Introduction

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using a lumen-apposing metal stent (LAMS) is a novel endoscopic technique used to treat gastric outlet obstruction mostly caused by malignant disease such as pancreatic, gastric or biliary cancer. It is a technically challenging procedure with a high-risk of complications especially when performed by an endoscopist with limited experience.

Aims & Methods

We retrospectively analyzed our prospectively collected data of all EUS-GE performed in our center from 2021. Clinical success was defined by the gastric outlet obstruction scoring system (GOOSS). All procedures were done by one endoscopist with no previous experience with the technique.

Results

In total 30 patients were included in the study (16 men, 14 women, mean age 69 years (range 44-90). The indication for EUS-GE was malignant disease (pancreatic cancer, cholangiocellular carcinoma, gastric cancer, gallbladder cancer, breast cancer, renal cancer, small bowel and liver cancer) in 28 cases and benign disease (chronic pancreatitis, aortic aneurysm) in 2 patients. The procedure was technically feasible in all but one patient (29/30, 96,7%). Clinical success when evaluated as restoration of solid oral intake was 86,2%
(25/29 patients) and 100% (29/29) when evaluated as restoration of at least liquid oral intake. The overall mean GOOSS achieved was 2,5 (1-3). Severe complications occurred in two patients (2/29, 6,9%). In one patient we experienced an unusual complication 6 months after the procedure when a gastrojejunocolic fistula developed, causing weight loss and fecal content vomiting. The fistula was successfully closed endoscopically. Another patient with a metastatic gastric cancer died one day after the intervention of a cardiac cause. Mean procedure time was 46 minutes (20-91) with no difference in mean time of the first and last five procedures. Mean survival post intervention was 135 days (1-560). No intervention for symptom recurrence was needed during a mean follow-up of 90 days.

Conclusion

EUS-GE is an efficient and safe technique in the treatment of gastric outlet obstruction even when performed by an endoscopist with no prior experience.

References

1. Itoi T, Ishii K, Ikeuchi N, Sofuni A, Gotoda T, Moriyasu F, Dhir V, Teoh AY, Binmoeller KF. Prospective evaluation of endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) for malignant gastric outlet obstruction. Gut. 2016 Feb;65(2):193-5. doi: 10.1136/gutjnl-2015-310348. Epub 2015 Aug 17. PMID: 26282674
2. Antonelli G, Kovacevic B, Karstensen JG, Kalaitzakis E, Vanella G, Hassan C, Vilmann P. Endoscopic ultrasound-guided gastro-enteric anastomosis: A systematic review and meta-analysis. Dig Liver Dis. 2020 Nov;52(11):1294-1301. doi: 10.1016/j.dld.2020.04.021. Epub 2020 Jun 3. PMID: 32505567
3. Hujova A, Stirand P, Turza P, Spicak J, Hucl T. Endoscopic management of gastrojejunocolic fistula as an unusual complication of endoscopic ultrasound-guided gastroenterostomy. Endoscopy. 2023 Dec;55(S 01):E151-E152. doi: 10.1055/a-1937-9558. Epub 2022 Oct 28. PMID: 36307072; PMCID: PMC9829763.

Introduction

The increasing number of performed gastroscopies worldwide has lead to higher detection rates of the subepithelial lesions (SELs) of the upper gastrointestinal tract. This study aims to describe the role of endoscopic ultrasonography (EUS) in the diagnosis and management of SELs at a tertiary public reference hospital in Northern Greece.

Aims & Methods

Records of patients who were referred to the Endoscopy Unit of Theageneio Hospital between 2018 and 2023 for upper EUS evaluation were retrospectively reviewed. We conducted data concerning patient characteristics, SELs features, details of the procedure and the final management of each case. All the examinations were performed by a single operator (DT).

