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

Atrophic gastritis(AG) is mainly caused by Helicobacter pylori(Hp)infection or autoimmunity. Hp-related AG affects both corpus and antral mucosa resulting in multifocal AG(MF-AG), whereas AG driven by autoimmunity is corpus-restricted(CR-AG).
Corpus mucosa gastric atrophy carries an increased risk of gastric dysplasia(GD) and cancer(GC);the neoplastic risk in CR-AG is considered lower, but still debated. GD-GC lesions in AG may arise in the antrum, incisura angularis or, less frequently,the corpus.Data on characteristics and potential differences of GD-GC lesions between MF-AG and CR-AG are lacking.

Aims & Methods

This study aimed to assess clinical,endoscopic,and histological characteristics of GD-GC in MF-AG and CR-AG pts.
A multicenter,cross-sectional study was conducted across 14 Italian GI centers. Data on GD-GC in patients with MF-AG or CR-AG(2001-2023) were retrospectively collected based on clinical,endoscopic, and histological charts: site,dimension,endoscopic,and histologic features of GD-GC, perilesional gastric antral and corpus mucosa(updated Sydney system),and patients’ clinical data (age,sex,outcome after GD-GC diagnosis,Hp infection, parietal cell antibodies(PCA), family history for GC). Inclusion criteria were:patients with MF-AG or CR-AG and GD or GC diagnosis,aged>18 years, availability of endoscopic and histological description of GD-GC and perilesional gastric mucosa, completeness of clinical data.Data were stratified for MF-AG/CR-AG and the GD-GC, perilesional mucosa, and clinical characteristics were compared.

Results

A total of 84 pts[(F46[54.8%];age 70(33-90yrs)] were included. MF-AG and CR-AG were observed in 45(53.6%) and 39(46.4%) pts,respectively. High-grade(HG)-GD,low-grade(LG)-GD,and non-cardia GC were diagnosed in 6(7.1%),31(36.9%), and 47(56.0%)pts.
Age, GC family history,smoking habits, and PCA positivity were similar between MF-AG and CR-AG.Women(69.2% vs 42.2%,p=0.01) and pernicious anemia(29% vs 9.1%,p=0.04) were more frequent in CR-AG than in MF-AG.
The proportion of GD and GC in MF-AG and CR-AG pts was similar:HG-GD was present in 4(8.9%) vs 2(5.1%),LG-GD in 17(37.8%) vs 14(35.9%),GC in 24(53.5%) vs 23(59.0%)pts(p>0.05).
Compared to MF-AG,in CR-AG pts GD-GC were more frequently polypoid lesions (51.6% vs 27.3%,p=0.048) and more frequent in the corpus (55.3% vs 28.6%,p=0.02), but also occurred in the antrum(34.2%) and incisura(10.5%).The intestinal-type GC was the most prevalent and was more frequent in MF-AG than in CR-AG (87%vs60.9%,p>0.046), while diffuse GC was 2 times more frequent in CR-AG than in MF-AG, albeit not reaching statistical significance (26.1% vs 13%, p=0.27).
Concerning GC differentiation grade and staging, no significant differences were observed between MF-AG and CR-AG.Endoscopic treatment of GD-GC was similar in both groups. CR-AG patients underwent surgery more frequently than MF-AG(48.6% vs 23.1%,p=0.0207), but outcome was similar with 90.7% MF-AG and 92.1% CR-AG pts being alive.
Histopathological features of corpus mucosa (acute-chronic inflammation, severity of atrophy,pseudopyloric and intestinal metaplasia) were similar between MF-AG and CR-AG(p>0.05). The histological evidence of Hp in the antrum and corpus was low in both groups (2.3% vs 2.9%,p=0.87).

Conclusion

Non-cardia GC and GD may occur in both,MF-AG and CR-AG, displaying differences in topography and endoscopic presentation, but similarities in perilesional gastric corpus mucosa, differentiation, staging and outcome.
Endo-histological surveillance should be considered in pts with gastric corpus atrophy, irrespective of its etiology and extension.

References

Lahner E, et al. Dig Liver Dis. 2019 Dec;51(12):1621-1632.
Lenti MV, et al. Nat Rev Dis Primers. 2020 Jul 9;6(1):56.
Rugge M, et al. Gut. 2023 Jan;72(1):30-38.

Introduction

Distinguishing gastrointestinal stromal tumors (GISTs) with high malignant risk is essential for the management of small submucosal tumors (SMTs).

Aims & Methods

We aimed to develop a machine learning model based on endoscopic ultrasound (EUS) images to diagnose GISTs and non-GISTs as well as distinguish their potential malignancy. EUS images of 205 small gastric SMT (<2cm) patients were retrospectively included in the model development phase. An automatically optimized radiomics modeling system (AORMS) framework was developed to carry out the model learning based on the features extracted from the retrospective cohort. Three-fold cross-validation was used to train the machine learning model and produce the optimal model for differentiating between GIST and non-GIST as well as groups 1 and 4 GIST. Images of 178 patients from different centers were prospectively enrolled in the validation phase of the model. The diagnostic performance of the AORMS was evaluated in the development set and compared with the performance of endoscopists. Then, the performance of the AORMS was evaluated in the prospective validation set.

