Clinical Case Summary

Introduction: Fistulas after laparoscopic sleeve gastrectomy (LSG) occur in 1-4% of patients, with 90% located at the cardia.
Case report: A 66-year-old female with grade III obesity, obstructive sleep apnea, type II diabetes and hypertension underwent LSG. She developed hypovolemic shock, abdominal pain and severe anemia (Hb 6.5 mg/dL). A CT scan revealed haemoperitoneum without active bleeding, managed with transfusion of packed blood cells. A week later, a new CT scan performed for leucocytosis and abdominal pain revealed pneumoperitoneum. An esophagogastroduodenoscopy (EGD) revealed a 2 cm fistula orifice at the cardia. A novel esophageal covered metallic stent was placed for five weeks. The fistula orifice decreased to 4mm and communicated through a fistulous tract with a residual subphrenic abscess measuring 62x20mm. Pus was collected from the abscess and drained internally with a double pigtail plastic 10Fr stent through the fistula orifice. After initial improvement, there was clinical deterioration requiring percutaneous subphrenic abscess drainage. Five weeks after the first EGD, the stent was removed, the fistula orifice ablated with argon plasma 40W/1L and closed with an over the scope clip of 7 mm. Patient improved and was discharged 4 months after LVG.
Discussion:The Luso-Cor esophageal stent is a specifically-designed covered stent with a 5mm uncovered ring near the proximal edge reducing risk of migration. Two articulating zones in the middle portion allow better adaptation to altered anatomy after LVG and a distal flare prevents retrograde reflux of fluid. This stent overcomes strictures in the gastric tube, concomitantly present in nearly 50% of patients with fistulas after LSG and has a low radial force to reduce tissue trauma. The novel Luso-Cor esophageal stent was able to serve as bridge to clinical stability with a significant decrease in the size of the fistula orifice which was closed with complementary therapeutic endoscopic procedures.

References

1. Rodrigues-Pinto E, Pereira P, Sousa-Pinto B, et al. Retrospective multicenter study on endoscopic treatment of upper GI postsurgical leaks. Gastrointest Endosc. 2021;93(6):1283-1299.e2. doi:10.1016/j.gie.2020.10.015
2. Bège T, Emungania O, Vitton V, et al. An endoscopic strategy for management of anastomotic complications from bariatric surgery: A prospective study. Gastrointest Endosc. 2011;73(2):238-244. doi:10.1016/j.gie.2010.10.010
3. Bemelman WA, Baron TH. Endoscopic Management of Transmural Defects, Including Leaks, Perforations, and Fistulae. Gastroenterology. 2018;154(7):1938-1946.e1. doi:10.1053/j.gastro.2018.01.067
4. Noronha Ferreira C, Reis D, Santos P, et al. Clinical Efficacy and Safety of a Novel Stent for Fistula Management Following Sleeve Gastrectomy. Tech Innov Gastrointest Endosc. 2024;26(1):12-20. doi:10.1016/j.tige.2023.07.005

Clinical Case Summary

A 34 year old female attended electively for liver biopsy for investigation of deranged liver function tests (LFTs).
Ultrasound guided percutaneous liver biospy was complicated by immediate abdominal pain with computed tomography (CT) abdomen revealing right subphrenic intracapsular fluid contained within the liver capsule in keeping with post biopsy haemorrhage. This was managed conservatively with overnight admission for observation.
The patient represented within 48h hours with worsening jaundice and severe abdominal pain. LFTs had significantly worsened with a hyperbilirubinaemia of 153 umol/L with a cholestatic pattern. Repeat CT abdomen showed new intrahepatic and extrahepatic bile duct dilation with common bile duct (CBD) measuring up to 16 mm in diameter. In the lower CBD, there was an obstructing opacity measuring approximately 7 mm in diameters by 24 mm longitudinal and given the clinical history, a blood clot was to be the most felt likely be the underlying aetiology.
Urgent endoscopic retrograde cholangiopancreatography (ERCP) was performed. An initial cholangiogram revealed a dilated biliary system with ill-defined opacity distally. Following sphincterotomy a large clot was extracted with a 12 millimetre balloon. Final cholangiogram showed clearance of bile ducts with no post procedural complications. The next day updated imaging with CT abdomen showed complete resolution of the biliary duct dilatation and LFTs had improved to pre-liver biopsy baseline. The patient was discharged with no further complications.
Discussion: Haemobilia is recognised as a rare complication from percutaneous liver biopsy with incidence rate of less than 1% (1). The management of haemobilia may be conservative in minor cases with transcatheter arterial embolization usually recommended as first line intervention and ERCP used for biliary drainage (2). In this case we demonstrated a successful outcome in biliary decompression following clot extraction with ERCP.