Results

A total of 310 patients, male:130 and female:180, with a median age of 59 (range:17-86) were referred to EUS examination. EUS showed extraluminal compression in 16 cases (5.2%), gastric folds in 8 cases (2.6%), vascular structure in 8 cases (2.6%), and in 26 patients (8.4%) no lesion could be identified. A total of 252 (81.3%) patients had confirmed SELs. The lesion's location was: gastric body/corpus in 40.0% (101/252), antrum 34.5% (87/252), duodenum 15.1% (38/252), esophagus 10.3% (26/252). Regarding the size of the lesion in 31.7% of the cases (80/252) was <10mm, 41.3% (104/252) 10-19mm and in 27% (68/252) was >20mm. The most common EUS features were the following: regular borders 98.8% (249/252), hypoechoic lesions 67.5% (170/252), homogenous 77.8% (196/252), without vascularity 90.5% (228/252), and 69.5% (155/252) were originating from the third layer. Sixty-nine SELs (69/252, 27.4%) were malignant or had malignant potential as defined by the EUS findings. More specifically, forty-three patients (43/69, 62.3%) were referred for surgical resection. Twenty-three patients (23/69, 33.3%) were referred for further radiological evaluation and one patient (1/69, 1.4%) was referred for endoscopic resection. Endoscopic reassessment was recommended in 155 patients (155/252, 61.5%). Only one patient had persistent regurgitation, as an examination-related complication, probably due to the periprocedural
anesthesia that led to discontinuation of the examination.

Conclusion

EUS is a practical and safe tool for characterizing and assessing the features and malignant potential of SELs. In our center we could identify the malignant or potential malignant lesions and refer them to surgery.

References

1)Deprez, P. H., Moons, L. M., O’Toole, D., Gincul, R., Seicean,A.,Pimentel‐Nunes,P.,Fernández,Esparrach,G.,Polkowski,M.,Vie
th, M., Borbath, I., Moreels, T. G., Van Dijkum, E. N., Blay, J., & VanHooft, J. E. (2022). Endoscopic management of subepithelial lesions including neuroendocrine neoplasms: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy, 54(04),412–429. https://doi.org/10.1055/a-1751-5742

Disclosure

Nothing to disclosure

Introduction

EUS-guided gastroenterostomy(EUS-GE) with lumen-apposing metal stent(LAMS) has emerged as a mini-invasive, effective and safe alternative to surgical gastrojejunostomy and endoluminal stenting to treat malignant gastric outlet obstruction(MGOO).Currently, intra-abdominal carcinomatosis represents a relative contraindication to this procedure, due to a possible higher risk of clinical failure.

Aims & Methods

The primary aim was to compare clinical success of EUS-GE in patients (pts) with MGOO with vs without concomitant intra-abdominal carcinomatosis.Secondary aims was to compare between the same subgroups of pts the clinical and procedural characteristics, the technical success rate and long-term outcomes.All pts undergoing EUS-GE for MGOO at our institution from Jun.2018 to Dec.2024 were retrospectively enrolled.Technical success was defined as successfully establishing EUS-GE and clinical success as oral diet tolerance without re-intervention for 14 days after the procedure. Inclusion criteria: 1)age>18 years; 2)MGOO; 3)complete clinical records. Exclusion criterium:missing data. Intra-abdominal carcinomatosis was defined according to CT/MRI imaging. Adverse events (AEs) recorded and classified (AGREE). Obstructive symptoms graded according to the GOOSS score. Data expressed as median [range], comparisons by the Student-t-test, Mann-Whitney-u test and X² test as appropriate.

