Introduction

Periampullary diverticulum (PAD) is ordinarily asymptomatic, which is inspected occasionally during gastroscopy and endoscopic retrograde cholangiopancreatography (ERCP). Previous studies demonstrated inconsistent effect of PAD on ERCP procedures and choledocholithiasis recurrence. Thus, this study was aimed to investigate the impact of different types of PAD on the technical success, post-ERCP complications and the safety of different stone extraction methods, as well as the association of PAD with the recurrence of common bile duct stones (CBDS).

Aims & Methods

The ERCP database (March 2019 to March 2021) in West China Hospital of Sichuan University was retrospectively reviewed. Inclusion criteria were: 1) presence of original duodenal papilla; 2) patients with CBDS. However, patients with the following characteristics were excluded: 1) ERCP for other reasons; 2) absence of original papilla; 3) duodenal ampullary mass; 4) anatomical abnormalities caused by surgery; 5) under 18 years old; 6) incomplete clinical data. In this study, PAD is classified into three types based on the location of the duodenal papilla within the diverticulum (type I), the edge of the diverticulum (type II), and the outside of the diverticulum (type III). The successful cannulation, procedures of ERCP and post-ERCP complications were compared between the PAD group and the non-PAD group, as well as among the different types of PAD groups. The patients with successful stone removal were followed up every 6 months until December 2023 to determine whether PAD was associated with the recurrence of CBDS.

Results

A total of 830 CBDS cases with original duodenal papilla were eventually enrolled, including 239 cases with PAD and 591 cases without PAD. The successful cannulation rate in the PAD group was lower than that in the non-PAD group (96.7% vs. 99.2%, P = 0.013). According to the different types of PAD, the successful cannulation rate of type I PAD was lower compared with non-PAD group (76.9% vs. 99.2%, P<0.001). Additionally, PAD was associated with a wider bile duct diameter (1.55 ± 0.58 vs. 1.37 ± 0.50 mm, P<0.001), larger stone size (1.21 ± 0.68 vs. 0.97 ± 0.54 mm, P<0.001) and a higher rate of endoscopic sphincterotomy (EST) combined with endoscopic papillary balloon dilation (EPBD) (29.0% vs. 15.7%, P<0.001) and mechanical lithotripsy (41.6% vs. 26.5%, P<0.001) during the ERCP procedure. But PAD did not affect the incidence of post-ERCP complications. Of note, PAD group had a higher recurrence rate (18.8% vs. 7.3%, P<0.001) and shorter recurrence-free time (39.9 ± 13.3 vs. 42.8 ± 9.8 months, P = 0.005) compared with non-PAD group during follow-up period. Based on multivariate analysis, the presence of PAD (OR = 3.265, 95%CI: 1.854-5.751) was an independent risk factor for the recurrence of CBDS, after adjusting for age, gender and other factors.

Conclusion

PAD, especially type I PAD, decreased successful cannulation rate and increased the complexity of stone extraction of ERCP in CBDS. However, PAD did not affect the incidence of post-ERCP complications in CBDS, nor did it affect the choice of stone removal methods. PAD was an independent risk factor for the recurrence of CBDS.

Introduction

Aims & Methods

Results

Conclusion

References

Introduction

There were conflicting results on the association between Vater ampulla type, success rate, and incidence of pancreatitis after Endoscopic Retrograde Cholangiopancreatography (ERCP). The objective of this investigation was to examine the frequency of pancreatitis characterized by ampulla of Vater type in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP), as well as to assess the rate of success in treating such cases.

Aims & Methods

Between January 2021 to December 2022, a total of 517 ERCP-associated procedures were conducted in Sayyad Shirazi Hospital, Gorgan, Iran. Prior to the procedure as well as at 6-, and 24-hours post-procedure, levels of serum amylase were assessed. Furthermore, the patient underwent an assessment to detect any indications of pancreatitis. Of all 517 individuals underwent ERCP, 69 patients were excluded due to a history of endoscopic sphincterotomy or papillary balloon dilatation in the past or who exhibited hyperamylasemia. Written informed consent was obtained from all included patients.

