Introduction

Treatment of gastrojejunal anastomotic ulcers, also known as marginal ulcers, is challenging, especially when established techniques such as proton pump inhibitor have failed.

Pura Stat, is a biocompatible transparent synthetic peptide hemostatic gel that is indicated for hemostatis of bleeding in small blood vessels or capillaries of the GI tract and vascular anastomoses. Our aim was to evaluate the feasibility of PuraStat in the setting of non-healing marginal ulcers when used in addition to proton pump inhibitor (PPI) therapy after failed standard therapies

Aims & Methods

We conducted a multi-center prospective case study of adult patients that underwent PuraStat application (3 ml) for marginal ulcers after failing multiple initial therapies with proton pump inhibitors for at least 8 weeks

Results

A total of 10 patients were included in the study. Patients who had an initial presentation of pain, nausea, anemia, with confirmed anastomotic ulceration seen on endoscopy were included. A total of 3mL of Purastat was applied on each of these patients’ ulcers, and a repeat endoscopy was performed to evaluate ulcers at ~3months. 9 out of 10 patients showed healing of marginal ulcer on repeat endoscopy in 3 months, while one patient did not present for repeat endoscopy. 9 out of 10 patients showed clinical improvement in their symptoms (90%), and one patient did not show improvement in their symptoms.

Conclusion

PuraStat is an important useful addition to the therapeutic toolbox for the treatment of anastomotic ulcers. Our small prospective case series shows effectiveness in symptom relief as well as clinical healing of anastomotic ulcers. Larger randomized clinical trials are needed.

References

1. Branchi F, Klingenberg-Noftz R, Friedrich K, Bürgel N, Daum S, Buchkremer J, Sonnenberg E, Schumann M, Treese C, Tröger H, Lissner D. PuraStat in gastrointestinal bleeding: results of a prospective multicentre observational pilot study. Surgical Endoscopy. 2022 May;36(5):2954-61
2. Tian Y, Rogers AM. Marginal ulcer: diagnosis and treatment. Clinical Algorithms in General Surgery: A Practical Guide. 2019:827-9.

Introduction

Peptic ulcer disease (PUD) is the most frequent cause of non-variceal upper gastrointestinal bleeding (NVUGIB). Over the decades, understanding the natural history of PUD and development of new treatment strategies has significantly improved clinical outcomes. In this study we explore the natural history of PUD, including risk factors, therapeutic approaches and mortality.

Aims & Methods

We conducted a retrospective cohort study including consecutive patients with PUD diagnosed by upper endoscopy between January-2020/June-2022. Data regarding risk factors, clinical presentation, endoscopic findings, therapeutic approaches, rebleeding and mortality rate were collected.

Results

We identified 468 patients (male sex-63.9%; mean age-71.8±15.6 years; median Charlson Comorbidity Index (CCI) - 5.4;range 0-18). Major risk factors: alcohol consumption - 31.6%; NSAIDs - 28.4%; Helicobacter pylori infection - 23.1%. Antiplatelet or anticoagulant drugs were part of the usual medication in 47.2% of the cases and were associated with major hemodynamic instability upon admission (χ² = 4.805, df=1, p=0.028), a situation that has been shown to significantly increase the risk of death (OR 3.10, IC95%: 1.745-5.509). PUD clinical presentation: melena and/or hematemesis - 65.4%; isolated anemia - 17.9%. Mean hemoglobin level at admission - 8.5±2.5 g/dl. Lower levels were associated with a higher 7-day rebleeding rate (Z=-2.383, p<0.05). Small Forrest III ulcers of gastric antrum and duodenal bulb were the most common and PPI perfusion was administered in 29.1% of the cases. Overall, 37% of patients benefited from treatment: endoscopic - 96.6%; transarterial embolization - 9.1%; surgery - 1.7%. Hospitalization was needed in 67.2% cases, with mean duration of 13.4±13.7 days. Complications occurred in 12.6% and there was need for further intervention in 7.9% of the cases. 30-day mortality was 12% (related to infections - 78%, stage IV neoplasia - 12%). Differently from age, the CCI demonstrated to be associated with 30-day mortality (Z=-4.230, p<0.001).

