Introduction

Post-esophageal variceal ligation (EVL) ulcer bleeding poses a significant challenge in clinical practice, with various management modalities employed. However, there is a lack of established guidelines for effective management. This study aims to evaluate the effectiveness and safety of self-expandable metal SX-DANIS-ELLA (DE) stents in controlling post-EVL ulcer bleeding.

Aims & Methods

This retrospective audit focused on cirrhotic patients who underwent SEMS placement for post-EVL ulcer bleed. The study assessed bleeding control rates within 48 hours post-treatment and mortality rates within 6 weeks post-treatment

Results

Among 1025 endoscopic procedures for variceal ligation over 40 months, 1.4% (15 patients) presented with post-EVL ulcer bleed, all managed with DE stents. SEMS successfully controlled bleeding in 100% of cases at 48 hours post-procedure without the need for alternative rescue strategies. Median SEMS placement duration was eight days, with complete ulcer healing observed in 14 patients upon stent removal. However, one patient passed away within 72 hours due to decompensation. Early rebleeding within 6 weeks occurred in two ( 13.3%) patients which was managed with EVL. The 6-week mortality rate was notable at 20%(3 out of 15 patients). Adverse events included superficial esophageal ulcers at upper end of stent mesh in 9 patients out of 15(60%), SEMS dislocations in 3 out of 15 patients (20%) and one very deep esophageal tear with ulcer at the upper end of the stent mesh (6.6%). Two patients also had aspiration pneumonitis post procedure which was managed conservatively

Conclusion

SX-ELLA esophageal stents effectively controlled post-EVL ulcer bleeding. Despite successful bleeding control, the high mortality rate underscores the need for further strategies. SEMS dislocations highlight the complexity of this intervention and the importance of expertise in stent placement. Future research should explore the role of early transplant referral in reducing mortality following SEMS placement and improving patient outcomes

Introduction

Esophageal variceal bleeding (EVB) is a severe complication of liver cirrhosis. An effective prophylactic intervention and treatment option in EVB is endoscopic band ligation (EBL). An average post-banding bleeding (PBB) rate of approximately 3.5% within two weeks post-intervention has been reported¹. This study aims to assess the risk of bleeding after EBL of esophageal varices and to identify patient-specific and procedure-related risk factors for PBB.

Aims & Methods

For risk stratification, a retrospective analysis was conducted on 233 patients who underwent ligation therapy for esophageal varices at a tertiary care centre between January 2019 and February 2023. In total, 616 ligation therapies were analysed with regard to the occurrence of PBB within 21 days post-intervention. Data collected included laboratory parameters, type and severity of underlying liver disease, recent alcohol consumption, anticoagulant use, and procedural details such as the number of bands applied and intra-procedural bleeding. Data was analysed using R and SPSS statistical software.

Results

In our study, PBB occurred in 30 of 616 EBL procedure (4.9%). Importantly, for interventions to treat acute variceal bleedings, the PBB rate was 20.8% (16/77 cases), whereas ligature in patients without acute bleeding had a low PBB rate of only 2.6% (14/539 cases, p<0.001). Additionally, recent alcohol abuse within 28 days prior to the procedure was reported in 50% (15/30) of interventions with PBB, whereas alcohol abuse was observed in only 20.3% (119/586) of non-PBB cases (p < 0.001). Furthermore, impaired liver function assessed by Child-Pugh and MELD scores was associated with an increased risk of PBB (p < 0.001). Conversely, low platelet counts below 50 G/L or even below 30 G/L did not show a significant increase in the occurrence of PBB in our patient cohort, suggesting that EBL can be safely performed in patients with platelet counts < 50 G/L². Additionally, the use of acetyl salicylic acid (ASA) was not associated with a significantly higher incidence of PBB in this cohort.

Conclusion

While the overall risk of PBB following EBL is relatively low, we could identify several risk factors that increased the likelihood of esophageal variceal bleeding following EBL. Relevant risk factors were ligature for acute EVB, impaired liver function, and active alcohol abuse. In contrast, patients with low platelet counts (<50 G/L) or those taking ASA medication did not show an increased risk of PBB in our cohort. These findings allow for a more precise risk stratification for PBB and will be useful to assess which patients require extended in-hospital observation after EBL and who can be safely discharged shortly after the procedure.

References

1. Vanbiervliet G, Giudicelli-Bornard S, Piche T, et al. Predictive factors of bleeding related to post banding ulcer following endoscopic variceal ligation in cirrhotic patients: a case-control study. Aliment Pharmacol Ther. 2010;32(2):225-232
2. Katsumi, T. and Y. Ueno, Prospects for treatment of esophageal varices considering the safety of endoscopic band ligation. Hepatology International, 2023. 17(5): p. 1079-1081

Introduction

Endoscopic submucosal dissection (ESD) is the standard treatment for superficial esophageal cancer. However, esophageal stricture following endoscopic ESD is a common and severe complication, leading to malnutrition, increased financial burden, and reduced quality of life.

