Introduction

Patients who have gastroesophageal reflux disease(GERD) on maintenance therapy with acid-secretion inhibition drugs, it is not clear what background factors allow patients to discontinue the drugs.
This study aimed to examine the relationship of the changes in the frequency and severity of gastrointestinal symptoms after discontinuation of acid-secretion inhibitors for erosive GERD (eGERD) with possible patient background factors and to identify factors that influence these changes.

Aims & Methods

This study was a multicenter, open-label, interventional, exploratory study. eGERD patients with mild mucosal injury whose symptoms were under control and who were on maintenance therapy with acid-secretion inhibition drugs were withdrawn from the drug treatment for 4 weeks. We examined the relationship of patient backgrounds (sex, age, body mass index, alcohol consumption, smoking habits), esophageal hiatal hernia, Helicobacter pylori infection, pepsinogen I and II concentrations and I/II ratios, blood gastrin levels before and after drug discontinuation with total score change in Frequency Scale for the Symptoms of GERD (FSSG).

Results

Of the 92 patients whose symptoms could be evaluated before and after withdrawal, 66 patients (71.7% of the total) had an FSSG <8 and did not have a recurrence of symptoms after withdrawal. In addition, background factors that might be associated with recurrence or non-recurrence of patient symptoms were examined, but no associated factors were detected. Maintenance medications prior to discontinuation in the above 92 patients were proton pump inhibitors (PPIs) and vonoprazan (VPZ, a potassium ion-competitive acid blocker); PPIs and VPZ were given incidentally but in approximately equal numbers, so additional patient relationships were examined.

Conclusion

There were no patient factors that are likely to affect the discontinuation of maintenance therapy for eGERD. There was no significant difference in the extent of disease or frequency of recurrence during the discontinuation period, regardless of whether the drug before discontinuation was PPIs or VPZ. Since 70% of patients did not experience recurrence for at least 4 weeks and there were no serious complications even in patients experiencing recurrence, temporary discontinuation of maintenance therapy with ASIDs, especially with PPIs, is acceptable for mild eGERD.

Introduction

If the diameter of the intrahepatic bile duct is much less dilated, bile duct puncture with a 19G needle can be challenging during EUS-guided transhepatic biliary drainage (EUS-THBD). These characteristics can decrease the difficulty of bile duct puncture, but use of a 22G needle is less feasible because of poor visibility, maneuverability, and stiffness of conventional 0.018-inch guidewire. A novel, improved 0.018-inch guidewire and dilation devices have recently become available.

Aims & Methods

We conducted a prospective study to evaluate the technical feasibility and safety of EUS-BD in patients with insufficient bile duct dilatation using a 22G needle and the new 0.018-inch guidewire. A 22G needle is used as the puncture needle for intrahepatic bile ducts of diameter <1.5 mm, and a 19G needle is selected for diameters ³1.5 mm. As the primary endpoint of the study, the technical success rate of EUS-THBD using a 22G needle with the novel 0.018-inch guidewire was evaluated in patients with insufficient dilation of the intrahepatic bile duct.

Results

A total of 63 patients who required EUS-THBD were enrolled (22G needle group, n=30; 19G needle group, n=33). Technical success was obtained in all patients in the 19G needle group. In the 22G needle group, technical failure occurred in two patients due to non-identification of the intrahepatic bile duct on EUS (technical success rate, 93.1%), and puncture of the bile duct itself was not performed in these patients. Mean procedure time was similar between the groups. Adverse events were observed in 10.3% (3/30) of patients in the 22G needle group, and in 24.2% (8/33) in the 19G needle group.

Conclusion

In conclusion, use of a 22G needle with a novel 0.018-inch guidewire was comparable to a 19G needle with 0.025-inch guidewire, even in the case of insufficient intrahepatic bile duct dilatation.

Disclosure

None

Introduction

In the case that tract dilation fails using the initially selected dilation device during EUS-guided hepaticogastrostomy (HGS), it should be re-attempted using another device. However, switching the device has the disadvantages of prolonged procedure time and sudden loss of the correct axis, and it is therefore highly desirable that the initial tract dilation is successful. Recently, a novel drill dilator has recently become available in Japan. However, comparison study between this device and other has been not reported as initial dilation technique. Here we describe the technical feasibility of this device for use during EUS-HGS, and compared with balloon catheter.

Aims & Methods

This retrospective study included patients who underwent EUS-HGS using SEMS between October 2021 and October 2022. Patients who developed bleeding associated with EST were enrolled. Excluded from the study were patients who underwent EUS-HGS using a plastic stent or stent deployment without tract dilation.

