Introduction

Hemorrhoidal disease (HD) is the most common pathology in proctology, with an estimated prevalence of between 4.4% and 39%. It can be managed in a variety of ways: hygienic-dietary measures, medical, instrumental or surgical treatment. The latter is considered especially after failure of medical and instrumental treatment.

Aims & Methods

Aims : The aim of our study is to report our experience with Milligan and Morgan technique in the management of hemorrhoidal disease.

Materials and methods: This was a monocentric retrospective descriptive-analytical study conducted over a 12-year period: from January 2011 to January 2023. The data studied were age, sex, clinical manifestations, stage of HD on proctological examination and therapeutic data. All patients who underwent Milligan and Morgan hemorrhoidectomy (MMH) and presented with stage IV and III hemorrhoids (after failure of instrumental treatment) were included in our study. Excluded were asymptomatic patients, patients with surgical contraindications and other stages treated by non-surgical means. The statistical study was carried out using IBM-SPSS 20.0 software. The chi-2 test was used to compare categorical variables.

Results

468 patients were enrolled during the study period. The mean age of this population was 41 years (22-71). The sex ratio M/F was 2,1. Clinical expression was dominated by rectal discharge in 246 patients (74%), proctalgia in 132 patients (28%), anal pruritus in 119 patients (25%) and anal oozing in 56 patients (12%). Proctological examination revealed stage IV haemorrhoids in 201 patients (43%) and stage III haemorrhoids in 267 patients (57%). 25 patients (5.3%) had an associated anal fissure. Anemia was present in 341 patients (72.8%), with a mean hemoglobin value of 7.8 g/dl. Transfusion was required in 65 patients (14%) who presented with severe anemia of less than 7g/dl. Colonoscopy was indicated in 87 patients (18.5%) over the age of 45 with rectal bleeding, and in 42 patients (9%) with a history of digestive cancer. Milligan and Morgan's indication was stage III hemorrhoids with severe anemia in 65 patients (14%), after failure of infrared photocoagulation in 194 patients (41.4%); after failure of HAL-RAR treatment n=8 (1.7%) and stage IV hemorrhoids in 201 patients (43%). The procedure performed was a hemorrhoidectomy.An open pedicle MMH type was performed. Patients with an associated anal fissure (5.3%) underwent the Bellan procedure in addition to hemorrhoidectomy. Immediate post-operative complications included post-operative pain in all our patients, urinary retention in 31 patients (6.6%), significant post-operative bleeding in 2 patients (0.5%) treated by electrocoagulation in the OR, and minimal post-operative bleeding in 117 patients (25%) treated by compression bandaging. The latter was reported in 43 patients (36.7%) with stage III hemorrhoids and 74 patients (63.2%) with stage IV hemorrhoids. This difference was statistically significant (p<0.001). Late complications included delayed healing in 9 patients (1.9%), 4 of whom were diabetic, anal stenosis in 5 patients (1%), requiring sphincterotomy combined with anoplasty in 3 patients, and finger dilatation in 2 patients. Anal stenosis was reported in 4 patients who did not undergo postoperative digital rectal examination and 1 patient who did. This difference is statistically significant p=0.03.

Conclusion

MMH remains the gold standard for the treatment of hemorrhoidal disease. The results are satisfactory, especially in the long term. Post-hemorrhoidectomy anal stenosis remains the most serious complication.

Introduction

Gastroparesis (GP) is defined as symptomatic delayed gastric emptying. The most frequent etiologies are diabetes mellitus, after esophageal or gastric surgery and about a third of patients have idiopathic GP. The gastric emptying study by using a scintigraphy scintigraphy (GES) is considered as a principal diagnostic method. Endoscopic pyloromyotomy (G-POEM) is a method improving symptoms in about 60-70% of patients with GP. Its effect on gastric emptying remains controversial.

Aims & Methods

We performed a retrospective single-center analysis to assess the clinical efficicacy of G-POEM based on GES parameters. Between 2016 – 2024, a total of 72 patients with GP (confirmed by scintigraphy) underwent G-POEM and were later invited for clinical as well as scintigraphic assessment after 3, 12 and 36 months. Of these patients, 4 were excluded for missing data, incomplete follow-up data or non-standard testing meal. GES was always performed using the standardized 4 hours protocol with the standard testing meal mixed with 99Tc-DTPA. For this study, all GES were reanalyzed and the following parameters were established : residual activity after 2 hours, residual activity after 4 hours, biological halftimes of ingested activity and proximal-to-distal count ratio for time 0 (PDCR0).