Results

A total of 448 patients with a mean (SD) age of 59.90 (16.03), and 57.1% being female met the inclusion criteria of the study (Table 1). The incidence of pancreatitis after ERCP in type 1, type 2, and type 3b Vater ampulla was 2.6% (5/191), 3.6% (1/28), and 12.5% (1/8), respectively. Post-ERCP pancreatitis was not observed in type 3a, type 4, and type D Vater ampulla. There was no statistically significant relationship between the type of Vater ampullar and the occurrence of post-ERCP pancreatitis (P-value= 0.259). Moreover, the success rate of the procedure in type 1, type 2, type 3a, type 3b, type 4, and type D Vater ampulla was 90.1, 69.0%, 79.7%, 55.6%, 90.9%, and 88.9%, respectively (P-value < 0.005).The result of the final diagnosis based on the Vater Ampulla type is shown in Table 2.

Conclusion

There was a significant relationship between Vater ampulla type and ERCP success rate, while the Vater ampulla type was not associated with the incidence of post-ERCP pancreatitis.

Introduction

Crohn's disease (CD) is a chronic inflammatory bowel disease, characterized by a progressive course that leads to structural bowel damage (SBD). There is no clear definition of SBD. The Lémann index has been proposed, but it's too complicated to calculate. However, the presence of detectable complications through imaging techniques, such as strictures, fistulas or abscesses is widely accepted to describe SBD. Their presence is strongly associated with the severity of the disease and predicts the risk of hospitalization and surgery. Therefore, reversing structural bowel damage is an emerging medical goal in the time of biological treatments.

Aims & Methods

The main objective of this study was to assess the ability of biological treatments to reverse structural bowel damage monitored by intestinal ultrasound (IUS) and compare the disease course of patients with CD with inflammatory behaviour vs complicated behaviour (stricturing or penetrating -abscesses and fistulas-).
This was a longitudinal observational study, which included patients with CD who started a biological treatment in our center and that were monitored with IUS. Clinical, laboratory and ultrasound variables were collected at the beginning of biological treatment, after 12 weeks and after one year of treatment in order to study the evolution of the disease.
To achieve our objective, we compared the transmural healing (TH) at 12 weeks and one year after starting biological treatment. TH is defined as intestinal parietal thickness ≤3 mm, with no detectable Doppler signals and absence of complications.
As a secondary objective, we compared the need for medical treatment, hospital admission and surgery during the first year of biological treatment

Results

A total of 137 patients with CD were included in this study. Their characteristics and treatments are shown in Table 1.

Conclusion

Patients with SBD showed a significantly lower rate of TH compared to patients with an inflammatory behaviour after 12 weeks of biological treatment. Additionally, the need for corticosteroid therapy, hospital admission, and surgery was significantly higher in patients with a complicated CD. However, after one year, the TH rate showed no differences between groups. This suggests that reversing structural bowel damage is possible but that the treatment of these patients is more complex.

References

1. Wilkens, Rune et al. Relevance of monitoring transmural disease activity in patients with Crohn's disease: current status and future perspectives. TherapAdvGastroenterol. 2021 Apr 16;14:17562848211006672.
2. Paredes, José María et al. Clinical Impact of Sonographic Transmural Healing After Anti-TNF Antibody Treatment in Patients with Crohn's Disease. Dig Dis Sci. 2019 Sep;64(9):2600-2606
3. Muñoz, Fernando et al. Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the use of abdominal ultrasound in inflammatory bowel disease. GastroenterolHepatol. 2021 Feb;44(2):158-174.
4. Calabrese, Emma et al. Ultrasonography Tight Control and Monitoring in Crohn's Disease During Different Biological Therapies: A Multicenter Study. ClinGastroenterolHepatol. 2022 Apr;20(4):e711-e722
5. Fraquelli, Mirella et al. Impact of intestinal ultrasound on the management of patients with inflammatory bowel disease: how to apply scientific evidence to clinical practice. Dig Liver Dis. 2020 Jan;52(1):9-18.
6. Wilkens, Rune et al. Relevance of monitoring transmural disease activity in patients with Crohn's disease: current status and future perspectives. TherapAdvGastroenterol. 2021 Apr 16;14:17562848211006672
7. Roda, Giulia et al. Crohn's disease. Nat Rev Dis Primers. 2020 Apr 2;6(1):22
8. Fiorino, Gionata et al. Impact of therapies on bowel damage in Crohn's disease. United European Gastroenterol J. 2020 May;8(4):410-417

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

Endoscopy is the first-line approach for managing Zenker's Diverticulum (ZD). Various endoscopic techniques, each with its own advantages and limitations, have been described. We have proposed a new technique, which we have named Submucosal Injection-Guided septomyotomy (SING technique).

