1: n=53, S2: n=75, S3: n=22, S4: n=156, S5: n=120) with male predominance (72.6%; median age: 57.1 years) were included. Median follow-up time was 26.4 months. Median copeptin levels significantly increased throughout the substages of ACLD (from S0: 7.5 pmol/L to S5: 14.3 pmol/L; p<0.001). Patients with ascites had significantly higher copeptin levels (11.3 pmol/L vs. 7.2 pmol/L in non-ascites patients; p=<0.001).
Serum copeptin correlated significantly with C-reactive protein (ρ=0.281; p<0.001) and interleukin-6 levels (ρ=0.416; p<0.001) in patients with decompensated cirrhosis.
AVP system activation (i.e., Copeptin high >11.4 pmol/L) was found in n=194/475 (40.8%) patients. Patients with high-Copeptin had a significantly higher median MELD-Na (15 vs. low-Copeptin: 12; p<0.001) as well as significantly lower median mean arterial pressure (97 mmHg vs. low-Copeptin: 101 mmHg; p=0.027). The cumulative incidence of ACLF and LRD was significantly higher in patients with high-Copeptin at 1 year (ACLF: 24.1% vs. 4.0%; LRD: 21.9% vs. 4.0%), 2 years (ACLF: 32.0% vs. 7.2%; LRD: 26.7% vs. 6.3%) and 3 years (ACLF: 34.4% vs. 11.6%; LRD: 29.9% vs. 11.2%) of follow-up (p<0.001 for ACLF and LRD).
In competing risk regression adjusted for age, Child Turcotte Pugh score, creatinine, sodium and HVPG, higher levels of copeptin were independently predictive of ACLF (adjusted subdistribution hazard ratio [asHR] per pmol/L: 1.01; 95% confidence interval [95%CI]: 1.00-1.01; p=0.014), as well as LRD (asHR: 1.01; 95%CI: 1.00-1.01; p=0.024).

Conclusion

In ACLD, copeptin levels are upregulated with increasing disease severity suggesting progressive AVP system activation, associated with hemodynamic dysregulation and systemic inflammation. High-Copeptin represents an independent risk factor for ACLF and LRD development.

References

1. Abudeif A, Hashim MS, Ahmed NM, Ahmed AO. Serum copeptin is associated with major complications of liver cirrhosis and spontaneous bacterial peritonitis. Clin Exp Hepatol. 2023;9(1):71-8.

2. Kerbert AJ, Weil D, Verspaget HW, Moréno JP, van Hoek B, Cervoni JP, et al. Copeptin is an independent prognostic factor for transplant-free survival in cirrhosis. Liver Int. 2016;36(4):530-7.

3. Hartl L, Jachs M, Desbalmes C, Schaufler D, Simbrunner B, Paternostro R, et al. The differential activation of cardiovascular hormones across distinct stages of portal hypertension predicts clinical outcomes. Hepatol Int. 2021;15(5):1160-73.

Introduction

Suspected foreign body ingestion and food bolus impaction are common indications for urgent esophagogastroduodenoscopy. Nevertheless, most of the ingested foreign bodies (80 to 90%) pass spontaneously throughout the gastrointestinal tract. In 2022, the Decision-To-Scope (DTS) Score was developed, revealing an excellent accuracy in predicting foreign bodies in the esophagus.

Aims & Methods

Our aim was to prospectively evaluate the diagnostic accuracy of the DTS-Score.
We have prospectively included consecutive patients admitted for suspected foreign body in the upper gastrointestinal tract, for a 6-month period. Previously to endoscopic evaluation, the DTS-score - time since ingestion < 6 hours (+1pt); absence of any meal since the suspected ingestion (+2pts); dysphagia (+3pts); odynophagia (+1pt) and drooling (+4pts) - was applied in each patient. The maximal possible value was 11 points, with a DTS-Score ≥5 being considered to assign a high probability of endoscopic confirmation of the foreign body.

Results

Final sample included 47 patients, from which 26 (55.3%) were females, with a mean age of 60±16 years. From these, most (n=42; 91.5%) were evaluated for accidental ingestion of food-related foreign bodies (fish or chicken bones) or suspected food bolus impaction. A DTS-Score ≥5 was calculated in 11 (23.4%) of the patients, with an esophageal foreign body being confirmed in 12 (25.5%) of them. DTS-score presented an excellent accuracy in predicting the endoscopic confirmation of a foreign body in the esophagus (AUC=0.94; 95%CI 0.85-1.00; p<0.001). The originally defined cut-off (DTS-Score ≥5) presented a specificity of 97.1%, a sensitivity of 83.3%, a positive predictive value of 90.9% and a negative predictive value of 94.4%.

Conclusion

When prospectively applied, the DTS-score demonstrated an excellent acuity in stratifying the probability of endoscopic confirmation of a suspected foreign body in the esophagus. This tool may be included in future clinical algorithms for suspected foreign bodies ingestion.

Introduction

Malnutrition, sarcopenia, and frailty constitute the three vertices of a nutrition-status-determined physio-pathological triangle constantly featuring and dramatically burdening the prognosis of advanced chronic liver disease (ACLD) patients.
Dysgeusia is defined by a distortion of the sense of taste whose prevalence, relationship with the progression of the disease, and the direct contribution to malnutrition (and consequently, sarcopenia-frailty) in ACLD have never been systematically explored.

