Introduction

It is unclear whether the insertion of an axis-orienting double-pigtail plastic stent (DPS) through biliary lumen-apposing metal stents (LAMS) in EUS-guided choledochoduodenostomy (CDS) improves the stent patency.

Aims & Methods

The aim is to determine whether this technical variant offers a clinical benefit in EUS-guided biliary drainage (CDS-type) for the management of distal malignant biliary obstruction. This is a multicentre, open-label, randomised controlled trial with two parallel groups. The primary endpoint was the rate of recurrent biliary obstruction (RBO), as a stent dysfunction parameter, detected during follow-up. Secondary endpoints: technical and clinical success (reduction in bilirubin >50% within 14days), adverse events, and others.

Results

Between November-2020 and October-2022, 123 patients (pancreatic cancer 85%, palliative status 80%) were screened and 84 with malignant biliary obstruction, and underwent EUS-CDS (rescue after failed ERCP, 62%), were randomised: 44 patients in LAMS group and 40 in LAMS-DPS group. The rate of RBO (29.5 vs 10%; OR 0.26 [IC95% 0.07–0.83],p=0.04) was lower, but with a longer procedure time (30 vs 20-min, p=0.02), in LAMS-DPS-group. Furthermore, less biliary reinterventions (12.5 vs 20.5%, p=0.38), longer time-to-RBO (155.5 vs 51.5 days, p=0.10), and shorter hospital stay (6 vs. 8.5,p=0.06) were encountered in LAMS-DPS group. No differences were found between technical (97 vs. 88%), clinical success (92 vs. 88.8%) and AEs (22.5 vs.11.4%). NCT04595058 ClinicalTrials.gov

Table1: Outcomes (RBO, recurrent biliary obstruction; BRI, biliary reinterventions).

Conclusion

This trial confirms that CDS with LAMS is an effective technique. The technical strategy of placing a pigtail within the LAMS is associated with a lower risk of RBO, and a non-significant trend of shorter hospital stay.

References

1-Garcia-Sumalla, A., Loras, C., Sanchiz, V. et al. Multicenter study of lumen-apposing metal stents with or without pigtail in endoscopic ultrasound-guided biliary drainage for malignant obstruction—BAMPI TRIAL: an open-label, randomized controlled trial protocol. Trials 2022; 23:181
2-Gornals JB, Consiglieri CF, Bergamino MA. Double pigtail for preventing ascending cholangitis after endoscopic ultrasonography-guided choledochoduodenostomy with lumen-apposing metal stent. Dig Endosc. 2016;28:100.
3-Garcia-Sumalla A, Loras C, Guarner-Argente C, et al. Is a coaxial plastic stent within a lumen-apposing metal stent useful for the management of distal malignant biliary obstruction? Surg Endosc. 2021;35:4873 –81

Disclosure

- A Garcia-Sumalla is a PhD student at the Faculty of Medicine and Health Sciences, University of Barcelona, and this paper is part of his doctoral project.
- Joan B Gornals acts as a PhD Director; is a consultant for Boston Scientific and has received a research grant from this company.
- Manuel Pérez-Miranda is a consultant and speaker for Medtronic, Olympus, Taewoong, and M.I.Tech.
- Enrique Vazquez-Sequeiros is a consultant for Boston Scientific.
Jose Ramon Aparicio is a consultant for Boston Scientific

Introduction

The success rate of endoscopic retrograde cholangiopancreatography (ERCP) is suboptimal in patients with complex surgically altered anatomy (e.g. Roux-en-Y anastomosis, pancreaticoduodenectomy) due to difficulty in advancement of scope to the target site and selective biliopancreatic duct cannulation. Although balloon-assisted enteroscopy can achieve a higher rate of intubation, its clinical application is limited by its small working channel and few compatible accessories.

