Introduction

Esophageal strictures are major secondary complications of ingesting caustic agents. Standard management techniques are often unsuccessful.

Aims & Methods

The aim of our study is to show that endoscopic radial incision (ERI) is more effective than Savary-Gilliard’s bougie dilatation (SGBD) in properly selected cases. Twenty-eight patients (10 males, 18 females, and a mean age 41.36±16.5) with post-caustic esophageal strictures were included in the study and randomly assigned to two equal groups, where 14 were treated with SGBD and the other 14 with ERI. We have defined and compared total procedure time, complications during and after procedures, as well as the necessity to repeat the technique.

Results

In short segment strictures (≤1cm in length), the requirement for repeating the procedure was 10 in SGBD vs. 3 in ERI (p > 0.006). Regarding the duration of the procedure, no statistically significant difference was observed (p = 0.167). In terms of complication rates, in SGBD, one complication occurred, while there was none in the ERI group (p > 0.5). In long segment strictures (≥1 cm in length), the duration, complication rate, and necessity to repeat the procedure were the same in both the SGBD and ERI groups (p > 0.1).

Conclusion

Overall, in short segment strictures, ERI was more effective in terms of the demand to repeat the procedure. However, there was no difference in duration or complication rate. In long segment strictures, the results were the same.

Introduction

The Tokyo Guideline 2018 recommends laparoscopic cholecystectomy as the gold standard therapy for acute cholecystitis regardless of the severity and the onset of symptoms, as long as the patient is fit for surgery. Approximately 20% of the patients undergo acute cholecystectomy in our region, and in the remainder of the patients, we have to take into consideration the likelihood of recurrent inflammation after the regression with conservative therapy. According to the TG 2018, the drainage of the gallbladder is recommended in grade II and grade III cholecystitis. This can be carried out by interventional radiologist as percutaneous transhepatic gallbladder drainage (PTGBD), by endoscopist as transpapillary gallbladder drainage (TPGBD) or endosonography-guided gallbladder drainage (EUS-GBD).

Aims & Methods

The primary endpoint of our prospective, non-randomized, observational study was to determine the technical (successful stent implantation into the gallbladder) and clinical success (repeated need for drainage and absence of recurrent cholecystitis) of TPGBD in those patients that underwent it from 01.01.2023 at the University of Szeged. Our secondary endpoint was the comparison of the time of hospitalization between the patients who underwent clinically successful TPGBD and those who underwent PTGBD for grade II/III cholecystitis.

Results

Altogether 19 patients had undergone TPGBD, 74% of them were female, the average age was 64,53. Previously 21% had cholecystitis, 47% had cholecystolithiasis, while 16% had choledocholithiasis and 11% of the patients gone under PTGBD. TPGBD was carried out because of grade II cholecystitis in 89% of the patients, and grade III in the rest of them. 63% was considered at least a 3 in the ASA physical status classification. Altogether the technical success rate was 58%, a cholangioscop was used in 37% of the cases. The successful canulation rate of the bile duct was 89%, while the canulation rate of the cystic duct was 68%. There were two cases, where after the canulation of the cystic duct the implantation of the plastic stent was not possible. 3 patients were referred for PTGBD after an unsuccessful TPGBD, the remainder patients with an unsuccessful TPGBD received conservative therapy. After a technically successful TPGBD, only one patient went under PTGBD due to his severe comorbidities, rather than a repeated TPGBD. 6 patients underwent cholecystectomy averagely in 8,5 weeks after the TPGBD, the remainder of patients did not have neither the need for repeated drainage nor any symptoms requiring urgent care due to cholelithiasis. Comparing this group with 11, randomly chosen patients who underwent PTGBD for at least grade II cholecystitis during the period of the study, we detected that the time of hospitalization after the drainage was less (8,2 days vs 13,3 days), and less patients required repeated drainage or had recurrent cholecystitis (1 vs 4).

Conclusion

Although TPGBD imposed a great challenge before the use of cholangioscop in everyday practice, nowadays it is becoming an accepted part of the therapeutic algorithm in the treatment of cholecystitis, where an acute cholecystectomy is not performed. Our results suggest that TPGBD can lead to shortened hospitalization and have less complications than TPGBD. Our findings will serve as a basis for a future extension of the study and for the design of a randomised prospective study with a control group.

Introduction

Endoscopic Vacuum Therapy (EVT) and Fully Covered Metal Stents (FC-SEMS) are standard treatments for anastomotic leaks (AL) following upper gastrointestinal (UGI) surgery^1-3. Recently, a new hybrid device combining an FC-SEMS with a polyurethane EVT sponge (VACStent) has been introduced, showing promising results⁴. However, there is not comparative data between VACStent and traditional endoscopic methods for ALs.

Aims & Methods

In this retrospective study, all patients with AL after UGI oncologic surgery who underwent EVT or VACStent at a tertiary academic center from March 2015 to September 2024 were included. The two endoscopic techniques were compared. The primary outcome was clinical success (CS), with secondary outcomes including number of devices used, treatment duration, and adverse events (AEs).

