Introduction

Anastomotic leakage after foregut surgeries are often difficult to manage. The conventional way of endoscopic treatment is endoscopic stenting (ES). However, it carries a risk of stent migration and erosion. Endoscopic vacuum therapy (EVT) has recently been proposed as an alternative way of treating these leaks. EVT has the benefit of providing negative suction and promotion of granulation tissue¹. However, an exchange every 3-7 days has been suggested.

Aims & Methods

The aim of this study was to compare the treatment outcomes between ES, EVT and the combination of both. This was a retrospective multi-centre cohort study from 3 major centres in Hong Kong that performs esophagectomy and gastrectomy. All patients with anastomotic leak after total gastrectomy and esophagectomy and who were treated with ES or EVT between Jul 2008 and Apr 2023 from the Prince of Wales Hospital, Queen Mary Hospital and United Chistian Hospital were included. Patients’ demographics, type of surgery, size of anastomotic defect, treatment success rate, complications, number of procedures, duration to healing were recorded and compared. Continuous data are compared with Mann-Whitney test and categorical data are compared with Chi-square/ Fisher's exact test.

Results

A total of 63 patients were recruited (ES: 49; EVT 14. The outcomes of the study are listed in Table 1. The mean (S.D.) of defect was 15.4 (16.0)mm in the ES group and 17.8 (14.1)mm in the EVT group (p=0.39). in the EVT group, there are 3/14 patients who had failed EVT therapy and converted to ES. The success rate of each arm as a single arm therapy were similar (29/49(59.2%) in the ES group vs 6/14(42.9%) in the EVT group; p=0.28). However, there were less complications in the EVT group (2/14 (14.3%) in ES group vs. 23/49(46.9%) in EVT group; p=0.03). On the other hand, the EVT group required more endoscopic procedures (median (range) 3 1-137) procedures in the ES group vs 6(2-16) in the EVT group ; p 0.002). The days required for the anastomosis to heal were also similar (ES (61.7 (38.4) vs EVT 45.3 (25.8); p=0.37). When comparing patients treated as a single-arm therapy (ES or ET) to combination therapy (ES + EVT), the success rates has a trend towards favouring combination treatment (p=0.07).

Conclusion

Both EVT and ES are feasible and safe in treating anastomotic leaks after foregut surgeries. Although more procedures are required, EVT achieved similar success rate while having less complications when compared to ES a single arm. The use of combination therapy as compared to single-arm endoscopic therapy may achieve a higher treatment success rate.

References

1. Chan SM, Auyeung KKY, Lam SF, Chiu PWY, Teoh AYB. Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas. Dig Endosc. 2022 Jan;34(1):43-62. doi: 10.1111/den.14061. Epub 2021 Jul 19. PMID: 34115407.

Disclosure

There is no COI.

Introduction

Since the report of Shaker in 1994, transnasal esophagogastroduodenoscopy (T-EGDS) has been reported worldwide as one technique to facilitate comfortable procedures avoiding sedation. From 1996 in our Centre, we routinely use this technique in all the patients for diagnostic and selected operative EGDS. This approach is also suitable for the placement of percutaneous endoscopy gastrostomy (PEG) but in the published papers it has been performed only when conventional upper gastrointestinal endoscopy was unusable (dysphagic patients with neurological disease or with stenosis and/or occlusion of the mouth or pharynx). On the contrary, since 2000 we have routinely used the transnasal approach for all patients requiring PEG, reserving the oral technique when the transnasal access route is impossible.

Aims & Methods

We performed a retrospective analysis of all patients who underwent PEG placement between January 2000 and March 2023 in the Unit of Gastroenterology of San Camillo De Lellis Hospital, Rieti, Italy, in order to demonstrate the feasibility and safety of T-PEG placement in routine practice. We used ultrathin gastroscope through a nostril after assessment and lubrification, and the pull technique was used for tube placement.

