Clinical Case Summary

Ballon-occluded retrograde transvenous occlusion (BRTO) is a minimal invasive procedure to treat mainly the gastric varices but it may be used in ectopic varices as well. We report a case of 70years old male known to have Alcoholic liver disease (cirrhosis) with portal hypertension, presented with malena. He underwent an urgent Gastroscopy which showed GAVE (Gastric antral vascular ectasia) and Grade 1 varix not needing any therapy. Due to persistent malena and haemoglobin drop, CT mesenteric angiogram was performed which reported multiple enlarged varices in the abdomen with no active site of haemorrhage. Video capsule endoscopy was performed which showed small bowel varices with evidence of fresh blood. Unfortunately, the ultrasound liver showed thrombosis of portal vein. Due to portal vein thrombosis TIPSS (Transjugular intrahepatic porto systemic shunt) was not performed and MDT decision for BRTO (Balloon-occluded retrograde transvenous occlusion) was made which the patient underwent successfully.
BRTO is advantageous over TIPSS because this can be performed with poor hepatic reserve and with hepatic encephalopathy however it increases the risk of bleeding from oesiphageal varices and ascites. Gastro-renal shunts are the most sites for use of BRTO however, this procedure was successfully done in this case.
Based on literature review BRTO procedure has been successfully used in gastric varices.
I’ve found few cases reported with small bowel varices treated with BRTO.
Learning points:

1. Whether BRTO is superior to TIPPS for ectopic varices
2. Whether BRTO can be considered in ectopic varices in patients without portal vein thrombosis

References

https://www.sciencedirect.com/science/article/pii/S1930043317305022


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444869/#!po=0.806452

Disclosure

No conflict of interest

Introduction

The introduction of lumen-apposing metal stents (LAMSs) has revolutionized the field of therapeutic endoscopic ultrasound (EUS). In the last decade, its utilization for off-label indications has markedly increased, particularly among patients with surgically altered anatomy to establish access in the excluded segment of the gastrointestinal tract. Indications for anastomosis creation include EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE), EUS-directed transgastric intervention (EDGI), or endoscopic reversal of Roux-en-Y gastric bypass (RYGB) for specific indications (see below).

Aims & Methods

This study aims to evaluate the effectiveness and safety of LAMS in patients with surgically altered anatomy for EDGE, EDGI, and reversal of RYGB. We collected data on all LAMS procedures conducted in patients with surgically altered anatomy, between October 2019 and February 2024 at the University Hospital of Ghent.
We used our prospective LAMS database and retrieved missing data from retrospective analysis of the medical patient records. The main outcome data of interest were technical success, clinical success, and adverse events. Technical success was defined as a successful placement of LAMS in the desired position. Clinical success was defined as either successful endoscopic access to the intended excluded gastrointestinal segment or achievement of the intended therapeutic goal when RYGB reversal was necessary. Adverse events were classified according to the AGREE criteria.

Results

A total of 73 LAMS procedures were performed: 70 cases of EUS-guided gastro-gastrostomy in patients with RYGB and 3 cases of EUS-guided gastro-enterostomy in patients with hepaticojejunostomy. Indications for LAMS procedures included 55 (75.3%) cases of EDGE, 13 (17.8%) cases of EDGI (such as gastroduodenoscopy and EUS), and 5 (6.8%) cases of RYGB reversal. Reversal of RYGB was required for one cachectic patient due to metastatic cholangiocarcinoma, three patients with hyperinsulinemic hypoglycemia, and one patient with therapy-resistant small intestinal bacterial overgrowth (SIBO).
The overall technical and clinical success rates were very high at 97.3% and 95.9%, respectively. Adverse events were observed in 11 out of 73 (15.1%) cases, including 7 (9.6%) minor events (AGREE score < 3) and 4 (5.5%) major events (AGREE score ≥ 3). Major events included stent migration (N=1), persistent fistula (N=2), and respiratory desaturation (N=1). All events could be successfully managed, and there were no procedure-related deaths. In 69.9% of cases, our method involved a dual-step approach, strategically implemented to await fistula maturation and reduce the risk of perforation. The median LAMS dwell time was 38 days (range 7, 431). LAMS was removed in 72.6% of the cases. Loss of LAMS patency occurred in 1 out of 73 (1.4%) cases and was endoscopically managed.

Conclusion

In conclusion, our study demonstrates that EUS-GG and EUS-GE offer an effective and safe approach to create anastomoses between gastrointestinal (GI) segments when performed by experts. With high technical (97.3%) and clinical (95.9%) success rates, LAMS proves beneficial for accessing excluded GI segments and reversing RYGB. Adverse events (15.1%) were mostly minor and manageable, with no procedure-related mortality. The extended patency duration and low re-intervention rate highlight LAMS as a minimally invasive and durable option in therapeutic endoscopic ultrasound procedures. Further prospective studies are required.

Introduction

Colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding (ALGIB) and often requires blood transfusion. There are several studies regarding the use of restrictive blood transfusion for acute upper gastrointestinal bleeding, but there is only one previous study regarding the use of restrictive blood transfusion for ALGIB [1]. Therefore, the efficacy of restrictive blood transfusion for CDB remains unclear.

