Clinical Case Summary

Background and Aims: A 66-year-old woman was referred to our center for a recent diagnosis of type 2 achalasia non-responsive to endoscopic dilatation (up to 35 mm). She reported the onset of daily dysphagia 5 years before and 8 kg weight loss, daily regurgitation and occasional chest pain (Eckdart score 7/12). Barium swallow videofluoroscopy showed normal transit through esophageal-gastric junction and upper GI endoscopy was normal.
Methods: Due to the lack of clinical response to endoscopic dilatation, the patient was referred to our center to perform Per Oral Endoscopic Myotomy (POEM).
We repeated a radiologic study of the esophageal transit and the upper endoscopy with esophageal biopsies.
Results: The radiologic study of the esophageal transit showed mild dilation of the proximal tract associated with dyskinesia of the mid-distal portion and asynchronous tertiary contractions without closed stenosis of the lower esophageal sphincter (LES).
In the endoscopy, the esophagus was macroscopically normal. The histological examination of esophageal biopsies showed numerous intraepithelial CD3 positive T lymphocytes predominantly located in the lower-middle compartment of the epithelium (> 200/HPF). The histologic finding was highly suspected for lymphocytic esophagitis and we decided to start with topic steroid therapy with galenic budesonide (2 mg/die) with symptomatic improvement after two months. We will perform endoscopic and histologic evaluation 3 months after the start of therapy.
Conclusion: This case report is an example of lymphocytic esophagitis with a dysmotility-like onset. This condition generally affects old women and, the most common symptom is the dysphagia and food impaction. Therefore is fundamental to perform always upper GI endoscopy with esophageal biopsies to complete the diagnostic flowchart to exclude eosinophilic and non-eosinophilic esophagitis in patients complaining with symptoms of esophageal dysfunction.

Clinical Case Summary

We describe the case of a 38-year-old patient referred to a general surgery consultation due to gastric polypoid lesions, suspected of neoplasia. Since the biopsies were negative for adenocarcinoma/dysplasia, another esophagogastroduodenoscopy was performed which showed several erythematous polypoid areas with a villous appearance, extensive and scattered, mainly in the gastric body and cardia. Only hyperplastic polyps were identified, without dysplasia. The patient underwent a colonoscopy which identified a pedunculated polyp with 50mm in the colon which was removed (serrated without dysplasia) and around 10 polyps measuring 5-10mm spread throughout the colon (two removed and identified as hyperplastic).
The mother underwent total gastrectomy for gastric polyposis associated with hypoalbuminemia and right hemicolectomy for cecum polyposis in 2004 (without access to the histology of the surgical specimens). During follow-up, colonoscopies were performed and the polyps removed were identified as hyperplastic.
The patient underwent a genetic study with a polyposis panel that detected a deletion of approximately 301.5kb that involved the entire SMAD4 gene, classified as pathogenic. Pathogenic variants in the SMAD4 gene are associated with Juvenile Polyposis syndrome (JPS), Myhre syndrome, and Juvenile Polyposis/Hereditary Hemorrhagic Telangiectasia. Given the clinical context, in the genetic consultation, it was assumed that it was Juvenile Polyposis syndrome, with autosomal dominant transmission. His mother will be tested for this mutation.

JPS is characterized by histologically characteristic hamartomatous polyps of the gastrointestinal tract, specifically in the stomach, small intestine, and colorectum. Patients with JPS associated with SMAD4 mutations are more likely to develop gastric polyps and have a higher risk of gastric cancer. To the authors' knowledge, this phenotype of hyperplastic/serrated polyps has not been described in patients with this pathology.

Introduction

Updated population-based studies on acute pancreatitis (AP) in Romania are lacking. Our aim was to evaluate the current data for AP in a tertiary center in Bucharest.

Aims & Methods

We performed an electronic health care records (EHRs) search ICD-10 codes: K85, B25.2, B26.3) for AP cases treated at University Emergency Hospital of Bucharest between 2015 and 2022. Aim of this study was to estimate the daily cost of AP and its probable correlation in regard to: type of case (gastroenterological or surgical), sex, age, ICU, outcome, etiology, severity, morphology (assessed as stated in Revised Atlanta Classsification (RAC). All costs reported in EUR by conversion from RON at the date of submission (28 april 2023).

