Clinical Case Summary

Percutaneous endoscopic gastrostomy (PEG) tube has been frequently placed for various indications in order to provide long term enteral nutrition support[i],[ii],[iii]. Approximately 160,000 to 200,000 PEG tubes are placed each year in United States[iv]. Advancements in surgical interventions of gastrointestinal tract has resulted in increased number of anatomically altered stomachs, and so anatomically changed on endoscopic examination as well; which makes endoscopic interventions a little different[v]. Multiple case series have been reported for PEG tube placement in patients with subtotal gastrectomy [vi], however, there is scarce data available for PEG tube placement in patients with history of sleeve gastrectomy. The case that is presented here is regarding 64 years old lady with history of sleeve gastrectomy and now referred for PEG tube placement as she was advised for radiotherapy for squamous cell carcinoma of right buccal mucosa. PEG tube was successfully placed and follow up to a month showed effectively functional PEG tube with no major complications.

References

[i] Powell-Tuck J, Van Someren N. Enterostomy feeding for patients with stroke and bulbar palsy. Journal of the Royal Society of Medicine. 1992 Dec;85(12):717-9.
[ii] Richards DM, Tanikella R, Arora G, Guha S, Dekovich AA. Percutaneous endoscopic gastrostomy in cancer patients: predictors of 30-day complications, 30-day mortality, and overall mortality. Dig Dis Sci. 2013;58:768–776. doi: 10.1007/s10620-012-2397-8.
[iii] Orphanidou C, Biggs K, Johnston ME, Wright JR, Bowman A, Hotte SJ, Esau A, Myers C, Blunt V, Lafleur M, Sheehan B. Prophylactic feeding tubes for patients with locally advanced head-and-neck cancer undergoing combined chemotherapy and radiotherapy—systematic review and recommendations for clinical practice. Current oncology. 2011 Aug;18(4):e191.
[iv] Wei M, Ho E, Hegde P. An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit. J Thorac Dis. 2021 Aug;13(8):5277-5296. doi: 10.21037/jtd-19-3728. PMID: 34527366; PMCID: PMC8411178.
[v] Morrell D, Pauli E, Juza R. Endoscopy in surgically altered anatomy. Annals of Laparoscopic and Endoscopic Surgery. 2019 Apr 24;4.
[vi] Singh P, Kahn D, Greenberg R, Indaram A, Pooran N, Bank S. Feasibility and safety of percutaneous endoscopic gastrostomy in patients with subtotal gastrectomy. Endoscopy. 2003 Apr;35(4):311-4. doi: 10.1055/s-2003-38156. PMID: 12664387.

Introduction

Gallbladder cancer (GBC) has a poor prognosis due to its aggressive nature and limited treatment options. Although early diagnosis through imaging is critical, it remains difficult—particularly in cases of focal gallbladder wall thickening (FGWT), which can mimic benign conditions such as adenomyomatosis or chronic cholecystitis.

Aims & Methods

This study aimed to identify lesions that progressed to GBC (precancerous lesions of GBC; PLGBC) by evaluating prior imaging and to describe their clinical characteristics and outcomes. Patients diagnosed with GBC at Iwata City Hospital between 2014 and 2024 were retrospectively reviewed. Those who had prior imaging—defined as abdominal ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI) performed more than three months before GBC diagnosis—were included for analysis. PLGBC was defined as a lesion identifiable on prior imaging but not diagnosed as GBC, and corresponding to the site of subsequently diagnosed GBC. Imaging features and clinical outcomes were compared between patients with and without PLGBCs.