Aims & Methods

We aimed to explore the feasibility and effectiveness of a novel endoscopic approach in patients with complex surgically altered anatomy.
This is a retrospective study of patients who underwent ERCP with complex surgically altered anatomy at our center with an annual ERCP volume of approximately 3000, between January 2018 and November 2022. The endoscopic procedures were performed by three senior endoscopists who had ERCP experience for at least 5 years. Long colonoscopy (measuring 168cm)-assisted ERCP was adopted as a first-line intervention, and selective biliopancreatic duct cannulation was performed after the target site (native papilla or the surgical anastomosis) was reached. For patients with failed cannulation, a plastic guide tube measuring 250 cm was inserted via the working channel of the colonoscope and its distal end was placed near the target site. The colonoscope was then withdrawn while the guide tube was left in-situ. By following the guide tube, a conventional side-viewing duodenoscope was cautiously advanced to the target site and biliopancreatic duct cannulation re-attempted.

Results

A total of 58 patients were recruited (mean age:56.7 years [standard deviation [SD]:14.4; male:36 [62.1%]]. The reconstruction methods were as follows – Roux-en-Y hepaticojejunostomy:32 (55.2%), Billroth-II gastrectomy with Braun anastomosis:11 (19.0%), pancreaticoduodenectomy:10 (17.2%) and Roux-en Y gastrectomy:5 (8.6%). Common bile duct stone was the most common indication for ERCP (n=30; 51.7%), followed by bilioenteric anastomotic stenosis (n=15; 25.9%), pancreaticojejunal anastomotic stenosis (n=7; 12.1%) and chronic pancreatitis (n=6; 10.3%). 55 (94.8%) of 58 had successful intubation by long colonoscope with a mean procedure time of 57.7minutes (SD:23.4). The mean time to reach target site was 19.1minutes (SD:9.0). The target site could not be identified in two patients and intestinal perforation occurred during endoscopic intubation in one patient. Among those with successful endoscopic intubation, biliopancreatic duct cannulation was achieved in 35 (63.6%) patients. For the remaining 20 patients with initial failure of biliopancreatic duct cannulation, intubation rate by duodenoscope was 100% by tracing the guide tube to target site. The success rate of biliopancreatic duct cannulation by duodenoscope was 85% (17/20) with a mean procedure time of 83.5 minutes (SD:21.1). The mean time to reach target site was 17.0minutes (SD:6.1). Notably, 90% (18/20) had either native papilla or pancreaticojejunostomy, in which selective biliopancreatic duct cannulation is known to be technically difficult with any type of forward-viewing scope due to unfavorable cannulation trajectory. For those with failed cannulation, two had anatomical stricture and one had impacted pancreatic stone.

Conclusion

ERCP by conventional duodenoscope with colonoscopy-assisted pre-placement of guide tube is a feasible, effective and safe alternative for patients with complex surgically altered anatomy in experienced endoscopists.

Introduction

Sexual health is a major determining factor in the quality of life and psycho-emotional development of every individual, and may be affected by chronic diseases as inflammatory bowel disease (IBD). The aim of this study is to measure the impact of the disease on patient’s sexual desire.

Aims & Methods

Cross-sectional descriptive study in which 107 patients over 18 years old anonymously undertook the Sexual Desire Inventory (SDI) survey validated in Spanish between the months of March and April 2022. The SDI consists in a questionnaire composed by 13 items that evaluate both dyadic (items 1-9) and solitary (items 10-13) sexual desire, measured from 1 to 8 with a total score of 101. Specifically, items 9 and 13 asked about patient’s sexual desire compared to their peers. Furthermore, they were also asked if they believed their disease affected their sexual desire and to what extent. Sociodemographic data and general information about their disease were collected as well.

Results

107 questionnaires were analyzed. Mean age was 47.21 years (± 13.54), 57.01% male. 39.01% of patients suffered from ulcerative colitis (UC), 59.81% from Crohn´s disease (CD). The average total score in the SDI of 52.99 out of 101 points. There is not a validated threshold to catalogue a reply as normal, considering that the higher the score, the greater the desire. When compared patients with UC and CD, their responses did not show statistically significant differences. Other variables that could have an impact on sexual desire as perianal disease or previous surgery were analyzed, again not showing differences with the overall average. When divided between dyadic and solitary sexual desire, results were constantly higher on dyadic answers (mean 4.6 vs 3.9), with statistically significant difference (p=0.03). However, when compared questions 1 to 8 (regarding dyadic sexual desire) with question 9 (compared to their peers), and questions 10 to 12 (regarding solitary sexual desire) with question 13 (compared to their peers), it did not showed differences. When asked whether they believed their disease affected their sexual desire, 41.12% (44) replied affirmatively, being women 24 of them. From those 44 patients, the average score on the degree to which their desire is affected of 5.43 out of 8, without differences between UC and CU. 38% of the 31 patients with perianal disease agreed with the affirmation as well, with a score of 6.16 out of 8. Patients who answered yes to this question tended to have lower score on the SDI, being statistically significant when compared to the answers on question 13 (p=0.05).