Aims & Methods

This study sought to elucidate the association between the restrictive blood transfusion strategy and the clinical outcomes in patients with CDB. We retrospectively analyzed 475 patients who were urgently hospitalized for CBD and received blood transfusions at two facilities between November 2013 and December 2021. Transfusion strategy was defined as the restrictive group when patients received transfusion for hemoglobin (Hb) ≤ 7 g/dl, and the liberal group when patients received for Hb > 7 g/dl. The hemoglobin cut-off value for restrictive blood transfusion was determined based on a prior randomized clinical trial regarding UGIB [2]. Rebleeding within 30-days, mortality within 30-days, and composite outcome within 30-days were evaluated. The composite outcome comprised the following endpoints: rebleeding, need for surgery or IVR for hemostasis, and mortality within 30 days. We also investigated medical costs during hospitalization. Logistic regression analysis was performed to calculate the odds ratios (OR) with 95% confidence interval (CI) to analyze associations between restrictive transfusion strategy and outcomes.

Results

Of 475 patients, 184 (38.7%) (124 males, 60 females, mean age 76.5±11.5 years) patients received blood transfusion. The mean hemoglobin levels at the time of transfusion in the restrictive and liberal groups were 6.3±0.6 g/dl and 8.2±1.2 g/dl, In the restrictive and liberal group, rebleeding within 30-days was 53.9% and 45.3% (P = 0.24), the mortality within 30-days was 1.1% and 0% (P = 0.30), the composite outcome within 30-days was 56.1% and 52.6% (P = 0.63), respectively. After adjusting for potential confounders, multivariate analysis revealed that restrictive transfusion strategy not associated with decreased rebleeding risk within 30-days, (P = 0.42 ; odds ratio [OR], 1.3), whereas endoscopic hemostasis significantly associated with decreased rebleeding risk (P < 0.01 ; OR 0.2). There was no statistically significant difference in total medical costs between the two groups (P = 0.68).

Conclusion

There were no statistically significant differences in rebleeding within 30-days, mortality within 30-days, and compositeoutcome within 30-days between the restrictive and liberal blood transfusion strategies. Restrictive blood transfusion may be a reasonable therapeutic strategy for patients with CDB, except for patients in which shock status cannot be withdrawn. However, further evidence is needed to advocated the efficacy of restrictive transfusion strategies for lower gastrointestinal bleeding.

References

[1] Kherad O, Restellini S, Martel M, Sey M, Murphy MF, Oakland K, et al. Outcomes following restrictive or free red blood cell transfusion in patients with lower gastrointestinal bleeding. Aliment Pharmacol Ther. 2019 Apr;49(7):919–25.
[2] Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan;368(1):11–21.

Introduction

Endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) with esophageal varices (EVs) is one of the most challenging endoscopic procedures due to the high risk of bleeding and fibrosis caused by prior treatment of varices. However, due to the small number of such cases, the clinical outcomes of ESD for ESCC with EVs have been reported in only a limited number of cases at single centers^​1-3.

Aims & Methods

We conducted a multicenter, retrospective, cohort study to clarify the safety and efficacy of ESD for ESCC with EVs.Eleven institutions in the Tohoku region of Japan participated in this multicenter, collaborative, retrospective study. We performed endoscopic resection for 3619 patients with esophageal carcinoma at the participating institutions during the period from January 2010 to April 2022. Among those, 30 patients who underwent ESD for ESCC with EVs were recruited for the present study.
Rates of en bloc resection and R0 resection, procedure time and adverse events were evaluated as indicators of the feasibility and safety of ESD. Additional treatment, recurrence and metastasis of the lesions were evaluated as indicators of the long-term efficacy of ESD.

Results

Portal hypertension was caused by cirrhosis, of which alcohol was the most common cause. En bloc resection was achieved in 93.3% and R0 resection in 80.0% of the patients. The median procedure time was 92 minutes. Adverse events included a case of uncontrolled intraoperative bleeding leading to discontinuation of ESD and a case of esophageal stricture due to extensive resection. During the follow-up period of a median for 42 months, a patient with local recurrence and another patient with liver metastasis were observed. One patient died of liver failure after receiving chemoradiotherapy as an additional treatment after ESD. No patient died of ESCC.

Conclusion

This multicenter, retrospective cohort study demonstrated the safety and efficacy of ESD for ESCC with EVs. Further studies are needed to establish appropriate treatment methods for EVs before ESD and additional treatments for patients with insufficient ESD.

References

1. Sawaguchi M, Jin M, Matsuhashi T, et al. The feasibility of endoscopic submucosal dissection for superficial esophageal cancer in patients with cirrhosis (with video). Gastrointest Endosc 2014;79:681-5.
2. Choi YK, Noh JH, Kim DH, et al. Outcomes of endoscopic submucosal dissection for superficial esophageal neoplasms in patients with liver cirrhosis. Clin Endosc 2022;55:381-9.
3. Zhang S, Liu YD, Chai NL, et al. Endoscopic submucosal dissection for early cancers or precancerous lesions of the upper gastrointestinal tract in cirrhotic patients with esophagogastric varices: Ten-year experience from a large tertiary center in China. Gastrointest Endosc 2023 Online ahead of print.

Disclosure

The authors declare that they have no conflicts of interest.