Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic procedure that carries risks of post ERCP pancreatitis (PEP), perforation and bleeding. Extensive studies have been carried out in a bid to reduce these risks and to modify procedural related risk factors to minimise the risk of PEP. One of these methods is utilising the needle knife fistulotomy (NKF) early into gaining biliary access.

Aims & Methods

We aim to study the effectiveness and safety of utilising NKF early in ERCP, both as a primary means of gaining biliary access and a salvage method in difficult biliary cannulation. Papillary morphology which has been thought to contribute to its effectiveness and safety is also studied. All the cases with NKF, either early NKF or primary, during ERCP by a single operator over a ten year period from 2013 to 2022 were identified. Early NKF has been defined as proceeding to the technique within 5 minutes of attempting biliary cannulation, less than 5 contacts with the papilla or after one pancreatic duct (PD) cannulation. Primary NKF has been defined as NKF prior to attempted cannulation. The notes and endoscopy reports of these patients who had undergone the procedure were reviewed for:

1. Success rate on first ERCP and the follow up managements for unsuccessful cases

2. Success rate on reattempt ERCP cases following an unsuccessful first ERCP after NKF

3. Success rate with various papillary morphology (classified according to the Haraldsson classification)

4. Complication rate of ERCP where NKF was attempted

5. The rate of PD cannulation, PD stent insertion and its associated rate of PEP

6. The rate of biliary cannulation and complications in patient who had undergone primary NKF

Results

There were 289 cases of ERCP that had early NKF by a single operator. The biliary cannulation rate was 88.9% (n=257) on first attempt ERCP. For the failed first attempt ERCPs, 15 patients were brought back for re-attempt at ERCP and the success rate was 93.3% (n=14). Cumulatively, the successful biliary cannulation is 93.8% (n=271). Successful cannulation was 95% in protruding papillas (Haraldsson Type 3), 89% for creased or ridge papillas (Haraldsson Type 4), 81.3% in the regular papilla (Haraldsson Type 1) and 66.7% in papillas within a diverticulum. The overall complication rate for early NKF was 3.1% (n=9). The mortality rate in this study was 0.3% (n=1) from severe pancreatitis. The rate of post-procedure bleeding was at 0.3% (n=1). There was a rate of 0.3% (n=1) for perforation caused by needle knife incision, which was managed with endoscopic clipping intraprocedurally. The rate of pancreatitis was 2.4% (n=7). There were 38 patients who underwent PD cannulation, of which 5.3% (n=2) suffered from PEP and did not have a PD stent inserted. Out of 38 patients, there were 5 patients who had PD stent inserted and none had pancreatitis. For the 251 patients who had not undergone PD cannulation, 2% (n=5) had PEP. There were 16 cases of primary NKF and 100% was successful with biliary cannulation. There were no complications.

Conclusion

Early NKF is an effective method of gaining biliary access in ERCP in experienced hands. In our experience, primary NKF has been highly successful with no complications. Additionally, a second attempt at ERCP should be considered ahead of more invasive interventions such as percutaneous transhepatic cholangiogram (PTC) if the clinical situation allows after an initial failed attempt at ERCP with NKF. Early NKF is also safe in experienced hands, as evidenced by low rates of complications.

References

1. Haraldsson E, Lundell L, Swahn F, Enochsson et al. Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study. United European Gastroenterology Journal. 2017 ; 5(4): 504-510

Introduction

Several biologic therapies are available for the treatment of Inflammatory Bowel Diseases (IBD). Anti-TNF agents have been, and continue to be, frequently used as first-line agents. Choice of a second biologic after failure of a first anti-TNF remains a common clinical scenario with limited data available to guide choice. Mode of failure for the first-line anti-TNF, classed as primary non-response (PNR) or secondary loss of response (LOR) has been suggested as a means of guiding treatment choice.