Results

PEG placement was required for 256 consecutive patients (male 49.4%; female 51.6%), the average age was 79 years, within a range from 26 to 104 years. Transnasal approach was used in 162 patients (nasal group: 63.3%) while oral approach was used in 94 (oral group: 36.7%). The failure of transnasal approach was related to impossibility of nasal intubation due to narrow nasal passages or to inability to transilluminate the stomach. In these cases we needed transoral route. 14 patients underwent transoral PEG placement due to unavailability of transnasal gastroscope. The duration of the procedures was similar in both approaches (12 ±3 minutes oral vs 13±4 minutes nasal).
The most common indications for PEG insertion were neurologic disorders (n=132, 51.6 %), cerebrovascular accident (n=73, 28.5 %), esophageal cancer or head and neck cancer (n=18, 7 %), other pathologies (n=33, 12.9 %). 167 procedures were performed without sedation: 77.8 % ( n= 130) in the nasal group and only 22.1% (n=37) in the oral group. Outpatient regimen PEG placement was also significantly higher in trans nasal group (79 % vs 58 % oral group). We registered 3 major complications, 1 in oral group and 2 in nasal group (one necessitated surgery). No procedure-related death was registered. There were no unplanned re-admissions of outpatients discharged from the gastroenterology unit for procedure-related complications.

Conclusion

The more than twenty years’ experience of our center demonstrates that the transnasal approach is safety, feasible and could be routinely used in daily endoscopic practice for PEG placement. The minimally invasive technique therefore reserves sedation to a few selected cases to reduce costs, improve logistic organization and avoid anesthesia related complications.

References

1. Campo R, Montserrat A, Brullet E. Transnasal gastroscopy compared to conventional gastroscopy: a randomized study of feasibility, safety, and tolerance. Endoscopy. 1998 Jun;30(5):448-52.
2. Schuldt AL, Kirsten H, Tuennemann J, Heindl M, van Bommel F, Feisthammel J, Hollenbach M, Hoffmeister A. Necessity of transnasal gastroscopy in routine diagnostics: a patient-centred requirement analysis. BMJ Open Gastroenterol. 2019 Apr 14;6(1):e000264.
3. Dumortier J, Lapalus MG, Pereira A, Lagarrigue JP, Chavaillon A, Ponchon T. Unsedated transnasal PEG placement. Gastrointest Endosc. 2004 Jan;59(1):54-7.
4. Dumortier J, Napoleon B, Hedelius F, Pellissier PE, Leprince E, Pujol B, Ponchon T. Unsedated transnasal EGD in daily practice: results with 1100 consecutive patients. Gastrointest Endosc. 2003 Feb;57(2):198-204
5. Preiss C, Charton JP, Schumacher B, Neuhaus H. A randomized trial of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) versus peroral small-caliber EGD versus conventional EGD. Endoscopy. 2003 Aug;35(8):641-6.

Introduction

Endoscopic Vacuum Therapy (EVT) and Fully Covered Metal Stents (FC-SEMS) are standard treatments for anastomotic leaks (AL) following upper gastrointestinal (UGI) surgery^1-3. Recently, a new hybrid device combining an FC-SEMS with a polyurethane EVT sponge (VACStent) has been introduced, showing promising results⁴. However, there is not comparative data between VACStent and traditional endoscopic methods for ALs.

Aims & Methods

In this retrospective study, all patients with AL after UGI oncologic surgery who underwent EVT or VACStent at a tertiary academic center from March 2015 to September 2024 were included. The two endoscopic techniques were compared. The primary outcome was clinical success (CS), with secondary outcomes including number of devices used, treatment duration, and adverse events (AEs).

Results

Over 114 months, 103 patients [92 EVT, 11 VACStent] were enrolled. Of these, 74.8% had AL following Ivor-Lewis esophagectomy. The two cohorts did not differ significantly in terms of comorbidities, neoadjuvant treatment, leak number/median size, or rates of redo-surgery before endoscopic management. Both EVT and VACStent were used as first-line treatments in a similar rate of patients (79.3% vs. 90.9%, p=0.36).
The EVT group had a higher CS rate than the VACStent group, though this difference was not statistically significant (72.8% vs. 54.5%, p=0.21). Compared to the EVT group, the VACStent group required significantly fewer endoscopic sessions (1±0.7 vs. 3±2.5, p<0.001) and had a shorter mean treatment duration (12.1±11.2 vs. 14.1±12.9 days, p=0.62). Additionally, a significantly lower proportion of patients in the VACStent group required admission to the intensive care unit (ICU) (27.3% vs. 84.4%, p<0.001). In the EVT group, three adverse events were recorded (one bleeding episode and two sponge dislodgments), while no AEs were reported in the VACStent group (p=0.54) (Table 1).