Results

Mean value of GCSI before G-POEM was 3.1 and decreased to 1.6, 1.0 and 0.7 after 3, 12 and 36 months. Median value of GES after 2 hours was 60.2% before G-POEM and 38%, 32.6% and 24.2% after 3, 12 and 36 months. Median value of GES after 4 hours was 21.9% before G-POEM and 7.8%, 6.5% and 3.9% after 3, 12 and 36 months. Correlation index was weakly positive for GCSI and GES after 4 hours only for the first follow-up visit and negative for all remaining visits.
The residual activity after 2 hours and residual activity after 4 hours decreased after G-POEM during all follow-up visits (p<0,001). Mean decrease of residual activity after 4 hours was 12.89%, 15.13% and 6.7% after 3, 12 and 36 months.
Biological halftime also decreased after the procedure with statistically significant results with the mean halftime before G-POEM being 150 min and 86 min, 78.4 min and 65.8 min after 3, 12 and 36 months.
There was a difference between the diabetic and non-diabetic groups, with higher residual activity after 2 hours [median 29.6% before G-POEM, 9.0% after 3 months (p<0.001) and 11.0% after 12 months (p=0.005)] and 4 hours [median 64.8% before G-POEM, 39.4% after 3 months (p<0.001) and 37.7% after 12 months (p=0.012)] respectively in patients with diabetes.
The predictive value of PDCR0 for treatment success after G-POEM was only calculated for the first follow-up visit but was not statistically proved (p=0,712).

Conclusion

In our group of patients there is a weak correlation between the decrease of GCSI and GES early after G-POEM. The decrease in GES parameters tends to be lower in patients with diabetes compared to non-diabetic patients. Based on our data, predicting clinical success of G-POEM using PDCR0 cannot be recommended.

Introduction

Current endoscopic ultrasound technologies (EUS) are suboptimal in the assessment of pancreatic cystic lesions (PCLs). We developed a new through-the-needle brush, the "loop brush", to improve the cellular yield, and thereby sensitivity, of EUS fine needle aspiration (EUS-FNA) of pancreatic cysts.

Aims & Methods

We aim to evaluate the "loop brush" safety, robustness, and efficacy.
We performed an in-vivo randomized controlled trial in pigs using artificial cysts. In one group, the loop brush was deployed through a 22G EUS-FNA needle into the cysts. In the control group, cystic punction was performed with standard EUS-FNA. Loop brushes were visually inspected post-procedure. Cytological assessment, cell counting, and hemoglobin analysis were performed in samples from both groups.

Results

Artificial cysts (n=114) were punctured in six pigs, 57 in each group. Neither adverse events nor significant device malfunction occurred during loop brushing. Samples collected with the brush had non-detectable concentrations of hemoglobin in 72% (41/57) of cases, and 26% (16/57) had less than 0.6 g/dL, with no significant difference to the controls (p=0.32). Brushing cell counts were associated with significantly increased cell counts (11.7× median difference, p<.0001). Cytological smears
were diagnostic in 77% of cases in the brushing group, while 54% in the control group (p=0.01, Fisher’s exact test; p=0.006, Chi-square test).

Conclusion

The new loop brush procedure appears to be safe, causing neither significant bleeding nor device malfunction. Samples obtained with the loop brush were suitable for cytological analysis and showed significantly higher cell yield than controls. Further clinical studies are warranted.

References

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Disclosure

FM, WW, UA, NR, and FBS have patent applications for the brush technology and are co- founders of Lucky LoopMedical AB, a company commercializing technology for improved sampling in EUS-FNA. UA has received a research grant from Boston Scientific and is a consultant to Boston Scientific, Medtronic, and Ambu. IS declares no conflict ofinterest.

Introduction

H. pylori infection has affected approximately 50% of the world’s population with the rates being higher in developing countries than in developed ones. Conventional proton-pump inhibitors (PPIs) have been used as first-line treatment for this condition. However, potassium competitive acid blockers (PCABs) were recently developed which may offer beneficial effects than PPIs.

Aims & Methods

This meta-analysis aims to assess the effectiveness of Potassium competitive acid-blocker against Proton pump inhibitors for the eradication of H. pylori among adults with H. pylori infection.
Electronic search of randomized controlled trials comparing H pylori eradication rate of P-CAB and PPI-based therapy was done. Quality assessment used the Modified Cochrane risk-of-bias tool, and statistical analysis was performed using ReviewManager 5.4.1

Results

Fifteen RCTs with 4129 participants who received H pylori eradication therapy comparing potassium competitive acid blockers (Tegoprazan, Vonoprazan, and YH808) with proton pump inhibitors were analyzed. H. pylori eradication rate of potassium competitive acid blocker-based therapy was higher than that of PPI-based triple therapy RR 1.04, CI 1.10-1.18, P < 0.05. Subgroup analysis showed that PCABs based regimens had significantly higher eradication rates than PPI in treatment naive patients (RR 1.14, 95% CI 1.1-1.18, pP < 0.05 ) and that Vonoprazan based regimen in particular had superior eradication rates compared to PPI based regiments (RR 1.16 95% CI 1.12-1.20 P < 0.05). No significant differences were seen between the Tegoprazan and YH4808 groups compared to the PPI group. Adverse events were also lower in the PCAB group compared to the PPI group.

Conclusion

A significant challenge that is being faced by current PPIs include nocturnal acid reflux despite treatment with twice daily PPI, and additional dosage of H2-receptor blocker at bedtime which deters successful control of gastritis under PPI treatment.Our study shows that potassium competitive acid blockers are effective and have significantly higher eradication rates compared to PPI, with lower incidence of adverse events.