Results

Over 114 months, 103 patients [92 EVT, 11 VACStent] were enrolled. Of these, 74.8% had AL following Ivor-Lewis esophagectomy. The two cohorts did not differ significantly in terms of comorbidities, neoadjuvant treatment, leak number/median size, or rates of redo-surgery before endoscopic management. Both EVT and VACStent were used as first-line treatments in a similar rate of patients (79.3% vs. 90.9%, p=0.36).
The EVT group had a higher CS rate than the VACStent group, though this difference was not statistically significant (72.8% vs. 54.5%, p=0.21). Compared to the EVT group, the VACStent group required significantly fewer endoscopic sessions (1±0.7 vs. 3±2.5, p<0.001) and had a shorter mean treatment duration (12.1±11.2 vs. 14.1±12.9 days, p=0.62). Additionally, a significantly lower proportion of patients in the VACStent group required admission to the intensive care unit (ICU) (27.3% vs. 84.4%, p<0.001). In the EVT group, three adverse events were recorded (one bleeding episode and two sponge dislodgments), while no AEs were reported in the VACStent group (p=0.54) (Table 1).

Table 1 EVT vs ​VACStent: Outcomes

Conclusion

In this retrospective study, EVT and VACStent showed comparable success in treating post-UGI surgery leaks. VACStent was associated with a reduced need for ICU admission and fewer endoscopic sessions. Larger comparative data are warranted to define the role of VACStent in the treatment of leaks after UGI surgery.

References

1. Mandarino FV, Barchi A, Leone L, et al. Endoscopic vacuum therapy versus self-expandable metal stent for treatment of anastomotic leaks < 30 mm following oncologic Ivor-Lewis esophagectomy: a matched case-control study. Surg Endosc. 2023;37(9):7039-7050. doi:10.1007/s00464-023-10213-8
2. Mandarino FV, Barchi A, D'Amico F, et al. Endoscopic Vacuum Therapy (EVT) versus Self-Expandable Metal Stent (SEMS) for Anastomotic Leaks after Upper Gastrointestinal Surgery: Systematic Review and Meta-Analysis. Life (Basel). 2023;13(2):287. Published 2023 Jan 19. doi:10.3390/life13020287
3. Mandarino FV, Barchi A, Fanti L, et al. Endoscopic vacuum therapy for post-esophagectomy anastomotic dehiscence as rescue treatment: a single center case series. Esophagus. 2022;19(3):417-425. doi:10.1007/s10388-022-00912-x
4. Dell'Anna G, Fanti L, Fanizza J, et al. VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New "Kid on the Block" Who Marries the Best of Old Techniques-A Review. J Clin Med. 2024;13(13):3805. Published 2024 Jun 28. doi:10.3390/jcm13133805

Introduction

Upper gastrointestinal bleeding (UGIB) is the most common diagnostic and therapeutic emergency in hepato-gastroenterology, potentially life-threatening and requiring multidisciplinary management.
Anti-thrombotic (AT) drugs commonly prescribed for cardiovascular diseases are considered a recognised risk factor for UGIB. However, few studies have evaluated their effect on endoscopic outcomes in patients admitted for UGIB, and have concluded that the results remain controversial.

Aims & Methods

Aims: Evaluate the effect of AT use on endoscopic outcomes in patients admitted for UGIB.
Methods: This is a prospective monocentric cross-sectional study of 332 patients conducted between June 2020 and August 2021.We considered as users of AT drugs all patients on antiplatelet agents (low-dose aspirin, thienopyrimidines) and/or anticoagulants (vitamin K antagonists, direct-acting anticoagulants, heparin).

Results

The average age was 59+/−16.7 years. Our series was characterised by a clear male predominance of 77.1%.63 patients (19%) were taking AT drugs (41 antiplatelet, 39 anticoagulant).The two groups differed in age (68 vs 57; p<0.001), comorbidities (75.8% vs 16.7%; p<0.001), however there was no statistically significant difference in active bleeding at endoscopy (12.7%vs 16.8%; p=0.425), and the need for endoscopic haemostasis (7.9%vs 16%; p=0.1).In multivariate analysis and adjusting for age, sex, comorbidities, presence of active bleeding and use of antithrombotics, only the presence of active bleeding could predict the need for endoscopic haemostasis. Indeed, the presence of active bleeding at the time of endoscopy multiplies by 26 the risk of recourse to endoscopic haemostasis (OR: 26, CI: 12.9–62.15, p<0.001), whereas the use of AT drugs does not influence the need for endoscopic haemostasis (OR: 0.386, CI: 0.105- 1.42, p=0.154)

Conclusion

Older patients using AT admitted for UGIB do not appear to have an increased risk of active bleeding at endoscopy or needing endoscopic haemostasis.