Table 1 EVT vs ​VACStent: Outcomes

Conclusion

In this retrospective study, EVT and VACStent showed comparable success in treating post-UGI surgery leaks. VACStent was associated with a reduced need for ICU admission and fewer endoscopic sessions. Larger comparative data are warranted to define the role of VACStent in the treatment of leaks after UGI surgery.

References

1. Mandarino FV, Barchi A, Leone L, et al. Endoscopic vacuum therapy versus self-expandable metal stent for treatment of anastomotic leaks < 30 mm following oncologic Ivor-Lewis esophagectomy: a matched case-control study. Surg Endosc. 2023;37(9):7039-7050. doi:10.1007/s00464-023-10213-8
2. Mandarino FV, Barchi A, D'Amico F, et al. Endoscopic Vacuum Therapy (EVT) versus Self-Expandable Metal Stent (SEMS) for Anastomotic Leaks after Upper Gastrointestinal Surgery: Systematic Review and Meta-Analysis. Life (Basel). 2023;13(2):287. Published 2023 Jan 19. doi:10.3390/life13020287
3. Mandarino FV, Barchi A, Fanti L, et al. Endoscopic vacuum therapy for post-esophagectomy anastomotic dehiscence as rescue treatment: a single center case series. Esophagus. 2022;19(3):417-425. doi:10.1007/s10388-022-00912-x
4. Dell'Anna G, Fanti L, Fanizza J, et al. VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New "Kid on the Block" Who Marries the Best of Old Techniques-A Review. J Clin Med. 2024;13(13):3805. Published 2024 Jun 28. doi:10.3390/jcm13133805

Introduction

Esophageal cancer (EC) is the eight most common cancer worldwide and causes the sixth highest number of deaths per year. The incidence of EC in Norway has increased by over 20 % over the past two decades, and a similar increase is seen in other Western countries. The overall five-year survival is approximately 20 %, which makes it one of the most fatal malignancies. Tumour stage at diagnosis is the main prognostic factor, and an early diagnosis is of most importance to improve survival. Upper endoscopy (UE) with biopsies is the standard procedure for diagnosing EC. However, several studies have questioned the efficacy of UE for diagnosis of esophageal neoplasms. The rate of missed esophageal cancers (MEC) at UE is of concern in many Western countries which have been reported to account for 6.4 to 12.7 % of all ECs. We aimed to calculate the rate of MEC and identify factors associated with MEC in Central Norway.

Aims & Methods

Retrospective population-based cohort study including 625 patients diagnosed with esophageal cancer (EC) in Central Norway 2004-2021. EC cases were identified by a search in the Cancer Registry of Norway, using ICD-10 codes C15x, and contained information about histological diagnosis and tumour localization. The dataset was verified by manual review of electronic patient records. MEC was defined as EC diagnosed 6-36 months after a previous non-diagnostic upper endoscopy. Clinical and disease variables were extracted from patient records. The rate of MEC in Central Norway was calculated annually and for the study period overall. Factors possibly associated with MEC, including tumour localization, histological type, as well as symptoms and findings were recorded. The median time interval from prior UE to date of diagnosis was calculated, as well as biopsy rates of patients with Barrett´s esophagus (BE) and ulcers at the prior UE.

Results

There were 625 patients in the entire cohort. The majority (n=404, 64.6%) were localized in the lower third of the esophagus and were adenocarcinomas (n=356, 57.0%). Fifty-one (8.2%) cancers were MEC. There was a significant increase in annual numbers of EC (p=0.001) and MEC (p=0.007) over the study period, but no increase in MEC rate (p=0.393). MEC patients were older than controls (74.0 years vs. 70.2 years, p=0.038), whereas sex did not differ significantly between MEC and controls. MEC was not associated with localization, sex or histological type. The most common findings at the prior UE were hiatus hernia (n=27, 52.9%), BE (n=26, 51.0%) and esophagitis (n=10, 19.6%), while the most common alarm symptom was gastrointestinal bleeding (n=11, 21.6%). The median time from prior UE to MEC diagnosis was 23.0 (6.2-35.6) months. In all patients with histological dysplasia (n=10) at the prior UE the follow-up interval was longer than recommended in current guidelines. A total of 24% of patients with either BE or an ulceration were not biopsied at UE preceding the MEC diagnosis.