Results

EUS-GE for MGOO was performed in 74 pts (36 [48.6%] males, age 71 [30-92]), with ECOG performance status ≥2 in 29(39.2%). Obstructive symptoms were reported by 72(97.3%) pts (GOOSS: 1 [0-3]). Intra-abdominal carcinomatosis was present in 29(39.2%) pts. Ascites was more frequent in pts with vs without carcinomatosis (19[65.5%] vs 12[26.7%], p=0.02). Other clinical characteristics were comparable between groups.All EUS-GE were performed in deep sedation. LAMS included Axios and Spaxus (Axios: 37[82.2%] vs 25[86.2%],p=0.89). 20mm LAMS were used in a comparable proportion of pts with vs without carcinomatosis (25[86.2%] vs 37[83.2%], p=0.89). Technical success rates and procedural time did not differ between groups (28[96.6%] vs 43[95.6%],p=0.69; 33[16-85] vs 40[20-106],p=0.52). Overall, 9 misdeployments were observed (carcinomatosis: 3[10.3%] vs no-carcinomatosis: 6[13.3%], p=0.98). AEs were 4 (19.8%) and 9 (20%) in pts with vs without carcinomatosis (p=0.71), all grade III. Time to refeeding (days) was comparable between groups (1[1-5] vs 1[1-5], p=0.96), while hospital stay (days) was longer in patients with carcinomatosis (8[2-18] vs 4[2-15],p=0.0009). Clinical success rate did not differ in pts with vs without carcinomatosis (25[86.2%] vs 43[95.6%],p=0.31). All 6 failures were due to malignancy progression. Median follow-up duration was 51[21-622] days. During follow-up, 27(93.1%) pts with and 38(84.4%) without carcinomatosis died(p=0.45). Median survival (days) and oral diet toleration until last follow-up/death were comparable between pts with vs without carcinomatosis (42[21-398] vs 66[26-622],p=0.07; 26[89.6%] vs 42[93.3%],p=0.89). Oncological treatments were resumed in 11(37.9%) pts with and 23(51.1%)without carcinomatosis (p=0.38). Rehospitalization rate for any cause was comparable in both groups (14[48.3%] vs 26[57.7%],p=0.57), requiring reintervention in 1case.

Conclusion

In our study population high technical and clinical success rates of EUS-GE were comparable in pts with and without intra-abdominal carcinomatosis. The major outcomes were comparable between these 2 subgroups of pts, suggesting the long-term efficacy of this procedure also in those with more advanced malignancy.

Introduction

Peroral endoscopic myotomy (POEM) is considered a standard method for achalasia treatment with excellent long term treatment success. However, the benefits of POEM are tempered by the risk of post-POEM reflux complications.

Aims & Methods

The aim of this retrospective analysis of prospectively collected data was to assess the long-term post-POEM reflux. Data from all consecutive patients who underwent POEM between December 2012 and April 2023 were analyzed. The patients assessed symptoms at 3 and 12 months after the procedure and every year thereafter. The patients underwent upper GI endoscopy, high-resolution manometry (HRM) and 24-hour pH monitoring 3 months after the procedure; endoscopy was then repeated at 2-3 years and at 6 year follow-up. Reflux esophagitis, reflux parameters measured by 24h pH monitoring (off PPIs), reflux symptoms and the use of proton pump inhibitors (PPIs) were the principal outcomes.

Results

A total of 539 POEM procedures (20x re-POEM) were performed in 519 patients. Three months after the procedure, 390 patients underwent 24h pH monitoring with abnormal acid exposure in 178 of them (45.6% [95% CI: 40.7, 50.6]). Reflux esophagitis was present in 181/463 patients (39.1% [95% CI: 34.7, 43.6]; LA C/D in 20 patients, 4.3%) at 3 months, in 94/263 patients (35.7% [95% CI: 30.2, 41.7]; LA C/D in 5 patients, 1.9%) at 24-36 months and in 18/88 patients (20.5% [95% CI: 13.3, 30]; LA C/D in 0 patients) 6 years after procedure. Follow- up questionnaires were completed in 185, 161 and 106 patients 48, 60, 72 months after the procedure and 34.6%, 35.7% and 34.4% of patients claimed occasional heartburn and 18.1%, 20.4% and 19.6% experienced occasional regurgitation of gastric content. However, only the minority (under 2% of the patients at 48, 60, 72 months) experienced the symptoms on daily basis. PPIs were administered to 53.3%, 48.4% and 54.3% of patients at 48, 60 and 72 months after POEM with majority of them (80%) taking PPIs on daily basis. We also investigated whether there were any differences in patients with and without PPIs. In patients with PPIs, there were less cases of reflux esophagitis 3 months after POEM (32.4% vs. 43.5%). More patients with PPIs experienced post-POEM heartburn (42.3% vs. 25.9%) at 48 months and at 60 months (48.7% vs. 25.4%). There were no significant differences in terms of pathological reflux on 24-hour pH monitoring and in the occurrence of severe esophagitis between patients with vs. without PPIs. Regarding severe reflux complications, there were no new cases of Barrett's esophagus and esophageal adenocarcinoma. One patient developed peptic stricture, which was successfully treated with balloon dilation. The outcomes were not different among patients who underwent anterior (60%) vs. posterior myotomy (40%).