Aims & Methods

This study aimed to develop a risk prediction model for stricture after non-circumferential ESD to improve prevention, treatment, and personalized management of post-ESD esophageal stricture. Clinical data were retrospectively collected from patients with suspected early esophageal squamous cell carcinoma undergoing ESD between January 2014 and December 2022 at four tertiary hospitals in Sichuan Province, China.
Cases were divided into non-circumferential and circumferential ESD groups. Non-circumferential ESD cases were split into a development cohort (70%) and a validation cohort (30%). Independent risk factors for stricture were identified using univariate and multivariate logistic regression analyses. A risk scoring model was established and internally validated.
For patients with circumferential lesions, a case-control study was first conducted to validate the efficacy of steroid-based interventions in reducing ​stricture​ rates, followed by subgroup analyses comparing the therapeutic differences between oral administration alone and oral combined with local injection.

Results

Among 2009 enrolled patients, the stricture rate was 12.9% (259/2009). Data from 1854 non-circumferential ESD cases were used for model construction. Independent risk factors included wound circumferential extent, lesion location, intraoperative titanium clip usage, and non-R0 resection. The risk stratification model (score range: 0–8) categorized patients into low- (0–2 points, 1.7% stricture), intermediate- (3–5 points, 25%), and high-risk (6–8 points, 80%) groups. In the validation cohort, the model demonstrated an AUC of 0.864 (95% CI: 0.814–0.914, P<0.001), Hosmer-Lemeshow test (P=0.187), and Brier score of 0.0456, indicating excellent discrimination and calibration (Table 1）.
Among 155 patients undergoing circumferential esophageal ESD, the stricture rate was 72.9% (113/155). The stricture rate was 100% (14/14) in the non-steroid group versus 70.2% (99/141) in the steroid group (P=0.017). Patients receiving steroids required an average of 7.4 ± 8.9 dilation sessions, which was significantly lower than the non-steroid group (P=0.031). Nevertheless, no significant differences were observed between oral steroids alone and combined oral with local injection steroids in preventing strictures (P=0.908) or reducing dilation sessions (P=0.652).
Table 1. Predictive Scoring System for Post-ESD Stricture (Non-Circumferential Lesions）

Conclusion

This multicenter study identified ​​wound circumferential extent, lesion location, titanium clip use, and non-R0 resection​​ as independent risk factors for stricture after non-circumferential ESD. A validated ​​risk stratification model (low/intermediate/high-risk)​​ enables tailored postoperative management. While steroids reduced strictures in circumferential ESD, ​​oral versus combined oral/local injection regimens​​ showed no difference in efficacy or dilation frequency.

References

1. Pimentel-Nunes P, Libânio D, Bastiaansen B A J, et al. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European society of gastrointestinal endoscopy (ESGE) guideline - update 2022[J]. Endoscopy, 2022, 54(6): 591-622.
2. Park C H, Yang D H, Kim J W, et al. Clinical practice guideline for endoscopic resection of early gastrointestinal cancer[J]. Intestinal Research, 2021, 19(2): 127-157.
3. Ishihara R, Arima M, Iizuka T, et al. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer[J]. Digestive Endoscopy, 2020, 32(4): 452-493.
4. Kitagawa Y, Uno T, Oyama T, et al. Esophageal cancer practice guidelines 2017 edited by the japan esophageal society: Part 2[J]. Esophagus, 2019, 16(1): 25-43.

Clinical Case Summary

A 28-year-old patient presented with recurrent episodes of overt gastrointestinal bleeding, requiring multiple blood transfusions over the past two months (5 units of packed red blood cells). Despite undergoing UGI endoscopy and colonoscopy twice at other medical centers, no abnormalities were detected. CT enterography with CT angiography yielded normal results. To further investigate, the patient underwent antegrade and retrograde power spiral enteroscopy, revealing gross active bleeding from a site of hookworm bite in the jejunum. Following the procedure, the patient was discharged with antihelminthic therapy. However, a week later, he experienced abdominal pain, difficulty passing stools, intermittent rectal bleeding again, and low-grade fever. A relook sigmoidoscopy revealed a large hematoma with intraluminal compression in the sigmoid colon. CT scan confirmed a localized sealed-off perforation along with the hematoma. Management included percutaneous aspiration of the hematoma, intravenous antibiotics, and repeat blood transfusion. Anti-helminthic therapy continued, and the patient recovered completely after approximately four weeks which was confirmed by sigmoidoscopy. The mechanism of this sigmoid colon hematoma involves potential mechanical injury by the overtube's spiral tip during insertion or manipulation. Although the localized perforation was sealed off in this case, the preceding bleeding and drop in hemoglobin complicated the initial treatment plan. Considering such technical challenges, the equipment and technology have now been withdrawn globally by the manufacturer. Close monitoring of patient symptoms, and vital signs, and prompt discontinuation of the procedure in case of discomfort or pain are crucial in preventing such complications. As advanced endoscopic techniques become more prevalent, maintaining a cautious approach towards technology and addressing complications promptly is essential for ensuring patient safety and effective care

