Clinical Case Summary

Case: A 71-year-old male with history of cutaneous melanoma resected from his lower back eight years ago, chronic back pain on narcotics, and chronic constipation presented with acute on chronic abdominal pain and weight loss. Labs were notable for hyperbilirubinemia and alkaline phosphatase elevations in an obstructive pattern. Computed tomography demonstrated a severely enlarged hydropic gallbladder with heterogeneous intraluminal material concerning for gallbladder carcinoma with additional lesions in the liver, lungs, and right adrenal gland. Magnetic resonance cholangiopancreatography also showed a large, enhancing, solid mass within the gallbladder and many small hepatic lesions highly suspicious for metastatic disease. The patient subsequently underwent percutaneous ultrasound guided core needle biopsy of one of his liver lesions with interventional radiology, however samples were negative for malignancy. Given the continued high suspicion for gallbladder carcinoma, he underwent endoscopic ultrasound guided fine needle core biopsy of the mass and liver lesions. The final pathology was positive for metastatic melanoma. He was referred to oncology and is currently undergoing immunotherapy for his metastatic disease.
Discussion: Cutaneous melanoma is a rare but very aggressive disease, with high morbidity and mortality due to its high tendency to metastasize¹. Gastrointestinal metastasis occurs in only 2-4% of patients with melanoma, most commonly to the small bowel, colon, or stomach². This is a rare case of melanoma with metastasis to the gallbladder diagnosed by endoscopic ultrasound guided fine-needle biopsy years after the initial diagnosis of cutaneous melanoma.

References

References:

1. Patel D, Sohrawardy S, Sedhai YR, Basnyat S, Daxini A, Basu A, Mehta VR, Mohammed A, Lichtenstein S. Metastatic Cutaneous Melanoma of the Gallbladder. Case Rep Gastrointest Med. 2017;2017:8532379

2. Giannini I, Cutrignelli DA, Resta L, Gentile A, Vincenti L. Metastatic melanoma of the gallbladder: report of two cases and a review of the literature. Clin Exp Med. 2016 Aug;16(3):295-300.

Introduction

Pouchoscopy is indicated for pouch assessment and surveillance following ileal pouch-anal anastomosis (IPAA) surgery. Annual surveillance is suggested in cases who are at high risk of neoplasia (i.e. Primary Sclerosing Cholangitis (PSC)/ colonic dysplasia/ neoplasia), and 5 yearly in low risk patients^1,2. Biopsies are recommended. With the pressures on endoscopy services continuing we reviewed endoscopy utilisation in our cohort of pouch patients.

Aims & Methods

We searched via health informatics for all patients who underwent IPAA surgery at our centre the Queen Elizabeth Hospital, Birmingham, United Kingdom, from 2012 to 2022. Via case note review, we reviewed indication, timing, presence of high-risk features and pouchoscopy report

Results

56 patients underwent surgery for formation of new IPAA during this study period. The majority were performed were performed from 2012- 2015 (36 cases, 62%). 6 (10%) were undertaken as a single stage procedure, the remainder were 2 stage and 1 (1.8%) was a conversion from an ileo-rectal anastamosis. Indication for IPAA was medically refractory inflammatory bowel disease (IBD) in 48 (86%) cases, colonic dyslpasia in the context of IBD in 5 (9%), and 3 (5%) had an underlying genetic disorder for malignancy e.g. FAP or HNPCC. 16 patients had high risk features (PSC colitis=5, Dysplasia/neoplasia =11), although 2 were referred elsewhere for surveillance.
148 pouchoscopies were performed on this cohort of patients, with an average of 1 pouchoscopy every 3 years from IPAA date (range: 1 pouchoscopy per 0.4 – 10 years). The majority (113, 76%) of procedures were for pouch symptoms e.g. frequency, pain. Biopsies were taken in 98 (66%). Dye spray surveillance was not performed. No biopsy showed pouch or rectal neoplasia, but 73 (74%) showed pouchitis/cuffitis/inflammation.
Despite high resource utilisation, adherence to surveillance protocols remained poor.