Results

The overall area under the curve (AUC), accuracy, sensitivity, and specificity of the AORMS were 0.762, 0.708, 0.819 and 0.649 for the diagnose of GIST, and 0.734, 0.872, 0.571 and 0.908 for the risk stratification of group 1 and 4 GIST. The accuracy of five experienced endoscopists ranged from 0.449 to 0.531 in diagnosing GIST, and from 0.702 to 0.809 in distinguishing group 1 and 4 GIST. The overall performance of AORMS is better than that of experienced endoscopists. In the prospective validation set, the AORMS also achieved 0.770 and 0.750 AUC for the diagnosis and risk stratification of small GISTs (<2cm).

Table 1. Diagnostic performance of the AORMS.

Conclusion

AORMS showed good and stable performance in diagnosis and risk stratification of GISTs, which may help endoscopists provide more accurate diagnosis for small gastric SMTs (<2cm).

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

Amyotrophic Lateral Sclerosis (ALS) is a progressive neurodegenerative disease in which muscle weakness develops insidiously. In advanced stages of the disease dysphagia, weight loss and malnutrition occur in the majority of patients. Thus, the consideration of Percutaneous Endoscopic Gastrostomy (PEG) tube placement is common. However, the optimal timing and setting for the procedure as well desired spirometry results are either are not stated in most guidelines or debated. Previous studies have suggested greater procedural risk for patients whose forced vital capacity (FVC) was less than 50% than predicted

Aims & Methods

The aim of this study was to assess the safety of our tertiary center simplified approach to PEG tube placement in patients with ALS.
The electronical records of patients who underwent percutaneous endoscopic gastrostomy (PEG) placement between 1.1.2020 to 1.1.2023 were retrospectively reviewed. All adult patients diagnosed with ALS who underwent ambulatory PEG tube placement were included. Patients who underwent PEG tube placement during hospitalization due to acute illness were excluded. The common practice of our center regarding PEG placement in patients with ALS is as follows: initial evaluation at the Gastroenterology clinic of patients referred by the neurology clinic, followed by ambulatory PEG placement under sedation by an anesthesiologist. We collected baseline information from the neurology and gastroenterology clinic visits regarding comorbidities and baseline FVC and the functional rating score [ALS-FRS, 0-48 points, lower score indicating a more severe disease). The data concerning the procedure and possible complications were collected from endoscopy reports, emergency department visits and clinic visits after the procedure.

Results

Six hundred and sixty patients had underwent PEG tube placement in our center during study period. Of them, 67 patients had an established diagnosis of ALS (10.2%). One patient was excluded due to PEG placement in the setting of an acute illness during admission, thus 66 patients were included (mean age at PEG placement 63.5±12.7 years and 37.8% were females). Mean ALS-FRS score was 23.6±8.81 and mean FVC was 49.8±19.45% of predicted. More than half (54.7%) of the patients were using non-invasive ventilation support device at home prior to the procedure and 12.1% of patients had underwent endotracheal tube placement prior to PEG tube placement.
The averaged duration of PEG tube placement was 11.96±5.3 minutes. All PEG procedures were completed successfully. Complications were documented during two PEG placements (3%): one patient suffered from aspiration and was hospitalized and later diagnosed with aspiration pneumonia and the second patient suffered from gastric perforation and peritonitis which was diagnosed a few hours after the procedure. During the 30 days following PEG placement, 3 (4.5%) complications were documented: Two patients (3%) suffered from PEG site infections and were treated with antibiotics and one (1.5%) was diagnosed with aspiration pneumonia. No deaths occurred during the procedure or during the 30 days that followed.

Conclusion

The simple straight forward approach to PEG placement in our institution was successful and safe in the vast majority of cases. The complications rate in our cohort is comparable to other studies, even though the patients in our cohort had significantly reduced lung function and functional scores then accepted in the common practice.

References

1. Miller R G, Jackson C E, Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology, Neurology, 2009 Oct 13;73(15):1218-26
2. EFNS Task Force on Diagnosis and Management of Amyotrophic Lateral Sclerosis: Andersen P M, Abrahams S, EFNS guidelines on the clinical management of amyotrophic lateral sclerosis (MALS)--revised report of an EFNS task force, Eur J Neurol 2012 Mar;19(3):360-75.
3. Korner S, Hendricks M, Weight loss, dysphagia and supplement intake in patients with amyotrophic lateral sclerosis (ALS): impact on quality of life and therapeutic options, BMC Neurol 13, 84 (2013).
4. Russ K B, Phillips MC, Percutaneous Endoscopic Gastrostomy in Amyotrophic Lateral Sclerosis, Am J Med Sci . 2015 Aug;350(2):95-7.
5. Gregory S, Siderowf A, Gastrostomy insertion in ALS patients with low vital capacity: respiratory support and survival, Neurology . 2002 Feb 12;58(3):485-7.
6. Thomas K, Schrager J, Percutaneous endoscopic gastrostomy tube placement in amyotrophic lateral sclerosis: a case series with a multidisciplinary, team-based approach, Ann Gastroenterol 2020 Sep-Oct;33(5):480-484