Introduction

Current guidelines provided information on the management of patients with gastrointestinal bleeding, in particular focusing on admission, endoscopic management and medical treatment during the hospital stay. So far, 11-15% of patients treated for GIB required a new hospitalization for a new bleeding episode.

Aims & Methods

The aim of the study is to verify if the management in a dedicated practice after hospital discharge for gastrointestinal bleeding reduces further bleeding and costs. This is an ambispective cohort single center study, including patients observed between May 2022 and September 2023 in our clinical practice dedicated to gastrointestinal bleeding. We enrolled consecutive patients with overt gastrointestinal bleeding or iron deficiency anemia affected by vascular lesions. The effectiveness was defined as a composite endpoint including iron supplementation, blood transfusion, medical treatment and number of hospital stay. Costs were evaluated starting from Diagnosis Related Groups (DRG) codes. The cost effectiveness analysis and ICER has been calculated using the ICERconf.EXE software (Software Prescriptions, c/o Bob Obenchain, California, USA).

Results

In our institute 602 patients with gastrointestinal bleeding were evaluated between May 2022 and September 2023, of these 79 were included in the study. The mean age was 73.8 years (SD±10,8), 46% were female. The source of bleeding was angiodysplasia in 63% of patients, GAVE in 9% (Gastric Antral Vascular Ectasia), erosions in 9%. After the introduction in the dedicated practice, the re-bleeding decrease from 1.3 episodes to 0.2 episodes, p<0.001. The cost average after the practice was 4074 euro (SD ±5485), the average cost before the practice was 4885 euro (SD ±4567), it has been observed a cost saving after the management in the dedicated practice, C diff= -751 euro. The average effectiveness after practice was 8.7 (SD±1.06) and the average effectiveness before the practice was 7.3 (SD ±1.3) with the E diff= 1.47, p<0.001.

Conclusion

The dedicated practice for patients with gastrointestinal bleeding provides effectiveness in reducing transfusion, iron supplementation and hospitalization with a consistent cost reduction.

Introduction

This study aims to compare the diagnostic efficacy and variables of standardized high definition white light endoscopy with image-enhancement versus non-standardized routine white light endoscopy) in detecting upper gastrointestinal mucosal lesions.

Aims & Methods

A prospective analysis was conducted on 270 patients undergoing Upper Gastrointestinal Endoscopy at Advanced Gastroenterology Institute: AGI the GASTROCITI, Ludhiana located in Punjab region of North India between December 2023 and March 2024. Patients were randomly assigned (135 each) to undergo assessment using standardized versus non standardized format. Endoscopic findings were recorded and later analyzed by experienced gastroenterologists blinded to the endoscopic modality used.

Results

In the standardized group, the mean age was 47 years, with 63 % males and 37 % females. In the nonstandardized group, the mean age was 45 years, with 58 % males and 42 % females. The most common indications for endoscopy in both groups were dyspepsia and heartburn. Due to use of premedication preparation (Surfactant Simethicone + Mucolytic N acetyl-cysteine solution), the mucosal visibility score in the standardized group was significantly better at 76% versus 32% in the nonstandardized group. Also, the time taken to examine the complete mucosa (8 minutes versus 5 minutes) and corresponding Propofol anesthetic requirement dose (140 mg versus 120 mg) along with the lesion detection rate (68% versus 53%) was higher in the standardized group. Among the 135 patients, 43 were normal in the standardized group versus 64 in the nonstandardized group. The diagnostic yield of standardized high-definition white light endoscopy with image enhancement was 68.1% versus 52.5 % in nonstandardized WLE. Specific lesions with higher rates of detection were Grade A Esophagitis, early short segment Barrett’s Esophagus, gastric atrophy, and intestinal metaplasia. The relative risk and odds ratio to find an abnormality while doing a standardized procedure was 1.3 and 1.93 respectively which showed very high statistical significance (p Value 0.009).

Conclusion

Standardized (High Definition White Light Endoscopy with Image-Enhancement) demonstrates superior diagnostic efficacy compared to non standardized routine white light endoscopy in detecting upper gastrointestinal mucosal lesions. Further large-scale studies are warranted to validate these findings and determine the optimal use of standardized (High Definition White Light Endoscopy with Image-Enhancement) in clinical practice.