Conclusion

This study shows poor implementation of pouch surveillance guidelines yet high use of endoscopy for pouch assessment often without biopsy. Our findings suggest that surveillance for neoplasia is an overlooked component of the care of patients who have under IPAA surgery. Furthermore, there is uncertainty within guidelines about frequency of surveillance particularly in low risk groups, although these patients do have a recognised risk of neoplasia^2,3.
We recommend that endoscopists take biopsies routinely when assessing pouch such as Type C mucosa in the pouch (mucosa exhibiting permanent persistent atrophy and severe inflammation) has a greater propensity for neoplastic changes. In addition, more data is needed to determine the risk of neoplasia in different subgroups of patients who have undergone IPAA surgery, as well as develop robust guidelines on use of endoscopy in pouch management.

References

1 = Derikx LA, Nissen LH, Oldenburg B, Hoentjen F. Controversies in Pouch Surveillance for Patients with Inflammatory Bowel Disease. J Crohns Colitis. 2016 Jun;10(6):747-51. doi: 10.1093/ecco-jcc/jjw035. Epub 2016 Jan 28. PMID: 26822612.
2 = Lamb CA, Kennedy NA, Raine T, et al British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults Gut 2019;68:s1-s106.
3=Samaan MA, Forsyth K, Segal JP, De Jong D, Vleugels JLA, Elkady S, Kabir M, Campbell S, Kok K, Armstrong DG, Penez L, Arenaza AP, Seward E, Vega R, Mehta S, Rahman F, McCartney S, Bloom S, Patel K, Pollok R, Westcott E, Darakhshan A, Williams A, Koumoutsos I, Ray S, Mawdsley J, Anderson S, Sanderson JD, Dekker E, D'Haens GR, Hart A, Irving PM. Current Practices in Ileal Pouch Surveillance for Patients With Ulcerative Colitis: A Multinational, Retrospective Cohort Study. J Crohns Colitis. 2019 May 27;13(6):735-743. doi: 10.1093/ecco-jcc/jjy225. PMID: 30590513.

Introduction

Bevacizumab is an anti-angiogenic monoclonal antibody targeting vascular endothelial growth factor used to treat advanced colorectal cancer (CRC). Self-expandable metal stents (SEMS) are employed in cases of advanced obstructive CRC but are linked to adverse events like bleeding, stent migration, and bowel perforation. To date, it is unclear whether bevacizumab-based chemotherapy increases the risk of perforation in patients with SEMS. Therefore, we conducted a systematic review and meta-analysis to evaluate the risk of bevacizumab-related perforation in these patients.

Aims & Methods

We conducted a comprehensive literature search from major databases until December 2023. We identified all potential studies that evaluated the risk of colonic perforation in patients with bevacizumab-based chemotherapy after SEMS insertion. We compared the risk of colonic perforation in patients who received bevacizumab-based chemotherapy with patients who received chemotherapy without bevacizumab or best supportive care. We calculated the odds ratio (OR) and 95% confidence interval (CI) using a M-H random-effects model and I-square method.

Results

Twelve studies, including 1,599 patients, met our inclusion criteria and were included in the meta-analysis. Of 1,559 SEMS patients, 320 received bevacizumab-based chemotherapy, and 1,274 received chemotherapy without bevacizumab or best supportive care. A total of 106 perforations have been reported. The risk ratio for colonic perforation in bevacizumab-based chemotherapy was 2.78 (95% CI: 1.21-6.38, p=0.02; I2=57%) when compared to non-bevacizumab-based therapy. In sub-group analysis, bevacizumab-based chemotherapy showed an increased risk of perforation when compared with chemotherapy without bevacizumab (OR, 3.71; 95% CI: 1.43-93.5; p=0.007; I2=0), but no statistically significant difference when compared with SEMS alone (OR, 3.75; 95% CI: 0.64-22.08; p=0.14; I2=62%).