Conclusion

The rate of post-POEM reflux esophagitis decreases over time, however approximately 50% of patients require long-term antisecretory treatment. Even if the risk of reflux complications is low, patients after POEM should remain under long-term surveillance.

Introduction

Peroral endoscopic myotomy (POEM) has become the mainstay of treatment of oesophageal achalasia in adult patients and recently also gained acceptance as effective therapy of achalasia in paediatric population. Here we retrospectively reviewed prospectively collected children with achalasia that had been treated with POEM at our institution.

Aims & Methods

Patients that were hospitalized in the Paediatric Clinic for POEM procedure from 11/2017 to 05/2023 were included. All patients had achalasia confirmed by high resolution manometry (HRM). We evaluated their symptoms in terms of duration and intensity (Eckardt score) and the integrated relaxation pressure (IRP) obtained by HRM before POEM. 3 months after POEM during the follow-up visit we determined Eckardt score, IRP and the presence of reflux oesophagitis on upper endoscopy. When finalizing the abstract we conducted a brief telephone survey to determine Eckardt score and presence of reflux symptoms.

Results

10 patients (6 boys and 4 girls), mean age 11.5 (5-18) years were included. 9 of these patients received POEM as their first therapy for achalasia, 1 patient had been previously treated surgically via thoracotomy. The median of the duration of symptoms was 8.5 (range 1-36) months. All patients were diagnosed with type I achalasia according to Chicago classification. Eckardt score decreased significantly 3 months after POEM (7.38±1.68 vs. 0.63±1.06 before and after POEM, respectively, p<0.0001) and sustained unchanged (0.4±0.66) during the median follow-up of 21.5 months (range 1-60 months). IRP also significantly decreased after the intervention (46.5±11.1 mmHg vs. 3.8±5.68 mmHg; before and after POEM, respectively, p=0.0001). Complications occurred in 2 patients. Pleuropneumonia in one patient led to extension of hospital stay and was solved conservatively. Upper GI bleeding occurred in one patient 2 weeks after discharge, was self-limited without any obvious source found. Follow-up endoscopy was performed off PPI therapy and revealed mild esophagitis (LA A) in 2 patients that also reported mild heartburn.

Conclusion

POEM represents an effective therapy for achalasia in paediatric population in mid-term follow-up as it significantly improves symptom and provides effective decrease of the IRP. Although in our case series no severe heartburn or reflux esophagitis occurred, more data with longer follow up are needed to prove either long-term safety with regard to the reflux issue and the need for long term PPI therapy in these patients. Supported by VEGA 1/0060/23.

Introduction

Some patients undergoing Capsule Endoscopy (CE) are at risk of retention and require Patency Capsule (PC). Due to limited CT scan access, most Irish CE units consider a visible PC on abdominal x-ray, 26-28 hours after ingestion as a failed test. Some patients with delayed GI transit may falsely fail their PC. Prokinetincs; Prucalopride and Gastrograffin is widely used in CE units as booster medications but their effect on PC has yet to be established.