Results

A total of 49 patients were enrolled, of whom 19 underwent EUS-HGS using the drill dilator and 30 underwent EUS-HGS using a balloon catheter. EUS-HGS using the drill dilator initially was performed mainly by non-expert hands (n=19), whereas non-expert hands performed few procedures in the balloon catheter group (n=2) (P<0.0001). The initial tract dilation was successful in all patients in the drill dilator group (19/19, 100%) and in 29/30 (97%) in the balloon catheter group (P=0.4214). However, to insert stent delivery system, additional tract dilation was needed in 73.7% (14/19) of the drill dilator group. On the other hand, stent delivery system insertion was successful in all patients of the balloon catheter group.

Conclusion

The novel drill dilator shows promise for initial dilation during EUS-BD. However, balloon dilation technique should be attempted first when deploying a dedicated metal stent using an 8.5Fr stent delivery system.

Introduction

To prevent stent migration during EUS-HGS, intra-scope channel release technique is important, but are unfamiliar to non-expert hands. The self-expandable metal stent (SEMS) is an additional factor to prevent stent migration. However, no comparative studies of laser-cut and braided types during EUS-HGS have been reported.

Aims & Methods

The aim of this study was to compare the distance between the intrahepatic bile duct and stomach wall after EUS-HGS among laser-cut- and braided-type SEMS. To evaluate stent anchoring function, we measured the distance between the hepatic parenchyma and stomach wall before EUS-HGS, one day after EUS-HGS, and 7 days after EUS-HGS.　Also, propensity score matching was performed to create a propensity score for using Laser cut type group and Braided group with a logistic regression model.

Results

A total 144 patients were enrolled in this study. Among them, 24 patients underwent EUS-HGS using a laser-cut-type SEMS, and 118 patients underwent EUS-HGS using a braided-type SEMS. EUS-HGS using the laser-cut-type SEMS was mainly performed by non-expert endoscopists (n=21). However, EUS-HGS using braided-type SEMS was mainly performed by expert endoscopists (n=98), showing a significant difference. The distance after 1 day was significantly shorter with the laser-cut-type group (2.91 ± 1.88 mm) compared with the braided-type group (8.19 ± 6.07 mm). In addition, this distance remained significantly shorter in the laser-cut type group compared with the braided-type group after 7 days.　Although these results were similar after propensity score matching analysis, the distance between hepatic parenchyma and stomach after 7 days was increased 4mm compared with the distance after 1 day in Braided group. On the other hand, in Laser cut type group, the distance after 1 day and 7 days was almost same.

Conclusion

In conclusion, EUS-HGS using a laser-cut-type SEMS may be safe to prevent stent migration, even in non-expert hands, compared with a braided-type SEMS, although a randomized trial is warranted.

Disclosure

None

Introduction

Balloon dilation and plastic stent deployment have been performed as hepaticojejunostomy stricture (HJS) treatment techniques by PTBD or under DB-ERCP guidance. Although these techniques have shown favorable clinical results, the treatment period can be long because stent deployment is required. In addition, HJS may recur even after treatment because the scar tissue itself remains. To overcome these challenges, we developed an transluminal antegrade piecemeal dilation technique (TAPD) for treating HJS. The aim of this study was to evaluate the technical feasibility and safety of this technique in terms of the pre- and post-cholangioscopic findings.

Aims & Methods

This retrospective study included consecutive patients who were complicated with symptomatic HJS between November and February 2022. The primary outcome of this study was the technical success rate of TAPD using a drill dilator. Technical success was defined as resolution of the HJS, based on the cholangioscopic findings. The secondary outcome was adverse events associated with TAPD such as bleeding or perforation.

Results

TAPD was attempted at around 11 days after EUS-HGS in 19 patients. Among the 19 patients, passage of the guidewire across the HJS into the intestine was unsuccessful in 4 patients, and the technical success rate of this procedure was 78.9%. TAPD was successful in all 15 patients in whom passage of the guidewire was achieved. After TAPD, cholangioscopy identified no bleeding or perforation in any patient. During the follow-up period, no recurrence of HJS was observed in any patient who underwent TAPD.

Conclusion

In conclusion, TAPD appears to be technically feasible and safe. Although it is necessary to conduct a randomized trial in comparison with other methods, with long-term follow up, TAPD may be a useful option for the treatment of HJS.