Conclusion

Sexual health is a complex issue which involves a great number of variables. Most statistically significative differences were seen regarding individual sexual desire, being impaired with respect to dyadic desire. There is a remarkable number of patients who felt their disease impaired their sexual desire, seeing a higher proportion between women. Moreover, for the ones affected, it was to a large extent. It is an issue that needs further studies, especially because its impact on quality of life and the lack of quality evidence in this area.

References

1. Ortega V, Zubeidat I, Sierra JC. Further examination of measurement properties of Spanish version of the Sexual Desire Inventory with undergraduates and adolescent students. Psychol Rep. 2006 Aug;99(1):147-65. doi: 10.2466/pr0.99.1.147-165. PMID: 17037461.
2. Spector IP, Carey MP, Steinberg L. The sexual desire inventory: development, factor structure, and evidence of reliability. J Sex Marital Ther. 1996 Fall;22(3):175-90. doi: 10.1080/00926239608414655. PMID: 8880651

Introduction

Esophageal food bolus obstruction (FBO) is a common presentation to Emergency Departments worldwide¹. There remains a paucity of data relating to efficacy of pre-endoscopic and endoscopic management resulting in a wide variety of clinical practice. Consensus guidelines do not advocate strongly for pre-endoscopic medications however they remain commonly used^2,3. This study evaluated the safety and efficacy of pre-endoscopic and endoscopic treatment in successful clearance of FBO and assessed the prevalence of underlying esophageal pathology.

Aims & Methods

ICD-10 codes retrospectively identified adult patients ≥18 years admitted to the Monash Health network (Melbourne, Australia) with esophageal FBO from 2010 to 2021. Medical records were reviewed to determine baseline characteristics, medical and endoscopic treatments and outcomes. Pre-endoscopic therapies included glucagon, glyceryl trinitrate (GTN), buscopan and Coca Cola. Multivariable analysis was performed to determine factors associated with pre-endoscopic clearance of FBO.

Results

608 patients were included. The median age was 56 years (IQR 39 – 71) and 405 (66.6%) were male. A prior history of FBO was noted in 228 (37.5%) patients, 110 (18.1%) had gastro-oesophageal reflux disease, 71 (11.7%) had dysphagia and 51 (8.4%) had a history of esophageal strictures. Inability to swallow saliva was noted in 296 (49.7%) patients at presentation.
Pre-endoscopic therapy was administered to 389 (64.0%) patients with a mean of 2 medications prescribed. Glucagon (47.4%), GTN (37.2%) and Coca Cola (36.3%) were most commonly administered. Successful FBO clearance was documented in 36.8% patients receiving medical therapy (glucagon 35.1%, GTN 36.2%, Coca Cola 38.0%); no individual medication significantly reduced the need for endoscopic intervention. Multi-variable analysis demonstrated that tolerating saliva (OR 1.95, p=0.025) and liquids (OR 2.28, p=0.001) significantly predicted spontaneous resolution of the EFBO without endoscopy.
474 (78.0%) patients proceeded to endoscopy. Median time to endoscopy was 14 hours (IQR 6 – 16) with 36.1% patients intubated for the procedure. The FBO was most commonly located in the lower esophagus (32.7%). The most common endoscopic findings were esophagitis (30.2%) and peptic ulcer disease (18.8%), with 3 (0.6%) malignancies identified. Endoscopic complications occurred in 35 (7.4%) patients (partial esophageal tear (n=24), aspiration pneumonia (n=5)). At endoscopy, a cause for the FBO was found in 130 (27.4%) patients, most commonly due to esophageal strictures (13.9%), eosinophilic esophagitis (11.2%) and Schatzki rings (9.1%). Esophageal biopsies were taken in 155 (32.7%) patients, of which 34.2% reached the diagnostic criteria for eosinophilic esophagitis.