Results

1503 episodes of AP (942 gastroenterological, 561 surgical) in 1314 unique patients were analysed, data about costs being found in 1246 episodes. Median daily cost (MDC) estimated at 170.91. Higher MDC was related to surgical AP, F(1,1244)=7,05, p<0,01. The Kruskal-Wallis analysis showed significant diferences in regard to: severity H(2)=85,20, p<0,01 with the highest cost in severe AP (Md=229.23) and the lowest in mild AP (Md=162.26); outcome H(4)=105,22, p<0,01 the deceased having the highest MDC (Md=204.84) and the one healed the lowest (Md=118.57). Significant differences H(6)=17,22, p<0,01 were found between Acute Necrotic Collection (Md=123.29) and Interstitial AP (Md=84.80) and between the biliary H(15)=203,96, p<0,01 (Md=139.34), hypertrigliceridemic (Md=97.45) and alchoolic etiology (Md=79.31). Pearson Correlation found a weak and unsignificant correlation with older age, r(1244)=0,25, p=0,373. No significant differences were found regarding sex, F(1,1244)=2,73, p=0,09, and admission in ICU F(1,1229)=1,46, p=0,23.

Conclusion

In this large retrospective study higher costs of AP correlate to hospitalization in surgical wards, severity, developement of local complications and biliary etiology. No correlations were found to age or ICU admission. Median daily cost (MDC) estimated at 170.91. This is the first report of AP related costs in Romania.

References

1. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-111. doi: 10.1136/gutjnl-2012-302779
2. Fagenholz PJ, Fernández-del Castillo C, Harris NS, et al. Direct medical costs of acute pancreatitis hospitalizations in the United States. Pancreas. 2007;35(4):302-307. doi: 10.1097/mpa.0b013e3180603f3a
3. Kim MK, Han J, Lee SY, et al. The economic burden of acute pancreatitis in Korea: a national population-based study. PLoS One. 2018;13(4):e0195550. doi: 10.1371/journal.pone.0195550
4. Barkin JA, Barkin JS, Hupertz V, et al. Hospital length of stay and cost of acute pancreatitis in the United States: a systematic literature review. Pancreas. 2015;44(6):810-815. doi: 10.1097/MPA.0000000000000349
5. Martínez-Moneo E, Sánchez-Pobre P, Pérez-Martínez I, et al. Impact of a standardized protocol of clinical management and follow-up on healthcare costs in patients with acute pancreatitis. Rev Esp Enferm Dig. 2017;109(10):719-725. doi: 10.17235/reed.2017.4562/2017

Clinical Case Summary

We present the case of a 51-year-old gentleman with von Hippel-Lindau disease and a complex surgical history involving bilateral adrenalectomy in childhood and a Whipple’s procedure for neuroendocrine tumor (NET) at 36 years of age. Surveillance imaging demonstrated recurrent paraganglioma adjacent to the left aspect of the coeliac axis and a 2 cm NET in the pancreatic tail. The paraganglioma was resected, but attempted resection of the tail was complicated by haemorrhage and had to be abandoned. He was readmitted two weeks later with abdominal pain. CT demonstrated a post operative pancreatic fluid collection which was initially managed by percutaneous drainage. This reduced the collection volume, but resulted in a chronic pancreatic fistula with daily output of 100-150 ml.
Initial attempt to drain this cavity by EUS cyst-gastrostomy proved unsuccessful due to an incomplete cavity wall precluding expansion of the cavity with saline injection. CT with contrast injection through the external drain delineated communication with the dilated main pancreatic duct (PD) and extension of the collection between the liver and gastro-jejunal anastomosis.
Previous Whipple’s procedure made ERCP challenging therefore EUS directed pancreaticogastrostomy was planned.. EUS demonstrated a dilated PD containing significant debris and calculi, particularly centrally towards the pancreatico-jejunal anastomosis. Due to the PD calculi burden it was not possible to insert sufficient wire to facilitate plastic stent insertion. Therefore an 8 mm X 8 mm lumen apposing metal stent (LAMS) was deployed from the stomach into the PD. Injection of contrast through the LAMS opacified the pancreatic duct confirming successful procedure.
The percutaneous drain output reduced to zero within two days and the patient clinically improved. The drain was removed at 4 weeks. Subsequent imaging demonstrated resolution of the collection.