References

(1) Thomaides-Brears, H.B., Alkhouri, N., Allende, D. et al. Incidence of Complications from Percutaneous Biopsy in Chronic Liver Disease: A Systematic Review and Meta-Analysis. Dig Dis Sci 67, 3366–3394 (2022).
(2) Yilmaz N: Hemobilia Causing Acute Cholecystitis and Pancreatitis after Percutaneous Liver Biopsy: A Case Report and Review of the Literature. Visc Med 2020;36:246-250.

Introduction

Patients with immune mediated inflammatory diseases (IMIDs) on immunosuppressive therapies have attenuated vaccine responses (1-3) and are prone to severe infections. Knowledge of COVID-19 outcome following vaccine and hybrid immunity, and identification of protective anti-Spike antibody concentrations are important to further develop vaccine strategies in this vulnerable patient group.

Aims & Methods

In this prospective observational study, adult patients with IMID on immunosuppressive therapies were followed from February 15, 2021, to February 15, 2023. Throughout the study, patients and controls reported data regarding COVID-19, COVID-19 related hospital admissions were recorded from The Norwegian Patient Registry. Anti-Spike antibodies were assessed 2-4 weeks following vaccination and COVID-19. The objectives of this study were to investigate the outcomes of COVID-19 in a large cohort of IMID patients compared to healthy controls, and to identify any associations between anti-Spike antibody concentrations and disease course.

Results

Of 2250 IMID patients included in the study, a total of 1729 with a documented COVID-19 history were included in the present analyses (305 Crohn’s disease, 215 ulcerative colitis, 648 rheumatoid arthritis, 272 psoriatic arthritis, and 289 spondyloarthritis) (median age 54 years (IQR 42-64), 971 (56 %) females). Of the patients, 1080 of 1729 (62%) used anti-TNF treatment (65% monotherapy, 35% combination therapy).
1140 (66%) of patients and 236 of 350 (67%) healthy controls (HC) reported COVID-19, the majority (85%) within the Omicron era. COVID-19 reinfection was reported in in 141 (12%) patients and 32 (14%) HC (p=0.66). Compared to hybrid immunity (COVID-19 after three vaccine doses), the risk of COVID-19 was six times higher following vaccine series only (HR 5.9, (95% CI [4.45, 7.80]), p<0.001). Anti-Spike antibody concentrations <8000 BAU/ml were predictive of COVID-19 after three (HR 1.5 (95% CI [1.14, 1.90]), p=0.003) and four vaccine doses (HR 1.4 (95% CI [1.13, 1.83]), p=0.003), and in hybrid immunity (HR 2.6 (95% CI [1.32, 5.13]), p=0.006). In the entire cohort, the median anti-Spike antibody concentration after the 2^nd vaccine dose was 2823 BAU/ml (IQR 999-6199), after the 3^rd dose 6529 BAU/ml (IQR 2325-10140), after the 4^th dose 7624 BAU/ml (3809-12751) and following hybrid immunity 23506 BAU/ml (11423, 37007). Hospitalisation due to COVID-19 (severe disease) occurred in 22 (2%) patients, 9 (41%) before any vaccination, and none of HC. Four patients were admitted to intensive care. Prior to hospitalisation, the median anti-Spike antibody concentration was 444 BAU/ml (IQR 31-1634). Patients with severe disease were older than non-hospitalised (median age 61 years (IQR 48-74) vs. 54 (42-64), p=0.04) and had a higher frequency of comorbidities (19/22 (86%) vs. 474/1118 (42%), p=0.02). No COVID-19 related deaths occurred.
Prolonged COVID-19 (symptoms >14 days) were reported by 201 (18%) patients compared to 29 (12%) HC (p=0.09). The risk of prolonged disease was higher in the vaccine group compared to the hybrid group (HR 8.5 (95 % CI [3.84, 18.90]), p<0.001).

Conclusion

IMID patients and healthy controls had a comparable occurrence of COVID-19, prolonged disease and reinfection. However, severe disease developed only in the patient group. Hybrid immunity protects against COVID-19 and prolonged disease. A high anti-Spike antibody concentration protects against COVID-19, supporting the role of repeated vaccination in IMID patients on immune-suppressive therapy.