Aims & Methods

To compare the efficacy of second line biologic therapies [infliximab (IFX), adalimumab (ADA), golimumab (GLM), vedolizumab (VDZ), ustekinumab (UST)] in patients with Ulcerative Colitis (UC) and Crohn’s Disease (CD) enrolled in the UK IBD BioResource, after first line anti-TNF failure.Demographic, disease, treatment and outcome data were retrieved. Inverse probability of treatment weighting (IPTW) was used to balance groups using a propensity score-weighting approach accounting for baseline patient or disease related clinical characteristics. Effectiveness of treatment was based on persistence free of treatment discontinuation or treatment failure. Failure was defined as occurring if any of the following occurred: (a) clinician-recorded treatment failure (b) start of treatment with a different biologic drug (c) occurrence of resectional or defunctioning bowel surgery. We compared Kaplan Meier curves for treatment failure-free survival after IPTW and used a log rank test for differences between the groups.To testwhether the mode of first line treatment failure affected different second-line treatments’ efficacies, we classified first anti-TNF failure as PNR or non-PNR (an approximation for LOR) for subgroup analyses.

Results

For patients with UC, we analysed efficacy after ADA (n=301) and IFX failure (n=519) separately due to differences in outcomes between these drugs when used in first-line therapy in the same cohort. Second line VDZ demonstrated superior outcomes up to the three year follow up, compared to second line IFX after ADA failure (p<0.01) and compared to second line ADA after IFX failure (p<0.001). After PNR to IFX, VDZ had a significantly better treatment survival free of discontinuation or failure compared to ADA (p = 0.002) whereas in the case of PNR to ADA, there were no significant differences between those who received second line VDZ and IFX. For NPNR after both IFX or ADA, VDZ therapy had significantly better efficacy than ADA or IFX respectively (p < 0.001).
For patients with CD, we combined first-line ADA and IFX cohorts due to similar outcomes observed when used in first-line therapy in the same cohort. Patients who experienced anti-TNF failure had significant better outcomes when treated with a second line non-anti-TNF biologic (UST or VDZ, n=614) than those who received a second line anti-TNF (n=1976, p=0.007). In the case of PNR, we found no difference between second line anti-TNF vs non-anti-TNF biologics. However, after NPNR to anti-TNF, there was a significantly better performance for non-anti-TNF compared to anti-TNF biologics (p=0.01).

Conclusion

In the common scenario of first line anti-TNF therapy failure switching out of class seems to offer better outcomes after anti-TNF failure both in UC and CD. In contrast to some algorithms, after NPNR to anti-TNF agents, a switch out-of-class to a non anti-TNF therapy afforded better outcomes in both UC and CD compared to switching within the class of anti-TNF agents.

Introduction

Diverticular disease of the colon is one of the most common diseases in Western world. Despite in the natural history in most of cases diverticulosis remains asymptomatic or manifests with mild abdominal pain, complications may occur. Bleeding from diverticula is one of the most common complications and, despite it is usually a self-limiting event, it may lead to anemia or shock. Among the endoscopic interventions for active bleeding, direct or indirect clipping of the diverticulum is the most diffuse one. However, it has been hypothesized that endoscopic band ligation (EBL) may be more effective, since it may improve the chance to close the bleeding vessel, with a better outcome on long term. Therefore we performed a meta-analysis comparing clipping versus EBL for diverticular bleeding.

Aims & Methods

Literature search on main databases (PubMed, Web of science, SCOPUS, EMBASE) was performed in November 2022. Studies comparing clip versus EBL for acute diverticular bleeding were selected. We excluded case series, abstract and articles not written in English. The following outcomes were analysed: short term effectiveness, early rebleeding, tardive rebleeding and need for surgery or radiologic embolization. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculate according to Mantel-Haenszel method. Heterogeneity was estimated by I² statistic with chi square test, and, if present, a random effect model was used, otherwise a fixed one was adopted.

Results

Seven studies were selected, overall enrolling 2322 patients (979 in EBL and 1343 in clip groups). Immediate haemostasis was achieved in the EBL and clipping group respectively in the 96.8% and 96.5% (OR=0.94, 95% CI 0.59-4.19, p=0.79). Early rebleeding was observed more frequently in the clipping (25.0%) than in the EBL group (11.8%), with an OR=0.40 (95% CI 0.32-0.51, p<0.001). Similarly, tardive rebleeding was more common in the clipping arm (37.4%) than in the EBL (24.5%), OR=0.39, 95% CI 0.22-0.68, p=0.0001. Patients receiving clipping needed more frequently salvage surgery or embolization than EBL (1.48% versus 0.53%, OR=0.40, 95% CI 0.17-0.93, p=0.03).

Conclusion

Despite EBL and clip have similar effectiveness in achieving immediate haemostasis, EBL showed better effectiveness in maintaining it on longer interval times, with less probable need for major surgical/radiologic interventions.

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