Introduction

The primary treatment goals of gastroesophageal reflux disease (GERD) include resolving symptoms, preventing complications and symptom relapses, and healing erosive oesophagitis.^{1, 2} Heartburn and regurgitation are frequent and typical symptoms of GERD. Vonoprazan, a potassium-competitive acid blocker, is approved in China for the treatment of reflux oesophagitis.^{3, 4} However, there is a paucity of real-world data assessing the relief of typical daily symptoms achieved with vonoprazan in adult Chinese patients.

Aims & Methods

VIEW (NCT04501627) was a multicentre, single-arm, prospective, observational, real-world study conducted in China. Patients received 20 mg vonoprazan, orally, once daily for 4 weeks (8 weeks for insufficient healing). This post hoc subgroup analysis conducted in enrolled patients with GERD assessed changes in symptom scores for all-day or night-time heartburn and/or regurgitation during the first 14 days of treatment. A mixed-effects model for repeated measures assessed statistical differences in symptom scores from baseline for each day; least-squares mean (LSM) and its 95% confidence interval are reported (negative values indicate improvement).

Results

Among the 2214 patients included in the effectiveness analysis population of the GERD group, 86.7% were aged <65 years[A.G.1] and 60.8% were male. The LSM change in symptom scores from baseline demonstrated a significant improvement from day 1 of treatment in all-day heartburn and/or regurgitation, daytime heartburn or regurgitation, and night‑time heartburn or regurgitation (Table). Significant improvement continued to be observed on day 14 and throughout all previous days of treatment.

Conclusion

Vonoprazan provided rapid (from day 1), significant and durable symptom relief in patients with GERD.

Table: Improvement in symptom scores^a from baseline to day 14 of vonoprazan treatment (effectiveness analysis population; MMRM analysis)

References

1. Antunes C, Aleem A and Curtis SA. StatPearls. Treasure Island (FL), 2023.
2. Heidelbaugh JJ, Nostrant TT, Kim C, et al. Am Fam Physician 2003; 68: 1311-1318.
3. Xiao Y, Lu Y, Yang H, et al. Am J Gastroenterol 2023; 118: S345-S345.
4. Oshima T and Miwa H. J Neurogastroenterol Motil 2018; 24: 334-344.

Disclosure

This study was funded by Takeda (China) International Trading Co. Ltd. Yinglian Xiao, Dekui Zhang and Jianyong Chen have no conflicts of interest. Kailun Liang and Li Xie are Takeda employees and hold Takeda stock options. Minhu Chen received speaker honoraria from Takeda China, AstraZeneca China, Xian Janssen and Eisai China.

Introduction

Volatile organic compounds (VOC) in stool samples may reflect functional activity of gut microbiome. Previous studies showed that gut flora may influence transient relaxations of lower esophageal sphincter through short-chain fatty acids production and thus - participate in pathogenesis of gastroesophageal reflux disease (GERD). However, the role of VOC in pathogenesis of GERD is poorly studied yet.

Aims & Methods

The aim of this study (FGMF-2025-0003) was to perform correlation analysis between concentrations of VOC in stool samples and GERD-Q score.
We enrolled willing to participate patients referred to perform multichannel 24-h pH-impedance recording (Ohmega, Laborie). According to the Lyon 2.0 criteria patients were allocated to the GERD or the control group. GERD-Q questionnaire was filled in by the participants on the same day as stool samples were collected. Thermo TSQ 8000 triple quadrupole mass-spectrometer (GC/MS) was used for the measurement of VOCs in stool samples were analyzed with. Correlation analysis (Spearman rank R) was performed between values of 80 VOCs in stool samples and the results of GERD-Q questionnaire.

Results

Data of 76 patients were eligible: 42 with GERD and 34 - of the control group. Participants in the GERD group were older (54.7±12.2 y.o. vs 46±14.9 y.o., P<0.05) and their BMI was greater (30.9±5.2 vs 27.2±6.5 kg/m², P<0.05). GERD-Q score was logically greater in GERD group (11.0±2.5 vs 5.2±1.2, p<0.01). Correlation analysis revealed significant correlations between GERD-Q score and concentrations of 2-methylbutyric acid (Spearman R =-0.31), caproic acid (0.34) and enantiic acid (0.396) in stool samples.

Conclusion

GERD-Q score positively correlates with concentrations of Caproic acid (0.34) and Enantiic acid (0.396) in stool samples and negatively – with 2-Methylbutyric acid. The data of this pilot study may serve as a basis for further research on the role of functional activity of gut microbiome in pathogenesis of GERD.