Aims & Methods

This observational study aimed to explore the prevalence of dysgeusia in a cohort of ACLD patients and evaluate the impact of this disorder on appetite levels and nutritional status (malnutrition, sarcopenia, and frailty), as well as to prospectively estimate the repercussions of dysgeusia-induced impaired nutritional status on liver-related events (LREs) occurrence. For this purpose, 40 controls, 50 chronic-liver disease-affected individuals staging initial-mild fibrosis (<F3), and 150 ACLD patients of various etiologies were enrolled. Anthropometrical, biochemical, clinical, and nutritional [European Prospective Investigation into Cancer and Nutrition (EPIC) questionnaire] data were collected. The opportunely modified Chemotherapy-induced Taste Alteration Scale (CITAS) questionnaire was used to assess the dysgeusia. Child-Pugh (CP) and Liver Frailty Index (LFI) calculations, Liver Stiffness Measurement (LSM), and Bioelectrical Impedance Analysis (BIA) were performed. Skeletal Muscle Mass (SMM) index (SMMI) (SMM/height²) < 7 kg/m² (male) and < 5.7 kg/m² (female) defined sarcopenia. ACLD patients were 3 years followed up semiannually and LREs (including ascites, hepatic encephalopathy, and bleeding) were collected.

Results

The prevalence of dysgeusia was significantly higher in ACLD (68%) in comparison to <F3 (8%) individuals and controls (5%) and in decompensated ACLD (dACLD) than compensated (cACLD) (54% vs 6%) patients (all p<0.0001). In line, CITAS-dysgeusia severity positively correlated with CP (R:0.81), as well as with the levels of appetite impairment (R:0.93) (both p<0.0001). Logistic regression analysis, appropriately weighted for factors notoriously impacting food intake in ACLD patients (low-sodic diet, drugs/supplements taken, physical activity frequency, occurrence of encephalopathy and ascites episodes in the previous 2 weeks), revealed the level of impairment of the appetite as a factor significantly associated with dysgeusia [HR: 2.12; p:0.02]. Compared to no-dysgeusia-affected dACLD (p:0.03), dysgeusia-affected dACLD patients (dys-dACLD) showed a decreased daily protein intake, reduced Free Fat Mass % (p<0.0001), and SMMI (p<0.0001: p:0.04), in contrast with increased LFI (p<0.0001). Consistently, dys-dACLD patients showed a higher prevalence (59% vs 39%) of sarcopenia (p:0.0002). The Kaplan-Meier Log-Rank Test analysis on LREs occurrence showed HR:3.53 [95% C.I: 1.58-4.92] for dys-dACLD individuals.

Conclusion

The prevalence of dysgeusia, increasing in parallel to the worsening of liver disease, promoted sarcopenia-frailty pictures, negatively influencing ACLD patients' outcomes.

References

1. Jafari A, Alaee A, Ghods K. The etiologies and considerations of dysgeusia: A review of literature. Journal of oral biosciences. 2021;63(4):319-26.
2. Sieber CC. Malnutrition and sarcopenia. Aging clinical and experimental research. 2019;31(6):793-8.
3. Tandon P, Montano-Loza AJ, Lai JC, Dasarathy S, Merli M. Sarcopenia and frailty in decompensated cirrhosis. Journal of hepatology. 2021;75 Suppl 1(Suppl 1):S147-s62.

Clinical Case Summary

Introduction: Locally advanced pancreatic tumors can lead to both biliary and duodenal obstruction by invasion or compression. Quality of life is severely affected if obstruction occurs: jaundice, emesis and pain can become invalidating and patients become too frail for palliative chemotherapy and are sometimes declared unfit even for derivative surgery. Recently, endoscopic techniques under EUS or ERCP guidance are being used to create biliodigestive and enteral anastomoses.
Clinical case: A 75-year-old female was diagnosed with locally advanced pancreatic head adenocarcinoma in January 2024. The tumor was declared unresectable and chemotherapy was initiated. A plastic stent was inserted into the main biliary duct (MBD) to ensure biliary drainage. In May 2024, she presented with cholangitis and emesis. EGD revealed duodenal stenosis and ERCP failed due to tumor infiltration. A combined endoscopic approach was performed: EUS-guided hepatico-gastrostomy (EHG) for biliary drainage and EUS-guided gastro-enterostomy using a lumen-apposing metal stent (LAMS). In July 2024, the plastic stent was removed, and in August 2024, two fully covered 60 x 10 mm SEMS were inserted antegrade through the EHG into the MBD to improve patency. At 11 months post-intervention, the patient returned for routine reassessment, declaring good clinical performance: she remained asymptomatic, with routine blood tests, including bilirubin levels within normal range and with all stents patent and correctly positioned (confirmed radiologically and endoscopically). The patient was able to maintain oral intake and continue chemotherapy. No late adverse events were noted.
Conclusion: This case demonstrates the long-term clinical and technical success of a staged endoscopic triple bypass for the management of complex biliary and duodenal obstruction due to unresectable pancreatic cancer. The approach was minimally invasive, well tolerated and remarkably improved the patient's quality of life.

References

1. Adler, Douglas G MD; Baron, Todd H MD, FACP. Endoscopic Palliation of Malignant Gastric Outlet Obstruction Using Self-Expanding Metal Stents: Experience in 36 Patients. American Journal of Gastroenterology 97(1):p 72-78, January 2002. | DOI: 10.1111/j.1572-0241.2002.05423.x
2. Giovannini, Marc. (2019). EUS-guided hepaticogastrostomy. Endoscopic Ultrasound. 8. 35. 10.4103/eus.eus_47_19.
3. Dumonceau, Jean-Marc & Tringali, Andrea & Blero, Daniel & Devière, J & Laugiers, R & Heresbach, D & Costamagna, Guido. (2012). Biliary stenting: Indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy. 44. 277-98. 10.1055/s-0031-1291633.
4. Van Der Merwe, S. W., Van Wanrooij, R. L., Bronswijk, M., Everett, S., Lakhtakia, S., Rimbas, M., ... & Van Hooft, J. E. (2022). Therapeutic endoscopic ultrasound: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy, 54(02), 185-205. 10.1055/a-1717-1391