Introduction

Portal hypertension (PH) is a significant complication of advanced chronic liver disease (ACLD), often leading to acute variceal bleeding (VB), a life-threatening emergency. Preemptive transjugular intrahepatic portosystemic shunt (pTIPS) has become a critical intervention in managing PH-related complications, specifically in reducing the risk of re-bleeding. The hepatic venous pressure gradient (HVPG) is the gold standard for assessing PH severity, but its invasive nature necessitates the exploration of non-invasive alternatives.

Aims & Methods

This study aimed to investigate the role of spleen stiffness, measured through shear-wave elastography (SWE), as a non-invasive predictor of PH severity and its correlation with HVPG in ACLD patients undergoing pTIPS after acute VB. We conducted a prospective study correlating spleen stiffness, measured by shear-wave elastography (SWE), with HVPG in ACLD patients (Child-Pugh class C<14 or B>7 with active bleeding) undergoing pTIPS placement following acute VB. Eleven patients with pre- and post-TIPS spleen stiffness measurements were included.

Results

Spleen stiffness was positively correlated with both pre-TIPS HVPG (Spearman's coefficient r=0.527; p=0.145) and post-TIPS HVPG (r=0.719; p<0.05). Furthermore, spleen stiffness significantly decreased after p-TIPS placement (pre-pTIPS: 36.42 [IQR 6.06] vs. post-pTIPS: 28.94 [IQR 7.80]; p<0.05), while the decrease in liver stiffness measurement was not statistically significant.

Conclusion

The results of this prospective study indicate that spleen stiffness, as measured by SWE, offers a valuable non-invasive method for assessing portal hypertension severity in patients with ACLD. We found a positive correlation between spleen stiffness and both pre- and post-TIPS HVPG. Additionally, significant reductions in spleen stiffness post-TIPS suggest that this metric can serve as a useful tool for monitoring patient response to pTIPS and potentially predicting outcomes. These findings highlight the importance of incorporating spleen stiffness measurement into the clinical management of patients with PH undergoing pTIPS, providing clinicians with an additional tool for assessing treatment efficacy and guiding patient care. Further research with larger cohorts is recommended to confirm these results and establish spleen stiffness as a reliable non-invasive alternative for PH assessment.

Introduction

Faecal incontinence (FI) is prevalent, being associated with a high biopsychosocial burden and considerable health costs. The pathophysiology of FI is varied and often multifactorial, representing a diagnostic and therapeutic challenge. Anorectal manometry is the first recommended diagnostic method, although its utility is debatable due to overlapping findings between healthy individuals and patients.

Aims & Methods

The aim of this study is to establish a relationship between FI clinical presentation, manometric findings, and imaging.
We prospectively included all patients undergoing high-resolution anorectal manometry, according to the London protocol, at a tertiary centre, who agreed to respond to a questionnaire to characterize their FI, between August 2021 and March 2023. Clinical records were consulted, in order to access demographic data and past imaging reports. Statistical analysis was performed using IBM SPSS Statistics version 26®.

Results

Forty-seven patients were included with a mean age of 63.5±11.6 years, 87.2% women, of whom 73.2% had an obstetric history. Depressive/anxious symptoms were described in 59.6%, previous perineal surgery in 38.3%, and concomitant urinary incontinence in 40.0%. Mean FI duration was 5.4±5.2 years, with 51.1% reporting daily complaints and a bowel movement median of 2.0 (IQR 3.0). Males tended to have more bowel movements than females (3.5 (IQR 5.0) vs 2.0 (IQR 2.0); p-value 0.03). FI for flatus and faeces was present in 57.4%, for faeces alone in 34.0%, and for flatus alone in 8.5%. Urgency FI was verified in 37.0%, passive FI in 37.0%, and mixed FI in 26.1%. Mean Wexner score was 10±5. Rectal examination revealed hypotonicity in 15.9%. Mean resting pressure on anorectal manometry was 55.9±22.5 mmHg, dyssynergy was identified in 16.7% and altered balloon expulsion in 19.5%. The mean value of first sensation, first urge to defecate, and maximum tolerated volume were within the normal range. Imaging was performed in 19 patients (40.4%), with external anal sphincter injury in 15.8% and internal sphincter injury in 10.5%. Mean thickness of the internal anal sphincter (IAS) was 2.3±1.0 cm. Patients with hypotonicity in rectal examination had lower anal resting pressure (35.7±16.0 mmHg vs 60.3±22.4 mmHg; p-value 0.09) and lower IAS thickness (1.6±0.8 mm vs 2.6±0.9 mm; p-value 0.07), although not statistically significant. Patients with depressive/anxious symptoms showed lower maximum incremental pressure (56.6±34.0 mmHg vs 81.2±46.2 mmHg; p-value 0.045), as well as females when compared to males (60.0±34.9 mmHg vs 108.7±53.2 mmHg; p-value 0.005). No other statistically significant results were found, especially correlating clinical findings with manometry or imaging.

Conclusion

Our study showed, as previously replicated, that clinical, manometric and imaging findings have low correlation in the assessment of FI, reflecting its pathophysiological complexity.