Aims & Methods

To evaluate the role of Gastrografin, Prucalopride, and fasting in improving the pass rates of PC
Retrospective, observational comparative study between two PC regimens in Beaumont Hospital, Ireland: Group A (Non-fasting and Prucalopride 2mg ingested with PC alone) vs Group B (Fasting, Prucalopride 2mg and Gastrografin 50mls ingested with PC and 2mg Prucalopride on day of x-ray). Data was collected from electronic records. Student t-test was used to compare pass rates and p<0.05 considered significant.

Results

Demographics: Group A, n= 59, mean age 50.3 (18-82), 47.5% (n=28) males. Group B, n=30, mean age 50.6 (21-85), 53% (n=16) males.
Pass rates: Group A 61% (n=36) vs Group B 92%(n=27), p=0.002.
No PC adverse events and no medication side effects were noted in both groups.

Conclusion

This pilot study shows that Gastrografin, fasting and Prucalopride is a promising regimen with a high pass rates in patients undergoing PC. This strategy is lucarative in centers which has limited access to CT post PC. Fasting then ingesting PC promotes the gastro-ileal reflex increasing GI motility. Prucalopride and Gastrografin both have pro-motility effects. Furthermore, Gastrografin has the advantage of delineating the colonic wall on abdominal x-ray and improving pass rates. Further prospective multi-center studies will be needed to confirm our findings.

Introduction

Transmural defects in the upper gastro-intestinal (GI) tract, e.g. anastomotic leak, Boerhaave syndrome or iatrogenic defects, are associated with severe morbidity. Treatment options include conservative, surgical and endoscopic modalities. Endoscopic vacuum therapy (EVT) has gained a greater role in endoscopic treatment of these defects and is most often applied using endoscopically placed vacuum-sponges. Recently, a vacuum-stent was introduced as a new device to apply EVT, combining the benefits of negative pressure wound therapy and an intraluminal stent, while allowing for oral intake of a soft diet.

Aims & Methods

The aim of this prospective case series was to describe the first experiences with the vacuum-stent for transmural defects in the upper GI tract, between March 2022 and March 2023, in an academic hospital that had experience with EVT using vacuum-sponges since 2018. All patients treated with a vacuum-stent were included. Patients who were already treated with vacuum-sponge and received a vacuum-stent when it became available were also included. All patients signed informed consent for prospective registration of relevant data on treatment and outcomes in a specifically designed database. Outcome measures included successful closure of the defect, adverse events, number of EVT-related endoscopies and treatment duration.

Results

23 patients were included (18 male, median age 65 years). Fourteen patients had anastomotic leakage after esophagectomy, five patients had an iatrogenic perforation and four had Boerhaave syndrome. Twelve patients were treated with vacuum-stent alone and eleven with a combination of vacuum-stent and vacuum-sponge (Table 1), which was mostly due to the later availability of or too little experience with the vacuum-stent. Three Boerhaave patients also underwent surgery for nettoyage of a large mediastinal cavity with decortication of the lung and placement of an intracavitary muscle flap. Successful defect closure was obtained in 91%, requiring a median of 4 (IQR 3-8) EVT-related endoscopies, and median treatment course of 14 (IQR 12-31) days in successful cases. During median 120 (IQR 15-221) days follow-up, four patients developed an anastomotic stricture treated with endoscopic dilation. No other adverse events were observed.

Conclusion

The vacuum-stent combines the benefits of EVT and an intraluminal stent and shows great feasibility and efficacy in treatment of transmural defects in the upper GI tract. More research is necessary, as this device could possibly prevent major (re-)surgery in these patients.

Disclosure

RP is consultant for MicroTech Europe and Medtronic bv., received speaker fee from Pentax and is on the advisory board of EsoCap AG.
MIvBH is consultant for Mylan, Johnson & Johnson, Alesi Surgical, BBraun and Medtronic, and received unrestricted research grants from Stryker. All fees paid to institution.