Clinical Case Summary

Objective: Early hepatic venous outflow obstruction (HVOO) is a rare but serious complication of liver transplantation (LT) mostly related to technical factors such as graft size or malposition, tight anastomosis, or kinking. HVOO is a complex and challenging complication that requires prompt diagnosis and tailored treatment.
Summary of the case: A 58-year-old woman transplanted due to alcoholic liver disease developed hepatic artery thrombosis, which required a liver re-transplant. Intraoperative Dopper ultrasound during the second LT procedure (whole graft from a donor after brain death using piggyback technique) showed decreased IVC flow but improved after the liver was lifted off the IVC. In the ICU, the patient remained hypotensive with elevated lactate and transaminase levels despite volume support and vasopressors, while a Doppler US confirmed a long-distance IVC stenosis caused by the external compression of the graft. A re-laparotomy with later-lateral anastomosis of the donor and recipient IVC was performed, and an additional tissue expander was placed under the right hemiliver to lift it off the IVC. An abdominal CT a week after revealed narrow confluent ischemic areas (VII segment, IVa segment and caudate lobe) of the graft. A follow-up CT three months later, showed significant regression of ischemic areas. After a year of follow-up, the patient's liver function is stable (ALP 160 U/L, AST 20 U/L, ALT 29 U/L, GGT 30 U/L), tissue expander is in a good position and vessels are patent with no new ischemic lesions.
Conclusion: This case underscores the critical role of tailored interventions for HVOO management and the potential of tissue expanders as an adjustable and minimally invasive solution with a long-term effect.

Disclosure

No confict of interest declared for all authors.

Clinical Case Summary

Introduction: Aortoesophageal fistula (AEF) is a rare but fatal cause of upper gastrointestinal bleeding. The disease progression is often rapidly if not promptly recognized.
The most common etiologies include thoracic aortic aneurysm (TAA) and prior aortic surgery. Early diagnosis remain challenge due to nonspecific symptoms. This case series highlights endoscopic features of AEF and the critical role of endoscopists in early detection.
Case present: We report three elderly patients (aged 76–82) who presented to the emergency department with massive hematemesis. One had a history of type B aortic dissection post thoracic endovascular aortic repair (TEVAR) ; the others had no known thoracic disease. None reported mid-thoracic pain. Laboratory data showed hemoglobin 5.1 to 6.2 g/dL without coagulopathy. Esophagogastroscopy (EGD) was performed within 1 hour in two patients, and at 9 hours in the third. EGD showed consistent findings in three cases: a subepithelial bulging mass with central blood clot adherent to the left quadrant (6–9 o’clock) of the mid-esophagus. CT confirmed AEF secondary to ruptured TAA in two patients. Unfortunately, one patient collapsed suddenly in the ED; the others underwent emergent surgery but died within 1 and 21 days postoperatively.(esophagectomy +/- TEVAR).
Discussion: Chiari’s triad (mid-thoracic pain, sentinel bleeding, fatal hematemesis) is classically associated with AEF but was absent in half patients. In our report, EGD can be a most timely and specific modality to early diagnosis of AEF, especially in patients without clear prior aortic disease. The typical endoscopic feature : bulging submucosal mass with central blood adherent clot may serve as a diagnostic clue. And the “hot-zone” of the AEF in EGD was located at left quadrant (six to nine o’clock) of mid esophagus .
Conclusion: Early recognition of typical characteristic and “hot zone” of AEF on EGD may improve timely diagnosis of AEF and guide life-saving interventions.

References

1. Bergqvist D. Arterioenteric fistula. Review of a vascular emergency. Acta Chir Scand 1987;153:81–6.
2. Hollander JE, Quick G. Aortoesophageal fistula: a comprehensive review of the liter- ature. Am J Med 1991;91:279–87.
3. Mortensen A, Hansen NF, Schiodt OM. Fatal aortoesophageal fistula caused by but- ton battery ingestion in a 1-year-old child. Am J Emerg Med 2010;28(984):e5-6.
4. Takeno S, Ishii H, Nanashima A, Nakamura K. Aortoesophageal fistula: review of trends in the last decade. Surg Today. 2020 Dec;50(12):1551-1559.