Conclusion

PUD is a common clinical condition, with known modifiable risk factors and diverse clinical presentation. Despite improvements in endoscopic techniques, mortality remains significant and CCI is a relevant prognostic factor.

References

1. Lanas, Angel, and Francis K L Chan. “Peptic ulcer disease.” Lancet (London, England) vol. 390,10094 (2017): 613-624. doi:10.1016/S0140-6736(16)32404-7
2. Kavitt, Robert T et al. “Diagnosis and Treatment of Peptic Ulcer Disease.” The American journal of medicine vol. 132,4 (2019): 447-456. doi:10.1016/j.amjmed.2018.12.009

Introduction

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are both standard endoscopic treatments for early-stage gastrointestinal tumors. Submucosal fluid injection is an important part of endoscopic procedure, increasing the space between the lesion and the muscle layer and enabling easy and safe resection. Recently, PuraLift^TM (3-D Matrix Ltd, Tokyo, Japan), a novel submucosal injection solution made from self-assembling peptide hydrogel (SAP) was developed in Japan. SAP is fully synthetic and consists only of amino acids present in the human body, giving it the advantages of biodegradability and biocompatibility over conventional solutions. In addition, the 3D structure of the hydrogel supports cell proliferation in vitro, and self-assembling peptide hydrogel (SAPH) may promote wound healing. However, there are no reports on the effect of SAPH on ulcer healing after endoscopic resection.

Aims & Methods

The aim of this study was to assess the effect of SAPH on wound healing after endoscopic resection. EMR procedures were performed in the stomach of 4 living pigs with 3 patters of submucosal injection solution; normal saline injection group (NS); sodium alginate injection group (SA); PuraLift^TM injection group (SAPH). Each pig received 3 separate submucosal injections with 3 mL of the different solutions and then EMR was performed using a 15mm diameter snare. Immediately after EMR (W0) and on week 1(W1) and week 2(W2), we measured the ulcer diameter endoscopically using a measuring device. On week 3(W3) after EMR, all pigs were sacrificed and necropsied by en-bloc gastrectomy, followed by macroscopic measurement of ulcer diameter. All wound sites of the resected specimens were examined histopathologically by haematoxylin and eosin (HE) and Masson's trichrome (MT) and immunohistochemistry staining (αSMA, CD3, CD 31, CD107a). The ulcer reduction rate was calculated as follows : [(ulcer diameter at W0) -(ulcer diameter at week X)] / (ulcer diameter at W0) x 100(%). Ulcer epithelialisation and submucosal foreign bodies were assessed by HE staining, tissue damage in the muscle layer and the thickness of the fibrotic layer by MT staining. Five random fields at each wound site were photographed, and the average rate of positive areas by immunostaining in each injection solution group was calculated.

Results

Ulcer reduction rate at W1 was higher in SAPH group and SA group than NS group (24.1±13.5%; 24.6±17.9%; -6.9±7.6%; p<0.05), b but there were no significant differences at W2 and W3 among three groups. Complete epithelialisation of the ulcer occurred in all except one case of NS group. In SA group, all four cases showed residual injection solution in the submucosal layer with foreign body giant cell reaction and fibrous tissue growth. In contrast, in SAPH group, only one case showed a focal foreign body giant cell reaction without residual injection solution. The thickness of the fibrotic layer is greater in SA group than SAPH and NS groups (SA: 4.2±0.8mm, SAPH: 1.6±0.4mm, NS: 2.0±1.2mm, p<0.05). Tissue damage was not observed in either group. There were no differences in the rates or positive area of αSMA, CD3 and CD31 staining between groups. In contrast, the rates of positive area of CD107a staining were significantly higher in SA group than SAPH and NS group(SA: 13.9±1.0%, SAPH: 5.7±2.2%, NS:1.2±2.1%, p<0.001), indicating a high degree of macrophage accumulation.