Conclusion

Despite limited evidence, pre-endoscopic medical treatment of FBO is safe, commonly utilised, and results in spontaneous clearance in 36.8% patients. Patients’ clinical symptoms, in particular the ability to tolerate saliva or liquids, is the best predictor for spontaneous FBO clearance. Endoscopy remains highly effective and has a low complication rate.

References

1. Longstreth GF, Longstreth KJ, Yao JF. Esophageal food impaction: Epidemiology and therapy. A retrospective, observational study. Gastrointest Endosc. 2001;53(2):193-198. doi:10.1067/mge.2001.112709
2. Ikenberry SO, Jue TL, Anderson MA, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091. doi:10.1016/j.gie.2010.11.010
3. Birk M, Bauerfeind P, Deprez P, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(05):489-496. doi:10.1055/s-0042-100456

Introduction

Gilbert's Syndrome (GS) is a benign polymorphism of the UGT1A1 gene, leading to decreased enzyme activity in the liver and mildly increased levels of unconjugated bilirubin in blood (= hyperbilirubinemia), that is affecting 5-12% of the worldwide population. A mild hyperbilirubinemia (HBIL) is associated with reduced chronic inflammation, a lower risk for metabolic and cardiovascular disorders, and lower levels of reactive oxygen species (ROS). Despite these associations, HBIL effects on the intestine, as the primary site of bilirubin excretion, and its interactions with the gut microbiota remain unclear. We propose that chronic HBIL redirects bilirubin excretion through the intestinal epithelium that affects microbe-host interactions in the colon.

Aims & Methods

Germ-free (GF) and specific-pathogen-free (SPF) C57BL/6N wildtype (WT) mice with induced HBIL and transgenic mice with the human UGT1A1*28 polymorphism (TG) were investigated, the latter one mimicking chronic HBIL. WT mice with induced HBIL received intraperitoneal bilirubin injections for 12-14 days. Bilirubin levels, in the intestine, gut content and serum were analyzed using the fluorescent protein UnaG, which specifically binds to unconjugated bilirubin, and microbiota composition was analyzed by 16S rRNA gene sequencing. To characterize HBIL-associated antioxidative function, colonic adenoma cell lines (Ptk-6, HCT116, HT-29-MTX-E12) and small intestinal organoids were incubated with different levels of bilirubin and the generation of ROS and oxidative stress markers measured.

Results

In general, mice of the induced HBIL groups exhibited higher bilirubin levels in the colonic mucosa, indicating "intestinal HBIL" with increased concentrations of mucosal bilirubin being detected in SPF HBIL > GF HBIL mice (SPF HBIL = 12.34 nM/mg, GF HBIL = 9.9 nM/mg; SPF control = 0.5951 nM/mg; GF control = 8.21 nM/mg), as well as a lower hepatic Ugt1a1 expression. Intracellular uptake of bilirubin was confirmed when different human and murine colonic epithelial cell lines were treated with bilirubin in vitro. Intestinal HBIL led to altered gut microbiota compositions, characterized by decreased abundances of operational taxonomic units (OTUs) associated with Gram-negative taxa (e.g., Prevotellaceae) and increased levels of OTUs associated with Gram-positive taxa (e.g., Lachnospiraceae) under intestinal HBIL conditions. Gut microbiota changes were more pronounced in TG (=chronic HBIL) compared to induced HBIL mice. In vitro experiments showed decreased detection of ROS and markers of cellular oxidative stress in a HCT116 reporter cell line dependent on bilirubin presence (Nfk-⁠β, Nrf2 and Hif1α). Small intestinal organoids from TG mice showed an altered proliferation pattern in comparison to WT organoids.

Conclusion

The results suggest an altered bilirubin excretion through the intestinal epithelium under mild HBIL that alters gut microbiota composition. These effects were more pronounced under chronic HBIL conditions, suggesting a sustained effect of GS-like HBIL on the gut microbiota.