Introduction

This study aims to assess the impact of antithrombotic therapy on endoscopic findings in patients hospitalized for upper gastrointestinal bleeding.

Aims & Methods

We carried out a prospective, single-center cross-sectional study including 332 patients between June 2020 and February 2025. Patients were classified as antithrombotic (AT) users if they were receiving antiplatelet agents (such as low-dose aspirin or thienopyridines) and/or anticoagulants (including vitamin K antagonists, direct oral anticoagulants, or heparin).

Results

The mean age of the study population was 59 ± 16.7 years, with a marked male predominance (77.1%). Among them, 63 patients (19%) were receiving antithrombotic (AT) therapy—41 on antiplatelet agents and 39 on anticoagulants. Patients in the AT group were significantly older (68 vs. 57 years; p < 0.001) and had a higher burden of comorbidities (75.8% vs. 16.7%; p < 0.001). However, there were no significant differences between the AT and non-AT groups regarding the presence of active bleeding at endoscopy (12.7% vs. 16.8%; p = 0.425) or the need for endoscopic hemostasis (7.9% vs. 16%; p = 0.1).
In multivariate analysis, after adjustment for age, sex, comorbidities, active bleeding, and AT use, only the presence of active bleeding was independently associated with the need for endoscopic hemostasis. Specifically, active bleeding at endoscopy increased the odds of requiring hemostasis by 26-fold (OR: 26, 95% CI: 12.9–62.15; p < 0.001), whereas AT therapy was not an independent predictor (OR: 0.386, 95% CI: 0.105–1.42; p = 0.154).

Conclusion

In older patients receiving antithrombotic therapy and admitted for upper gastrointestinal bleeding, the risk of active bleeding during endoscopy and the need for endoscopic hemostasis do not appear to be increased.

Introduction

Gastrointestinal (GI) endoscopy requires not only technical skills but also strong non-technical abilities like communication, teamwork, and decision-making. Traditional training is often individualized, with little focus on interdisciplinary collaboration. Role Swapping (RS) — where physicians and nurses exchange tasks during simulated procedures — may enhance teamwork and mutual understanding.

Aims & Methods

A prospective pilot study was conducted involving 22 participants (10 endoscopists, 12 nurses) using in-silico colonoscopy simulators. The training included a pre-simulation skills assessment, theoretical onsite classes, randomized role-swapping simulation sessions, and a post-simulation evaluation after two weeks. Technical skills, non-technical skills (assessed via NOTSS and SPLINTS frameworks), and satisfaction were evaluated using validated questionnaires. Wilcoxon tests compared pre- and post-training scores.

Results

RS in simulated GI endoscopy training significantly enhanced both technical and non-technical competencies among participants. Post-training assessments using validated tools showed improvements across all evaluated domains. Situational awareness, decision-making, communication, teamwork, and leadership skills all exhibited statistically significant gains. Participants improved their ability to gather information (p=0.02), understand data (p=0.008), and anticipate future scenarios (p=0.002). Decision-making skills were notably enhanced, with better option consideration (p<0.001), more transparent communication of decisions (p=0.001), and greater adaptability to dynamic conditions (p<0.001). Communication improvements included more effective information exchange (p=0.007), better shared understanding (p=0.035), and increased team coordination (p=0.001). Leadership skills were also significantly strengthened, particularly in setting standards (p=0.002) and supporting teammates (p=0.012). Regarding technical skills, endoscopists reported substantial confidence improvements in tasks traditionally performed by nurses. Significant progress was observed in preparing endoscopic equipment (p=0.016), medication dilution (p=0.016), patient discharge procedures (p=0.014), instrument arrangement during interventional colonoscopies (p=0.026), and setup of patient monitoring systems (p=0.041). Confidence also increased in tasks initially rated as low-confidence, such as proper waste disposal after GI procedures (p=0.01). Nurses, conversely, enhanced their technical capabilities related to GI endoscopy performance. They showed greater proficiency in advancing the colonoscope (p=0.004), reducing loops (p=0.007), navigating angled turns (p=0.007), executing ancillary maneuvers (p=0.038), and conducting thorough mucosal inspections during withdrawal (p=0.036). Improvements were also seen in colonoscope insertion (p=0.026), understanding of colonoscopy quality indicators (p=0.011), and lesion identification (p=0.046). Participant feedback revealed high satisfaction with the RS training experience. Participants appreciated the opportunity to engage in cross-disciplinary tasks, reporting that the simulation increased their mutual respect, role awareness, and confidence in collaborative practices.