Conclusion

SAPH induced good healing after EMR and was more biodegradable and biocompatible than sodium alginate.

Introduction

Post-esophageal variceal ligation (EVL) ulcer bleeding poses a significant challenge in clinical practice, with various management modalities employed. However, there is a lack of established guidelines for effective management. This study aims to evaluate the effectiveness and safety of self-expandable metal SX-DANIS-ELLA (DE) stents in controlling post-EVL ulcer bleeding.

Aims & Methods

This retrospective audit focused on cirrhotic patients who underwent SEMS placement for post-EVL ulcer bleed. The study assessed bleeding control rates within 48 hours post-treatment and mortality rates within 6 weeks post-treatment

Results

Among 1025 endoscopic procedures for variceal ligation over 40 months, 1.4% (15 patients) presented with post-EVL ulcer bleed, all managed with DE stents. SEMS successfully controlled bleeding in 100% of cases at 48 hours post-procedure without the need for alternative rescue strategies. Median SEMS placement duration was eight days, with complete ulcer healing observed in 14 patients upon stent removal. However, one patient passed away within 72 hours due to decompensation. Early rebleeding within 6 weeks occurred in two ( 13.3%) patients which was managed with EVL. The 6-week mortality rate was notable at 20%(3 out of 15 patients). Adverse events included superficial esophageal ulcers at upper end of stent mesh in 9 patients out of 15(60%), SEMS dislocations in 3 out of 15 patients (20%) and one very deep esophageal tear with ulcer at the upper end of the stent mesh (6.6%). Two patients also had aspiration pneumonitis post procedure which was managed conservatively

Conclusion

SX-ELLA esophageal stents effectively controlled post-EVL ulcer bleeding. Despite successful bleeding control, the high mortality rate underscores the need for further strategies. SEMS dislocations highlight the complexity of this intervention and the importance of expertise in stent placement. Future research should explore the role of early transplant referral in reducing mortality following SEMS placement and improving patient outcomes

Introduction

Ulceration at the gastrojejunostomy is a late complication following gastric bypass surgery, usually responsive to high dose PPI. However, in refractory cases, patients may require surgical treatment. Recently, a new technique of endoscopic jejunal flap over-suturing has been reported with exceptional success rates. We aimed to evaluate the implementation of this approach in our practice.

Aims & Methods

Consecutive patients with symptomatic marginal ulcers, who failed to response to a two-month course of high dose PPI were included. Patients were treated with endoscopic suturing of a jejunal flap over the ulcer. In case of a narrow anastomosis, a self-expandable metallic stent (SEMS) was used alone or in combination with suturing. The stent was removed after 2 months. Endoscopy was repeated 8 weeks after the procedure. Technical success was defined as a fully covered marginal ulcer. Clinical success was defined as an ulcer heal on repeat endoscopy, while persistent ulcer, perforation or need for surgical repair was considered as failure.

Results

Ten patients were included, seven after Roux-en-Y gastric bypass and after 3 single anastomosis gastric bypass. All patients were negative for Helicobacter Pylori, deny alcohol abuse or NSAIDS use, 2 patients were active smokers at the time of diagnosis. All patients were on chronic PPI at the time of diagnosis, and the average therapy duration was 27 months. Jejunal over-suturing was performed in 9 patients of them 3 in combination with a SEMS, and 1 patient was treated only with a SEMS. Overall technical success rate was 100%, and a clinical success rate was 50% with 4 patients going through surgery thereafter. No adverse events occurred during the procedure or follow up period.

Conclusion

To date, marginal ulcers remain a dreaded late adverse event necessitating prolonged PPI use, repeat endoscopies and even revisional surgery. Endoscopic treatment to promote healing of refractory marginal ulcers appears safe. Technical success was achieved in all patients while clinical success only in half. However, since the only alternative treatment is surgery the endoscopic approach should still be considered. The lower than expected clinical success might be related to a more PPI resistant population compared with previous published series. Further research is needed to determine the appropriate therapeutic algorithm.