Conclusion

Bevacizumab-based chemotherapy appears to increase the risk of perforation in advanced CRC patients after SEMS compared with non-bevacizumab-based therapy. These results were especially pronounced in chemotherapy without bevacizumab than in SEMS alone.

References

1. van Hooft JE, Veld JV, Arnold D, et al. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2020. Endoscopy 2020;52:389-407.
2. van Halsema EE, van Hooft JE, Small AJ, et al. Perforation in colorectal stenting: a meta-analysis and a search for risk factors. Gastrointest Endosc 2014;79:970-82.
3. Lee JH, Emelogu IE, Kukreja K, et al. Safety and efficacy of metal stents for malignant colonic obstruction in patients treated with bevacizumab. Gastrointest Endosc 2019;90:116-124.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive endoscopic procedure that is crucial for pancreato-biliary diseases and selective cannulation is the most important step. However, even an experienced endoscopist can face cannulation failure in up to 15-30% of cases in the first ERCP when standard methods alone are used.¹ Many studies suggested the various needle knife fistulotomy or papillotomy as an alternative technique in difficult cannulation cases.^2,3 However, needle knife papillotomy (NKP), which is modified technique with needle knife has not been evaluated well.

Aims & Methods

To evaluate the clinical outcomes and adverse events of bile duct cannulation by NKP, we performed a retrospective review on medical records of all ERCP cases in Sheikh Khalfia Specialty Hospital, UAE. For six years, Sphincterotomy (SPT) naïve patients except altered-anatomy cases were enrolled and their procedure times, cannulation success rates, radiation exposures, and adverse events were measured between the procedure time matched two cohort group of SPT only and rescue NKP.

Results

In total 416 ERCP cases, 43 procedure time matched cases were selected among 352 (84.7%) SPT only cohort and 43 cases from 64 rescue NKP cohort. Biliary cannulation was succeeded in all cases (100%) by using SPT cannulation with rescue NKP technique without failure. There was no differences in cumulative radiation doses, cannulation time, and adverse event rates in rescue NKP group compared to SPT only group: Post-ERCP hyperamylasemia/hyperlipasemia (16.5% vs. 34.8%, p=0.080), pancreatitis (3.9% vs. 4.3%, p=0.883), cholangitis (4.7% vs. 4.3%, p=0.695), and no perforation case was noticed in both groups.

Conclusion

The SPT with rescue NKP technique can be used in the difficult biliary cannulation cases during ERCP safely and effectively.

References

(1) Testoni PA , Testoni S , Giussani A .
Difficult biliary cannulation during ERCP: how to facilitate biliary access and minimize the risk of post-ERCP pancreatitis.
Dig Liver Dis 2011;43:596–603
[2] Testoni PA , Mariani A , Aabakken L , Arvanitakis M , Bories E , Costamagna G,et al.
Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.
Endoscopy 2016;4 8:657–6 83 .
[3] Lopes L , Dinis-Ribeiro M , Rolanda C .
Early precut fistulotomy for biliary access: time to change the paradigm of "the later, the better"?
Gastrointest Endosc 2014;80:634–641 .

Introduction

The introduction of biological drugs has led to great expectations and growing optimism in the possibility that this new therapeutic strategy could favourably change the natural history of Inflammatory Bowel Disease (IBD) and in particular that it could lead to a significant reduction in surgery in the short and long term. The evaluation of the incidence of intestinal resection after the introduction of biological therapy is very complex and subject to several potential bias, the most prominent being the shift in IBD management over the last few decades.