References

1. Jorgensen KK, Hoivik ML, Chopra A, Benth JS, Ricanek P, Moum PB, et al. Humoral immune response to SARS-CoV-2 vaccination in patients with inflammatory bowel disease on immunosuppressive medication: association to serum drug levels and disease type. Scand J Gastroenterol. 2023:1-9.
2. Bjorlykke KH, Orbo HS, Tveter AT, Jyssum I, Sexton J, Tran TT, et al. Four SARS-CoV-2 vaccine doses or hybrid immunity in patients on immunosuppressive therapies: a Norwegian cohort study. Lancet Rheumatol. 2023;5(1):e36-e46.
3. Syversen SW, Jyssum I, Tveter AT, Tran TT, Sexton J, Provan SA, et al. Immunogenicity and Safety of Standard and Third-Dose SARS-CoV-2 Vaccination in Patients Receiving Immunosuppressive Therapy. Arthritis Rheumatol. 2022;74(8):1321-32.

Disclosure

Have received speakers bureaus from Bristol-Myers Squibb and Roche

Introduction

There is an increasing incidence of young-onset colorectal cancer (YOCRC), which is defined as patients with colorectal cancer at age 50 years and younger. They present with a distinct clinical phenotype compared to classical-onset CRC (COCRC), with a more aggressive disease at presentation, as well as different tumour location and mutational signatures. There is an unmet clinical need to elucidate the unexplained epidemiologic rise in incidence as well as disease pathogenesis of YOCRC.

Aims & Methods

Aim: To compare the clinical presentation, tumour characteristics and survival of young-onset versus classical-onset CRC.

A retrospective evaluation of patients diagnosed with colorectal cancer from 2019 to 2022 at a district general hospital was performed. We extracted data from electronic patient records for clinical, biochemical, radiological as well as histopathological reports. Comparisons were made between patients diagnosed at </=50 years (YOCRC) and >50 years of age (COCRC) respectively, and statistical analyses were performed. A p-value of <0.05 was considered statistically significant.

Results

34 (11.1%) and 273 (88.9%) patients were diagnosed as YOCRC and COCRC respectively. There was a difference in clinical presentation between the two groups, with haematochezia (n=12, 35.3%) (p=0.03) and change in bowel habit (n=7, 20.6%) predominating in the YOCRC group, versus positive faecal immunochemical test (FIT) (n=102, 37.4%) and anaemia (n=78, 28.6%) in the COCRC group respectively. There were no differences in the tumour location between groups, with >50% of cases arising from the left colon (22 YOCRC versus 149 COCRC). Thrombocytosis (platelet count>450x10⁹/L) (24% vs 11%, p=0.038) and tumour budding (12% vs 3%, p=0.006) were significantly increased in the YOCRC group. There were no significant differences in the histological subtype, TNM staging, mutational profiling and survival between groups. 6 (17.6%) YOCRC patients had died compared to 116 (37.8%) in the COCRC cohort over a median follow-up of 16 months.

Conclusion

Young-onset colorectal cancer represents a challenging subset of CRC, which has a different clinical and tumour phenotype to classical-onset CRC. Our study reflects the reported incidence rates of YOCRC of 11%, although the true epidemiology and frequency of YOCRC remains to be clarified. Haematochezia was the commonest presentation, while thrombocytosis and tumour budding were higher in the YOCRC group, suggesting a more advanced disease at diagnosis. Although the overall survival rates were similar between groups, further research would benefit from larger prospective studies with subdivision of YOCRC cases by age as poorer survival have been suggested in patients aged <30 years. There is a need to elucidate the respective aetiologies, environmental risk factors and pathogenesis of YOCRC, to allow early targeted treatment of such cases.

Table 1: Clinical presentation of YOCRC and COCRC

References

Mauri G, Sartore-Bianchi A, Russo AG, Marsoni S, Bardelli A, Siena S. Early-onset colorectal cancer in young individuals. Mol Oncol. 2019;13(2):109-131.

Introduction

Endoscopic suturing offers a novel minimally invasive technique for deploying full thickness sutures in the gastrointestinal (GI) tract. Indications range from defect closure, post operative leaks, fistula repair, stent fixation and tissue plication for endoscopic sleeve gastroplasty.
Here we report our updated experience of endoscopic suturing for non-bariatric applications in the upper GI tract using the Apollo OverStitch^TM device (Apollo Endosurgery, Austin, Texas). This represents the largest and most diverse case series in a UK cohort of patients.