References

1. Preprocedural CT demonstrating communication between the collection and the pancreatic duct.
2. EUS demonstrated dilated PD containing debris and calculi.
3. Fluoroscopic image confirming technically successful pancreaticogastrostomy
4. Follow up CT confirming resolution of percutaneous fistula and associated collection

Clinical Case Summary

Patient of 71 years old with CP was admitted for painless jaundice with benign common bile duct (CBD) stricture. ERCP failed at her center due to duodenal edema that prevented seeing the papilla so the patient was transferred to our center for assisted EUS drainage.

After after a first attempt with an unsuccessful rendezvous ERCP due to guidewire loss in the exchange of devices, cholecystoduodenostomy was performed with a coaxial double pigtail after confirmation of cystic duct permeability in the cholangiogram (previously performed under EUS guidance with puncture of the CBD to perform de rendezvous). In a second attempt to treat the stricture, a rendezvous through the gallbladder was performed. After papilloplasty and dilating the stricture, a 10 x 60 mm FCMS was placed. The patient improved and the lumen apposing metal stent of the cholecystoduodenostomy was removed. In followup, proximal migration of the stent was observed, impossible to remove by ERCP at her center due to impossibility of accessing the papilla.

In our center, a new endoscopy was performed. CBD was punctured by EUS with a 22 G needle through the biliary stent to perform a rendezvous and a novagold guidewire was advanced to the duodenum. The CBD was accessed with a monorail sphincterotome over the guidewire and rigid guidewire was advanced to the biliary tract. Papilloplasty was performed againd and the migrated stent was removed with rat tooth forceps. A new FCMS was placed successfully.

To conclude, endoscopic management of patients with CP can be very complex and several advanced combined bile duct access techniques are sometimes required. So, these patients should ideally be managed in referral centers.

Introduction

EUS-guided drainage using lumen-apposing metal stents (LAMS) has become standard treatment of symptomatic walled-off necrosis (WON). The development of these fully covered self-expanding metal stents with special design of the flanges and large diameter, improved the drainage of debris and facilitated further direct endoscopic necrosectomy. Delivery systems with integrated electro-cautery (EC) enable direct access and stent deployment whilst the conventional stent insertion technique requires several steps including access using a needle or cystotome, wire insertion and enlargement of the created tract before the stent placement.

Aims & Methods

In this single center study, we aimed to compare the practicality of EUS-guided procedures and their outcome between conventional LAMS (cLAMS) and those with integrated EC (LAMS-EC).
From our prospectively maintained database, we included consecutive patients undergoing EUS-guided LAMS insertion with or without integrated electro-cautery for drainage of walled-off necrosis. Infection of the walled-off pancreatic necrosis, biliary compression with cholestasis or gastric outlet obstruction were accepted indications for intervention. Data on procedure time, sedation, hospital stay, technical and clinical success as well as adverse events were analysed.

Results

We analysed 107 consecutive procedures of transmural EUS-stenting for drainage of walled-off necrosis. 39 cLAMS and 68 LAMS-EC were placed successfully. Mean size of the walled-off necrosis was 12.9 ± 4.2 cm with mean 30% ± 15% solid necrosis.
Procedure times were shorter with LAMS-EC (18 .0 ± 6.6 min vs. 39.7 ± 8.3 min; p<0.05). All EUS-guided procedures with cLAMS drainage were performed under propofol sedation administered by an anaesthetic team. In the LAMS-EC group, 36 patients tolerated the procedure under iv sedation (fentanyl/midazolam) in left lateral position and 17 interventions were performed as daycase procedures. None of the patients developed sedation related adverse events such as aspiration.
Adverse events, technical success and clinical outcome did not differ between both groups.

Conclusion

The findings of this study suggest that cLAMS and EC-LAMS achieve similar rates of technical and clinical success without difference in the rate of adverse events. Compared to cLAMS, deplayment of EC-LAMS is faster and technically less demanding. This might allow to perform the procedure under conventional intravenous sedation and as daycase procedure in carefully selected patients.