Aims & Methods

The performance of SING technique was evaluated in a prospective observational cohort of patients with ZD who underwent the procedure at two Italian hospitals: San Raffaele Hospital (Milan, Italy) and San Giovanni Bosco Hospital (Turin, Italy).
SING technique involves a classic septotomy, which consists of a mucosal incision with a Hook-Knife in the middle of the septum and a cricopharyngeal myotomy for all the length of the Zenker's Diverticulum and beyond 10 mm into the esophageal proper muscular layer. The novelty of the technique lies in the submucosal injection during the septomyotomy on both the esophageal and diverticular sides, which helps to better delineate the muscular layer and guide the complete myotomy, without the need for bilateral submucosal tunnelling.
Clinical success (CS) was defined as a Dakkak and Bennet Dysphagia Score (DBDS) of ≤1 and a Kothari-Haber Score (KHS) of <2 at 3 months. Recurrence was defined as an increase in DBDS of >1 after achieving CS or a KHS of ≥2 after CS. Follow-up included clinical evaluations at 3 and 6 months, and then annually. Adverse Events (AEs) are classified according to the AGREE Classification.

Results

42 patients with ZD underwent SING technique between March 2021 and January 2024 (median age 74 [IQR 67-80], 66.7% males, BMI 24.6 [IQR 21-27]). The median diverticula depth was 30mm (IQR 25-45) with a median septum length of 20mm (IQR 14-30). Median KHS at diagnosis was 4 (IQR 4-6), dysphagia for solids (42.9%) was the most common symptom, with a median symptom duration of 12 months (IQR 6-24). While a technical success rate was observed in all cases (42/42, 100%), a clinical success rate was observed in 40/42 patients (95.2%). In the 2/42 (4.8%) cases of clinical failure, endoscopic evaluation revealed the presence of a minimal residual muscular septum successfully treated with septomyotomy. Median procedural time was 34 minutes (IQR 29-60), with a hospital stay of 2 days (IQR 2-2). No AEs were recorded. After a median follow-up of 370 days (IQR 297-747), no cases of symptom recurrence were recorded.

Conclusion

SING technique is a safe and effective technique for the endoscopic treatment of ZD. It improves and enhances the efficacy of traditional endoscopic septotomy and can also be utilized as rescue therapy.

Introduction

Thermal ablative methods (such as argon plasma coagulation (APC) and soft tip snare coagulation (STSC) are commonly used to treat polyp margins.

Aims & Methods

We aim to appraise the current literature and compare clinical outcomes between patients with treated (with APC vs STSC) and non-treated EMR margins.
We searched major databases from inception until November 2023 for RCTs comparing EMR of large non-pedunculated colorectal polyps with and without treated margins. Pooled data was analyzed for the primary outcome of recurrence at first screening colonoscopy, as well as adverse events. Analysis was performed using a random effects model and data was reported using 95% confidence intervals (CI).

Results

A total of five RCTs were found which included 1020 polyps (577 in treatment and 443 in control groups). Three studies included treatment with STSC and three studies used APC as the modality for margin ablation. Of included patients, 53% were female and average age was similar between treatment and control groups (65.9 vs 66.1 years). Overall, 71% of lesions were proximal to the splenic flexure. Mean follow up to first colonoscopy and average polyp size were comparable (6.3 vs 6.2 months; 28.2 mm vs 28.0 mm, respectively). Pooled analysis showed that margin ablation was associated with significantly lower rates of recurrence (OR = 0.267, 95% CI 0.18 - 0.4, P< 0.001) with low heterogeneity between studies (I²=0%, P = 0.47). Pooled analysis showed no significant difference between STSC and APC in terms of recurrence (OR = 0.6, 95% CI 0.27 - 1.7, I²=0%, P=0.3) or adverse events (OR = 0.67, 95% CI 0.3 - 1.6, I² 13%, P = 0.46).

Conclusion

Our study shows that ablation of EMR margins is very effective at preventing recurrence at first surveillance colonoscopy. We found no difference between STSC or APC in terms of polyp recurrence or adverse outcomes.