Aims & Methods

This study aims to assess the impact of biological versus conventional therapy on surgery-free survival time (from the diagnosis to the first bowel resection) and on the overall risk of surgery in patients with Crohn’s disease (CD) who were never with the surgical option.
This is a retrospective, double-arm study including CD patients treated with either biological or conventional therapy (mesalamine, immunomodulators, antibiotics, or steroids). All CD patients admitted at the GI Unit of the S. Salvatore Hospital (L’Aquila, Italy) and treated with biological therapy since 1998 were included in the biological arm. Data concerning the CD patients receiving a conventional therapy were retrospectively collected from our database. These patients were divided into a pre-1998 and post-1998 group (pre and post biologic era, respectively). Our primary outcome was the evaluation of the surgery-free survival since CD diagnosis to the first bowel resection. Surgery-free time and event incidence rates were calculated and compared among all groups, both in the original population and in the propensity-matched population.

Results

203 CD patients (49 biological, 93 conventional post-1998, 61 conventional pre-1998) were included in the study. Kaplan-Mayer survivorship estimate shows that patients in the biological arm had a longer surgery-free survival compared to those in the conventional arm (p=0.03). However, after propensity matching analysis, no significant difference was found in surgery-free survival (p=0.3). A sub-group analysis showed shorter surgery-free survival in patients on conventional therapy in the pre-biologic era only (p=0.02) while no significative difference was found between the biologic and conventional post-biologic groups (p=0.15).

Conclusion

This study shows that the introduction of biological therapy had only a slight impact on the occurrence of surgery in CD patients over a long observation period. Despite the milder disease, patients in the conventional group in the biologic era had the same surgery-free survival compared to patients in biological therapy. Nevertheless, biological therapy appears to delay the first intestinal resection. However, the cumulative incidence of first intestinal resection between patients who underwent biological or conventional therapy ends up being similar considering a very long period.

Disclosure

None

Clinical Case Summary

Introduction: While endoscopic retrieval of gastric bezoars has been described involving various instruments and adjuncts, there is no consensus about the management of large non-obstructing gastric trichobezoars¹. This case report describes how a novel endoscopic device primarily developed to resect recurrent or scarred gastrointestinal lesions or pancreatic necrosis, was used to safely remove a large gastric trichobezoar after unsuccessful attempts with standard endoscopic adjuncts.
Case report: A 19-year-old female presented to our ED with CT-proven trichobezoar within the gastric lumen, measuring 123 x 51 mm (image 1).
An initial attempt at endoscopic removal was performed under general anaesthesia. Despite the use of multiple standard instruments (hot and cold snares, biopsy forceps, argon plasma coagulation, and endoscopic scissors) the congealed trichobezoar could not be sufficiently fragmented for removal.
A decision was made to repeat the procedure using EndoRotor™ (Interscope Inc, Whitinsville, Massachusetts), an endoscopic ‘morcellator’ device (image 2), which we have used to safely resect large or scarred, recurrent colorectal and duodenal polyps². The device allowed us to make dents in the trichobezoar, which facilitated the use of hot snares for complete fragmentation and retrieval via Roth net. Our novel use of this for trichobezoar removal was assisted by a team from EndoRotor.
Conclusion: We report the use of this new endoscopic technique to remove a large trichobezoar, which would otherwise have had to been removed surgically. Apart from reduced therapeutic morbidity, this approach facilitated a shorter hospital stay and quicker return to normal activity for our patient, compared to surgical intervention.

References

1. Gorter, R. R., Kneepkens, C. M. F., Mattens, E. C. J. L., Aronson, D. C., & Heij, H. A. (2010). Management of trichobezoar: Case report and literature review. In Pediatric Surgery International (Vol. 26, Issue 5, pp. 457–463). https://doi.org/10.1007/s00383-010-2570-0
2. Emmanuel A, Williams S, Gulati S, Ortenzi M, Gunasingam N, Burt M, Ratcliff S, Hayee B, Haji A. Incidence of microscopic residual adenoma after complete wide-field endoscopic resection of large colorectal lesions: evidence for a mechanism of recurrence, Gastrointestinal Endoscopy, (Volume 94, Issue 2, 2021, Pages 368-375). https://doi.org/10.1016/j.gie.2021.02.010.