Results

Among 140 patients diagnosed with GBC, 66 (47%) had prior imaging available for review and were included in the analysis. The median age at GBC diagnosis was 80 years (interquartile range [IQR]: 71–86), with 33 male patients (50%). The median interval between prior imaging and GBC diagnosis was 753 days (IQR: 404–1796). The modalities of prior imaging included CT only in 42 patients, US only in 7, MRI only in 1, US and CT in 6, CT and MRI in 6, US and MRI in 3, and all three modalities in 1 patient.
PLGBCs were identified in 32 patients (48%). Regarding lesion morphology, 28 patients presented with FGWT, 2 patients with diffuse gallbladder wall thickening (DGWT), and 2 patients with gallbladder polyps. Lesion locations were the neck in 5 patients, the body/fundus in 25 patients, and the entire gallbladder in 2 patients. Features such as intramural stones or Rokitansky–Aschoff sinuses (RAS) were observed in 15 patients, and gallstones in 7 patients.
No significant differences were found between patients with and without PLGBCs regarding resectability (36% vs. 35%, P = 1.00), radical resection rates (13% vs. 13%, P = 1.00), or survival from diagnosis (median: 640 vs. 791 days, P = 0.96). Six patients with PLGBC were diagnosed with GBC during observation of gallbladder lesions (median follow-up: 406 days, range: 350–552 days), and all underwent successful radical resection of GBC.

Conclusion

PLGBCs were identified in approximately half of the patients who had undergone imaging before their GBC diagnosis, with FGWT being the predominant imaging feature. Recognizing PLGBCs and ensuring appropriate follow-up may enable timely surgical intervention, offering a potential opportunity to improve outcomes in patients with GBC.

Introduction

The post endoscopic retrograde cholangiography induced pancreatitis (PEP) rate among high-risk cohort can reach up to 15%. Precut papillotomy and fistulotomy have been found beneficial in reducing the risk of PEP in usual risk patients for PEP. However, a head-to-head comparison of these 2 techniques as primary modalities of cannulation without attempting standard approach among patients with high risk for PEP is lacking

Aims & Methods

We conducted a randomized controlled trial at a tertiary referral teaching hospital of national importance in North India. Patients undergoing endoscopic retrograde cholangiography (ERC) for various indications were screened and those with a naïve papilla and having high risk features for PEP as per the ESGE guidelines (1 definite or 2 likely risk factors were considered as high risk for PEP) were enrolled. The exclusion criteria were-1- previously sphincterotomised papilla, 2-small flat type of papilla, 3-severe coagulopathy (INR>1.5 and/or platelet count <1 lac/dl), 4-suspected ampullary growth, 5- recent history of pancreatitis/case of chronic pancreatitis, 6-periampullary diverticulum except type III, 7-age <18 or>80 years and 8-not giving informed consent. Patients were randomized in a 1:1 ratio in group A- primary precut papillotomy or group B- primary precut fistulotomy groups. In both the groups cannulation was attempted with the precut technique without giving any trial of standard cannulation. A four hour amylase was sent for all the patients and they were observed for 6 hours after the ERC and discharged if asymptomatic. All the patients were asked to follow up after 48 hours in the out patient department for any missed or delayed presentation of post ERC adverse events. The primary outcome was to compare the PEP rate between the 2 groups. The secondary outcomes were to compare the success rate of biliary cannulation, adverse event rate, cannulation and total procedure time.

Results

Between February 2021 and June 2024 1259 patients undergoing ERC for various indications were screened. After exclusion, 324 patients (162 in each group) were randomized into primary precut papillotomy (group A) or primary precut fistulotomy (group B) groups. The mean age, gender, indications, type of papilla, 4-hour amylase and number of risk factors for PEP among other demographic characteristics were comparable between the 2 groups. The primary outcome (PEP rate) was comparable between the 2 groups (group A-4 versus group B-5, p value- 1.000). All the 9 patients (2.7%) had mild PEP and were managed conservatively. The success rate of biliary cannulation both primary and overall were comparable between the 2 groups. The cannulation (5.4 vs 6.8 min) and total procedure time (22.9 vs 23.4 min) were also comparable between the groups. One patient each in both the groups developed bleeding leading to abandoning of the procedure. None of the patients developed perforation.

Conclusion

Primary precut techniques (papillotomy and fistulotomy) have comparable efficacy and safety and reduce the risk of PEP among high-risk cohort for PEP undergoing ERC and can be used as upfront modalities of cannulation without attempting standard method in situation where we anticipate difficulty and patient has high risk features of PEP.