Conclusion

MEC accounted for 8.2% of esophageal cancer in Central Norway. MEC was associated with higher age at diagnosis. There was no association between MEC and histological type or localization and a thorough examination of the entire esophagus is necessary to reduce MEC rates. Inappropriate follow-up of endoscopic BE, histological dysplasia or ulcerations were identified as preventable causes. Awareness of MEC, and more consistent biopsies of ulcerations and BE could reduce the MEC rate.

Disclosure

No conflict of interest.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a cornerstone in the diagnosis and treatment of pancreatobiliary diseases. However, it carries the risk of complications including potentially fatal post-ERCP pancreatitis (PEP). Despite ongoing efforts, effective strategies for managing PEP remain unestablished. Current guidelines define PEP based on symptoms and findings occurring within 24 hours after ERCP; however, early diagnosis and intervention may prevent its incidence and severity. Recently, urinary trypsinogen-2 (UT2) has emerged as a potential biomarker for early acute pancreatitis, but its role and the optimal timing for PEP remain unclear. Therefore, we aimed to evaluate the diagnostic performance of UT2 at multiple time points following ERCP.

Aims & Methods

This is a single-center prospective observational study conducted at The University of Tokyo Hospital. Patients who underwent their initial ERCP at our institution between February 2022 and June 2024 were enrolled. Patients with choledochojejunostomy, biliary pancreatitis, or those undergoing hemodialysis were excluded. UT2 levels were measured using a rapid dipstick test before ERCP, immediately after, and at 1 and 3 hours post-procedure. Serum amylase (AMY) levels were measured 3 hours after ERCP. We evaluated the diagnostic performance (sensitivity, specificity, and accuracy) of UT2 at multiple time points, for the diagnosis of PEP. PEP was defined as an elevation in pancreatic enzyme >3x upper limit of normal with abdominal pain at 24 hours post-pocedure.

Results

A total of 521 patients underwent initial ERCP during the study period, and 337 were included in the final analysis. The median age was 74 years, and 64% were male. A naïve papilla was present in 89% of patients. The indications for ERCP included bile duct stones (39%), malignant biliary obstruction due to pancreatic cancer (13%) or non-pancreatic cancer (18%), benign biliary stricture (5%), diagnostic pancreatogram (24%), and others (1.2%). EST, EPBD, and EPLBD were performed in 37%, 6.5%, and 4.5%, respectively. Prophylactic pancreatic stent placement and rectal NSAIDs administration were performed in 29% and 20%, respectively. PEP occurred in 10% (mild 8.6%, moderate 1.2%, and severe 0.3%) of patients. UT2 demonstrated a trend toward higher sensitivity compared to AMY (AMY: 52.9% vs. UT2 at 0 h: 52.9%, 1 h: 64.7%, 3 h: 64.7%), while AMY exhibited significantly higher specificity (AMY: 92.7% vs. UT2 at 0 h: 65.3%, 1 h: 64.7%, 3 h: 65.0%) and accuracy (AMY: 88.7% vs. UT2 at 0 h: 64.1%, 1 h: 64.7%, 3 h: 65.0%). Notably, 28.5% of patients were positive for UT2 prior to undergoing ERCP. These patients were significantly older (79 vs. 71 years, P < 0.01), more likely to have pancreatic cancer (19.8% vs. 9.5%, P = 0.02), and less likely to have chronic pancreatitis (3.1% vs. 12.9%, P = 0.01). After excluding 96 cases (28.5%) who were UT2-positive before ERCP, we further evaluated the diagnostic performance of UT2 and AMY. UT2 at 0 h had lower sensitivity compared to AMY (AMY: 54.2% vs. UT2 at 0 h: 37.5%, 1 h: 54.2%, 3 h: 54.2%). In contrast, specificity was similarly high across all markers (AMY: 91.7% vs. UT2 at 0 h: 88.9%, 1 h: 87.1%, 3 h: 87.1%). Diagnostic accuracy was comparable between AMY and UT2 (AMY: 88.0% vs. UT2 at 0 h: 83.8%, 1 h: 83.8%, 3 h: 83.8%).

Conclusion

UT2 showed slightly lower predictive performance for PEP compared to AMY. However, excluding UT2-positive pre-ERCP improved the diagnostic accuracy. The diagnostic performance plateaued at 1 hour after ERCP, suggesting its potential utility in predicting PEP earlier.

Disclosure

The author is affiliated with Nipro Corporation through a labor-related arrangement, but has received no financial support or remuneration related to this study.