Introduction

Plastic stent placement during endoscopic retrograde cholangiopancreatography (ERCP) is a well-established therapy for a wide variety of obstructive biliary and pancreatic disorders. While proximal or distal stent migration is uncommon, with migration rates ranging from 4.1% to 13.5%, it can result in serious complications. Endoscopic retrieval of proximally migrated stents is intricate and may present a technical challenge to the endoscopist.

Aims & Methods

Aims: This study aims to ascertain the proximal stent migration rate, complications associated, risk factors, success rate, and the endoscopic techniques applied for retrieval.
Materials and Methods: We conducted a retrospective cohort study including 546 consecutive ERPC procedures performed at a tertiary center between January 2022 and March 2023. Data regarding indications for stenting, presentation of migration, stent length and diameter, endoscopic retrieval techniques, and success rate were collected.

Results

Overall, a total of 429 plastic stents were inserted (372 biliary and 57 pancreatic) in 245 patients. Proximal migration occurred in 2.8% of cases (9 biliary and 3 pancreatic), all of which were asymptomatic. Stent length <10cm (p=0.08) was identified as a risk factor for proximal migration. The success rate of endoscopic retrieval was 100%. Stent extraction was accomplished on the first attempt in 9 cases (75%), with three cases (25%) requiring re-attempt. Retrieval techniques employed included the Soehendra stent retriever (n=5, 41.7%), forceps (n=3, 25%), snare (n=3, 25%), and balloon catheter (n=1, 8.3%). Cholangiopancreatoscopy-assisted retrieval was necessary in two cases as a rescue therapy. Notably, there were no complications or procedure-related mortality.

Conclusion

ERCP is an effective and safe approach for the retrieval of proximally migrated plastic stents, however, it requires experience with different techniques and endoscopic accessories. In challenging scenarios, cholangiopancreatoscopy-assisted stent retrieval may offer a viable solution when conventional methods are unsuccessful. Our cohort analysis revealed that stent length <10cm was potentially associated with an increased risk of proximal migration.

Introduction

Oesophageal leaks and fistulae are a major complication of upper gastrointestinal surgery leading to high rates of postoperative morbidity and mortality. Self-expanding metal stents (SEMS) are the endoscopic mainstay of treatment. Recently, endoscopic vacuum therapy (EVT) as emerged as a promising alternative. The present study intends to evaluate the success rate and safety of EVT versus SEMS in upper gastrointestinal tract surgical leaks/fistulae in a referral centre.

Aims & Methods

We included all patients undergoing EVT in 2022-2023 (n=5) versus all patients submitted to SEMS from 2014 to 2022 (n=39) due to upper gastrointestinal tract surgical leak/fistulae.

Results

There were no statistically significant differences regarding distribution by gender, age, benign vs malignant disease, time from complication diagnosis to endoscopic treatment, time from surgery to endoscopic treatment and leak size (p>0.05).
The success rate, defined as complete closure of the surgical leak/fistulae, was reached in all patients submitted to EVT and in 56.4% of patients with SEMS (p=0.14). Two patients undergoing EVT were previously submitted to unsuccessful SEMS treatment. The median number of endoscopic treatment sessions were significantly superior for EVT [4 (IQR:3) vs 2 (IQR:1); p<0.01].
Technique related complications, readmission and mortality rates were superior in SEMS vs EVT (76.9% vs 0%; 51.3% vs 20%; 35.9% vs 0%, respectively), although these differences were only statistically significant for complication rate (p<0.01). None of the deaths were related to stent placement.

Conclusion

Although with a higher number of treatment sessions, our experience showed that EVT is a safe and effective alternative to endoscopic stenting, with higher success rate (100% vs 56.4%) and lower complication, readmission, and mortality rates. Our data shows that EVT has the potential to become the new gold standard in the endoscopic treatment of oesophageal leaks and fistulae.

Introduction

The first international guideline for managing preneoplastic conditions of the stomach (MAPS I) was published in 2012, followed by an update (MAPS II) in 2019. As adherence to these guidelines remains uncertain, we evaluated adherence by comparing the management of preneoplastic gastric conditions before and after the introduction of MAPS I and II in selected European centers.

Aims & Methods

Patient data were retrieved from nine endoscopy units in seven European countries during three periods: pre-MAPS I (2010/2011), post-MAPS I (2017/2018), and post-MAPS II (2022/2023). Screening and dyspepsia-related endoscopies were included. Data on endoscopy, histopathology, Helicobacter pylori (H. pylori) treatment, and surveillance were collected using a standardized form. Adherence to nine MAPS recommendations was assessed, with improvement defined as a ≥10% increase in guideline-concordant management.

Results

A total of 2,426 patients were included. Most centers (57%) improved in at least seven of the nine recommendations over time. Virtal Chromoendoscopy use improved in six centers, with four reporting its use in >50% of cases. All centers improved in performing biopsies from the antrum and corpus, five conducted random biopsies in nearly all patients, and four performed these plus an incisura biopsy in >90% of cases. Endoscopic scores for patient stratification were rarely used, while five centers improved in histological scoring or intestinal metaplasia subtyping. H. pylori treatment recommendation remained high (71%-100%), and endoscopic surveillance adherence improved in four of seven centers

Conclusion

Adherence to MAPS guidelines improved in most centers. However, gaps in virtual chromoendoscopy, targeted biopsies, and endoscopic/histopathological scoring remain, potentially affecting surveillance recommendations. This underscores the need for a more tailored approach to enhance implementation.

References

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