Aims & Methods

We retrospectively evaluated cases where the Apollo OverStitch^TM device was used at our tertiary upper GI centre. The primary outcomes were immediate technical and clinical success. Technical success was defined as the successful application of sutures. Immediate clinical success was defined according to indication. For defect closure this was evaluated using on the table fluoroscopy/endoscopic visualisation. For stent fixation it was determined by the absence of stent migration at follow up endoscopy.
Secondary outcomes included defect recurrence at follow up investigation. We also evaluated long term clinical success by assessing for resolution of the index clinical issue at the time of latest follow up.

Results

The Apollo OverStitch ^TM device was used 56 times across 35 patients (57% female) between August 2018 and March 2023. The mean age of patients at the time of the index procedure was 58 (+/-17.3 years). Outcomes according to indication are highlighted below (Table 1).
There were five cases (5/56, 8.9%) of technical failure. Three (3/5, 60%) involved iatrogenic perforations at the junction between D1/D2. Three cases (3/37, 8.1%) of immediate clinical failure were reported for the defect closure cohort. In the defect closure cohort there was a recurrence rate of 61.8% (21/34), with a long term clinical success rate of 68.2% (15/22). 14 cases of stent fixation were conducted with a stent migration rate of 35.7% (5/14).
There were two (2/56, 3.6%) cases of bleeding following endoscopic suturing. In both cases bleeding was stemmed endoscopically on the table and prior to the end of the procedure.

Conclusion

Our case series suggests that the Apollo OverStitch^TM device can be used for a diverse range of indications with high rates of immediate technical and clinical success.
We note a high recurrence rate reflecting that many defects require repeat suturing attempts to achieve durable long term closure. We postulate that this may be related tissue epithelisation and/or friability impacting opposition. Furthermore, technical failure occurred most with perforations at the D1/D2 junction. This is likely related to acute angulation which impedes the ability to deploy sutures.
The heterogenous follow up data from this case series impacts the ability to draw firm conclusions regarding long term outcomes. There is an ongoing prospective multicentre registry which will assist in evaluating long term outcomes.

Introduction

Video capsule endoscopy(VCE) is an useful and safe examination in diagnosis of small bowel disease. VCE is composed of one wide-view front lens, flashlight and 8 hour battery to take small bowel images.. In early models, the relative short battery time lead to a modest completion rate about 83.5% in meta-analysis. The battery time of new generation VCE increased to at least 12 hour and even up to 18 hours in real-world practice which made extended examination possible. The effect of prolonged VCE examination time on VCE performance was less explored.

Aims & Methods

This study is aimed to evaluate the completeness and diagnostic yield in patients receiving prolonged VCE examinations. From year 2016 we started to perform an overnight protocol for VCE examination in our hospital using Olympus endocapsule 10, EC-10; Olympus Corp., Japan). After 10 ml simethicone ingestion, the patient swallowed the capsule endoscope. The doctors checked the capsule endoscopy 2-3 hours after capsule endoscope for confirmation of small bowel entering. The patient kept capsule endoscope recording overnight until the coming morning when patients came back to clinic. For some inpatients with active bleeding, VCE was checked at least after 12 hours at midnight. The VCE recording was stopped earlier if colon arrival is confirmed. All the CE procedures were read by experienced endoscopist. We reviewed consecutive VCE examination records from Jan 2016 to Dec 2020. VCE Completeness was defined as the capsule endoscopy reached the cecum within recording time. We subcategorized the VCE records into within 8 hours, within 12 hours and whole procedure and compared VCE complete rate and diagnostic yield between groups. The Cochran’s Q test was used for statistical analysis. P values less than .05 were considered significant.

Results

Total 88 patients aged 20-90 years old received VCE in the study period. Their median age was 69 years old and 46 patients(52.3%) were male. 69 patients(78.4%) were inpatient and 84 patients(95%) were suspected with small bowel bleeding. The small bowel transit time was 342 minutes(91-1134minutes) with total exam time measuring 1031 minutes (452 to 1273 minutes). 58% of patients completed small bowel evaluation within 8 hours since capsule endoscope ingestion, significantly lower than 79.5% within 12 hours(p<0.001), and 93.2 %(p<0.001) in whole course overnight study. The diagnostic yield was 71.6% within 8 hours, also significantly lower than 81.8% within 12 hours(p<0.001) and 83% in whole course overnight study(<0.001%).(Table) No capsule retention was encountered in this study.

Conclusion

1. Prolonged overnight VCE examination can improve complete rate and diagnostic yield using capsule endoscope whose battery life over 12 hours. 2. Prolonged overnight VCE examination should be considered to be routine practice, especially for inpatients.

Disclosure

None