Introduction

In Crohn’s disease (CD) a symptomatic luminal stricture occurs in up to 20% of patients at the diagnosis and in more than 50% during lifetime (1,2). Endoscopic balloon dilatation (EBD) or surgical procedures are the currently available treatments (3,4). However, a considerable percentage of patients often require further surgery for post-operative CD recurrence (5). A consequent increased burden of short bowel syndrome is warranted. The combination of biological therapy with EBD could potentially reduce this risk.

Aims & Methods

The aim of our study was to evaluate the efficacy of EBD combined with biologic therapy in symptomatic gastrointestinal strictures in CD’s patients. We conducted a retrospective study including consecutive CD patients who underwent EBD for low bowel strictures from December 2015 until November 2022 at our tertiary IBD Center. Clinical strictures recurrence, needs for steroids and for surgery due to CD stenosis relapse were the primary outcomes evaluated during a follow-up period of six and twelve months. Chi-square and univariate statistical analyses were used when appropriate.

Results

A total of 52 patients treated with EBD with an overall number of 55 strictures were included. In the study population, 14 patients (27%) were smoker, the mean age was of 46,8 (18-77) years; the median of disease duration was 9 (0-42) years. Thirty-nine patients (75%) were in active treatment with biologic therapy at the moment of EBD. Twenty-three patients (44%) underwent EBD for anastomotic stricture, 8 (15%) for ileal stricture, 11 (21%) for ileocecal valve stricture, 5 (6%) for anal stricture and 4 (8%) for colic stricture. Three patients (6%) underwent EBD for multifocal bowel stenosis. Twenty-two (42%) patients had increased CRP value, 40 patients (77%) had evidence of moderate or severe endoscopic disease activity and 42 (81%) patients showed ulcerative lesions at stricture site. EBD was performed by 8-10, 12-15 or 15-18 mm dilation balloon. Technical success was reported in 60% of procedures and no adverse events were registered.
After 6 months from EBD, at univariate analysis, active smoke resulted a risk factor for clinical stricture recurrence (OR 10,25; IC 1,350 to 135,4; p value = 0,022) and for subsequent surgery (OR 10,25; IC 1,350 to 135,4; p value = 0,022). Moreover, increased CRP at the time of dilatation resulted a risk factor for need of steroids (OR 14,63; IC 2,69 to 71,50; p value = 0,0006). Concomitant biologic therapy and presence of ulcerative lesions did not show significative correlation with considered outcomes.
After 12 months from EBD, concomitant biologic therapy resulted a protective factor for prevention of surgery (OR 0,061; IC 0,005 to 0,502; p value = 0,0047), while anastomotic strictures were associated with a lower risk of sub-occlusion events than ileal stenosis (OR 0,07; IC 0,005 to 0,651; p value = 0,015). Increased CRP at the time of EBD, ulcerative lesions at the stricture site and active smoke were not significantly correlated with the considered outcome.

Conclusion

Our results suggest that in patients with CD undergoing EBD for bowel CD stricture, concomitant biological therapy reduces the risk of surgery for CD stenosis recurrence. Further prospective and controlled studies are underway to confirm these observations.

References

1. Rieder F Managing Intestinal Fibrosis in Patients With Inflammatory Bowel Disease. Gastroenterology & hepatology. 2018. February; 14(2):120–122
2. Yoo JH, Holubar S, Rieder F. Fibrostenotic strictures in Crohn’s disease. Intest Res. 2020;0.
3. Paine E, Shen B. Endoscopic therapy in inflammatory bowel diseases (with videos). Gastrointest Endosc 2013;78:819–35.
4. Hassan C, Zullo A, De Francesco V, Ierardi E, Giustini M, Pitidis A, Taggi F, Winn S, Morini S. Systematic review:
Endoscopic dilatation in Crohn's disease. Aliment Pharmacol Ther. 2007 Dec;26(11-12):1457-64
5. Olaison G, Smedh K, Sjödahl R. Natural course of Crohn’s disease after ileocolic resection: endoscopically visualised ileal ulcers preceding symptoms. Gut 1992;33:331–5.