Conclusion

Role swapping during simulated GI endoscopy training enhanced both technical and non-technical skills and fostered better collaboration between nurses and physicians. This innovative educational approach shows potential to improve clinical practice quality and patient safety.

References

1. Hedges AR, Johnson HJ, Kobulinsky LR, et al. Effects of Cross-Training on Medical Teams’ Teamwork and Collaboration: Use of Simulation. Pharmacy (Basel) 2019; 7: 13.
2. de Laurentis C, Pirillo D, Di Cristofori A, et al. Boosting teamwork between scrub nurses and neurosurgeons: exploring the value of a role-played hands-on, cadaver-free simulation and systematic review of the literature. Front Surg 2024; 11: 1386887.

Introduction

Colorectal cancer (CRC) is the second most common cancer and the third leading cause of cancer-related deaths in Brazil. High-income countries with organized screening programs have achieved significant reductions in CRC mortality in the last decades through early detection, polypectomy, and improved therapeutic interventions. Meanwhile, several low- and middle-income nations continue to experience rising incidence and persistently high mortality rates. Understanding CRC mortality patterns across different age groups and sexes is essential to guide public health policies and optimize resource allocation for prevention, early detection, and treatment strategies.

Aims & Methods

This study aimed to analyze CRC mortality trends in Brazil from 2012 to 2021. We conducted a descriptive analysis of CRC-related deaths (ICD-10 codes C18, C19, and C20) using data from the Mortality Information System of the Unified Health System (DATASUS). The crude annual mortality rate (deaths per 100,000 inhabitants) was calculated by dividing the number of deaths by the estimated population provided by the Brazilian Institute of Geography and Statistics (IBGE). We also analyzed annual mortality rates by age range and sex and calculated the average annual percent change (AAPC) in mortality rates to assess trends over time.

Results

A total of 175,159 CRC-related deaths were recorded in Brazil between 2012 and 2021, with 86,330 occurring in men and 88,829 in women. Among men, 27.4% of deaths occurred before age 60, 53.8% between ages 60 and 79, and 18.8% at age 80 or older, while among women, these proportions were 27.4%, 47.1%, and 25.5%, respectively. During this period, CRC mortality rates increased in both sexes, rising from 7.06 to 9.73 deaths per 100,000 men and from 7.29 to 9.16 deaths per 100,000 women. Consequently, the male-to-female mortality ratio grew from 0.97 in 2012 to 1.06 in 2021, leading to a slight predominance of male gender at the end of the assessed period. The AAPC in mortality was higher in men than in women across all age groups, except for those aged 40–59 years (Table 1). Among younger individuals, those aged 30–39 years had a low absolute mortality rate (<0.4 deaths per 100,000 inhabitants) but showed the highest AAPC (3.5% per year in men and 2.8% per year in women). Among individuals within the recommended CRC screening age range, the highest AAPC was observed in those aged 60–69 years (2.1% per year in men and 1.7% per year in women).

Conclusion

The concerning rise in CRC mortality in Brazil underscores the need for enhanced public health strategies, including improved access to screening and better healthcare resources. Additionally, the greater increase in mortality rates from early-onset colorectal cancer, particularly between ages 20 and 39, warrants attention, with a focus on identifying high-risk individuals and addressing modifiable risk factors in the population.

Table 1 –Average annual percent change in colorectal cancer mortality rate by sex and age range.