References

Yu, K. et al. (2020). Randomized clinical trial: tegoprazan, a novel potassium competitive acid blocker or lansoprazole in the treatment of gastric ulcer. Aliment PHarmacol Ther. 2020 Sept;52 (5);789-797
Tan, N. et al. (2023). Efficacy and safety of keverprazan compared with lansoprazole win the treatment of duodenal ulcer: a phase III, randomized double blind multicenter trial. Clinical and Translational Gastroenterology. 2023 Jul; 14(7)
Kim, J. et al. (2023). Efficacy of tegoprazan-based bismuth quadruple therapy compared with bismuth quadruple therapy for Helicobacter pylori infection: A randomized, double-blind, active-controlled study. Helicobacter. 2023 June; 28(3)
Zhou, S. et al. (2023). Keverprazan, a novel potassium-competitive acid blocker: Single ascending dose safety, tolerability, pharmacokinetics, pharmacodynamics and food effect in healthy subjects. European Journal of Pharmacetucial Sciences 190(1)2023;2-12
Zhou, B. et al. (2023). Vonoprazan-amoxicillin dual therapy for Helicobacter pylori eradication: A systematic review and meta-analysis of randomized controlled trials. Saudi J Gastroenterol.2023 Nov-Dec; 29(6): 347–357.
Yang, C. et al. (2022). Effectiveness and safety of vonoprazan-based regimen for Helicobacter pylori eradication: A meta-analysis of randomized clinical trials. J Clin Pharm Ther. 2022 Jul;47(7):897-904

Disclosure

authors have no conflict of interest

Introduction

Eosinophilic esophagitis (EoE) is a complex disease that often coexists with different conditions. Given the complexity of this pathology, a multidisciplinary approach, with gastroenterologist, allergist, dietitian, psychologist, and endoscopist may benefit to diagnosis and management of patients, reducing time to diagnosis as well.

Aims & Methods

To evaluate impact of multidisciplinary team in diagnosis and management of eosinophilic esophagitis disease. A retrospective study was conducted to include all patients referred to Fondazione Policlinico Universitario A. Gemelli between September 2016 and April 2023. Prevalence of allergic, nutritional, and psychological disturbs was evaluated. Referral for each patient was reviewed. Diagnostic delay (time interval between first occurrence of EoE symptoms and confirmed diagnosis with endoscopy) was analyzed in patients with suspected eosinophilic esophagitis and diagnosis made in our center, compared to data reported in literature. Publications from 2014 to 2023 were reviewed.

Results

A total of 98 patients, 76 males and 22 females, with a mean age at diagnosis of 25 years, were included in the study. For all patients, each visit was conducted in team with gastroenterologist, allergist, dietitian, and psychologist. 81 patients presented allergic diseases (82 %), 51 patients (52 %) needed nutritional support by a dietitian and 63 patients (64 %) presented psychological implication by the disease to necessitate clinical support. 42 patients (43%) were referred by team members. 13 patients (13%) presented to our center with suspect eosinophilic esophagitis. For these patients, ab initio evaluated with multidisciplinary approach, mean time to diagnosis was 2.25 months. Diagnostic delay reported in literature was 3 years.

Conclusion

Multidisciplinary team is needed to manage patients with eosinophilic esophagitis because its several associated diseases. In fact, most of our patients presented allergic, nutritional, and psychological disturbs. This approach assures more appropriate medical management through shared decision making. Almost half of patients was referred by team members. Thank to awareness of each physician of the team and his early referral, we assisted in a reduction of diagnostic delay in our center compared to data reported in literature.

References

Lenti MV, Savarino E, Mauro A, Penagini R, Racca F, Ghisa M, Laserra G, Merli S, Arsiè E, Longoni V, de Bortoli N, Sostilio A, Marabotto E, Ziola S, Vanoli A, Zingone F, Barberio B, Tolone S, Docimo L, Pellegatta G, Paoletti G, Ribolsi M, Repici A, Klersy C, Di Sabatino A. Diagnostic delay and misdiagnosis in eosinophilic oesophagitis. Dig Liver Dis. 2021 Dec;53(12):1632-1639. doi: 10.1016/j.dld.2021.05.017. Epub 2021 Jun 8. PMID: 34116974
Sauer BG, West A, McGowan EC. Multidisciplinary Eosinophilic Esophagitis Care: A Model for Comprehensive Patient-Centered Care Through Shared Decision Making Between Gastroenterology, Allergy, and Nutrition. Clin Gastroenterol Hepatol. 2021 Nov;19(11):2226-2229. doi: 10.1016/j.cgh.2021.07.025. Epub 2021 Jul 16. PMID: 34280551.
Murray FR, Kreienbuehl AS, Greuter T, Nennstiel S, Safroneeva E, Saner C, Schindler V, Schlag C, Schoepfer AM, Schreiner P, Straumann A, Biedermann L. Diagnostic Delay in Patients With Eosinophilic Esophagitis Has Not Changed Since the First Description 30 Years Ago: Diagnostic Delay in Eosinophilic Esophagitis. Am J Gastroenterol. 2022 Nov 1;117(11):1772-1779. doi: 10.14309/ajg.0000000000001950. Epub 2022 Aug 12. PMID: 35971224.