Clinical Case Summary

A 77-year-old male patient complains of abdominal discomfort and moderate anemia. Computed tomography (CT) revealed a space-occupying lesion in the cardia, measuring 71.23mm × 47.59mm. EUS-FNA biopsy confirmed the diagnosis of intermediate-risk gastrointestinal stromal tumor (GIST).
The patient had acute myocardial infarction during hospitalization and received anticoagulant therapy. Due to the large tumor size and the patient’s overall poor health, conventional surgical resection was deemed unsuitable. After a multidisciplinary discussion and informed consent, neoadjuvant imatinib therapy (400 mg/d) was initiated aiming to perform endoscopic resection after tumor shrinkage.
After 5 months of imatinib therapy, follow-up CT showed a significant reduction in tumor size to 39.93mm × 29.26mm. Endoscopic full-thickness resection (EFTR) of the gastric GIST was performed successfully [1]. Postoperative imatinib treatment was continued for 7 months. At the one-year follow-up, Endoscopy showed no recurrence of the GIST, but new lesions were identified adjacent to the scar, and the pathology revealed HGIN. ESD procedure was performed uneventfully and evaluated as eCura A.
Neoadjuvant imatinib therapy for giant GISTs has never been reported in patients undergoing endoscopic treatment [2-4]. This strategy offers a novel option for the treatment of giant GIST.

References

[1] RAJAN E, WONG KEE SONG L M. Endoscopic Full Thickness Resection [J]. Gastroenterology, 2018, 154(7): 1925-37.e2.
[2] KONG S H, KUROKAWA Y, YOOK J H, et al. Long-term outcomes of a phase II study of neoadjuvant imatinib in large gastrointestinal stromal tumors of the stomach [J]. Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association, 2023, 26(5): 775-87.
[3] VAN DER BURG S J C, VAN DE WAL D, ROETS E, et al. Neoadjuvant Imatinib in Locally Advanced Gastrointestinal Stromal Tumors (GISTs) is Effective and Safe: Results from a Prospective Single-Center Study with 108 Patients [J]. Annals of surgical oncology, 2023, 30(13): 8660-8.
[4] RENBERG S, ZHANG Y, KARLSSON F, et al. The role of neoadjuvant imatinib in gastrointestinal stromal tumor patients: 20 years of experience from a tertial referral center [J]. International journal of cancer, 2022, 151(6): 906-13.

Introduction

Biliary obstruction caused by food is a little-known and reported long-term complication of endoscopic sphincterotomy (ES). This retrospective study aimed to characterize patients diagnosed with this condition between 2012 and 2025 and assess the outcomes of surgical therapy.

Aims & Methods

Patients were included when diagnosed with symptomatic duodenal reflux of food (DBR-F) following prior ES and who subsequently underwent hepaticojejunostomy with partial resection or ligation of the common bile duct. DBR-F was diagnosed by pathological examination of material extracted from the common bile duct during episodes of biliary obstruction. Data were assessed retrospectively using the hospital’s electronic patient record system. The long-term outcome and satisfaction with treatment were also evaluated using a questionnaire.

Results

We identified 12 patients (6 male; median age 60.9 years) who had previously undergone cholecystectomy and ES for gallstone disease and thereafter required frequent hospitalization and multiple ERCPs for stone or sludge removal with microscopic proof of DBR-F. All these patients presented with (episodic) abdominal pain; 9 had episodes of cholangitis, in 2 associated with liver abscesses. The median interval between ES and the first ERCP for symptoms of DBR-F was 2.2 years and ranged from 4 months to 22 years. The median interval between the first ERCP for DBR-F related symptoms and diagnosis, i.e. the diagnostic delay, was 3.3 (IQR 2.1-6.6) years. Conservative management, including antibiotics and ursodeoxycholic acid, and endoscopic treatment such as repeat sphincterotomy and biliary stenting were ineffective. The median number of ERCPs for DBR-F related symptoms/complications before surgery was 9.5 (IQR 7.3-10.0). Surgical treatment was associated with several complications, including insufficient ligation of the common bile duct requiring re-operation in 2 cases and stenosis of the hepatico-jejunostomy anastomosis requiring 3 sessions of balloon dilatation in 1 case. The median follow-up after surgery was 8.9 years. At last follow-up 90% of patients were asymptomatic and expressed a high level of satisfaction with surgical treatment.

Conclusion

This single-center series suggests that DBR-F is a long-term and serious complication of ES that must be more prevalent than is currently indicated by anecdotal literature. This diagnosis should be considered when patients present with recurrent ‘stones’ or ‘sludge’ after previous ES. In patients with recurrent symptomatic DBR-F surgical therapy is an effective option.