Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis.

BACKGROUND: Endoscopic techniques have become the first-line therapy in bariatric surgery-related complications such as leaks and fistulas. We performed a systematic review and meta-analysis on the effectiveness of self-expandable stents, clipping, and tissue sealants in closing of post-bariatric surgery leak/fistula. METHODS: A systematic literature search of the Medline/Scopus databases was performed to identify full-text articles published up to February 2019 on the use of self-expandable stents, clipping, or tissue sealants as primary endoscopic strategies used for leak/fistula closure. Meta-analysis of studies reporting stents was performed with the PRISMA guidelines. RESULTS: Data concerning the efficacy of self-expanding stents in the treatment of leaks/fistulas after bariatric surgery were extracted from 40 studies (493 patients). The overall proportion of successful leak/fistula closure was 92% (95% CI, 90-95%). The overall proportion of stent migration was 23% (95% CI, 19-28%). Seventeen papers (98 patients) reported the use of clipping: the over-the-scope clips (OTSC) system was used in 85 patients with a successful closure rate of 67.1% and a few complications (migration, stenosis, tear). The successful fistula/leak closure using other than OTSC types was achieved in 69.2% of patients. In 10 case series (63 patients), fibrin glue alone was used with a 92.8-100% success rate of fistula closure that usually required repeated sessions at scheduled intervals. The complications of fibrin glue applications were reported in only one study and included pain and fever in 12.5% of patients. CONCLUSIONS: Endoscopic techniques are effective for management of post-bariatric leaks and fistulas in properly selected patients.

Retrospective multicenter study on endoscopic treatment of upper GI postsurgical leaks.

BACKGROUND AND AIMS: Therapeutic endoscopy plays a critical role in the management of upper GI (UGI) postsurgical leaks. Data are scarce regarding clinical success and safety. Our aim was to evaluate the effectiveness of endoscopic therapy for UGI postsurgical leaks and associated adverse events (AEs) and to identify factors associated with successful endoscopic therapy and AE occurrence. METHODS: This was a retrospective, multicenter, international study of all patients who underwent endoscopic therapy for UGI postsurgical leaks between 2014 and 2019. RESULTS: Two hundred six patients were included. Index surgery most often performed was sleeve gastrectomy (39.3%), followed by gastrectomy (23.8%) and esophagectomy (22.8%). The median time between index surgery and commencement of endoscopic therapy was 16 days. Endoscopic closure was achieved in 80.1% of patients after a median follow-up of 52 days (interquartile range, 33-81.3). Seven hundred seventy-five therapeutic endoscopies were performed. Multimodal therapy was needed in 40.8% of patients. The cumulative success of leak resolution reached a plateau between the third and fourth techniques (approximately 70%-80%); this was achieved after 125 days of endoscopic therapy. Smaller leak initial diameters, hospitalization in a general ward, hemodynamic stability, absence of respiratory failure, previous gastrectomy, fewer numbers of therapeutic endoscopies performed, shorter length of stay, and shorter times to leak closure were associated with better outcomes. Overall, 102 endoscopic therapy-related AEs occurred in 81 patients (39.3%), with most managed conservatively or endoscopically. Leak-related mortality rate was 12.4%. CONCLUSIONS: Multimodal therapeutic endoscopy, despite being time-consuming and requiring multiple procedures, allows leak closure in a significant proportion of patients with a low rate of severe AEs.

Effects of different omeprazole dosing on gastric pH in non-variceal upper gastrointestinal bleeding: A randomized prospective study.

OBJECTIVE: We aimed to identify the best method of omeprazole (OME) application with respect to intragastric pH, cytochrome P450 2C19 (CYP2C19) genotype and phenotype. METHODS: The patients with non-variceal upper gastrointestinal bleeding (NVUGIB) were prospectively enrolled. After the achievement of endoscopic hemostasis, the patients were randomized to 40-mg intravenous (i.v.) OME bolus injection every 12 h or 8-mg/h continuous i.v. infusion for 72 h after an 80-mg i.v. OME bolus administration. The intragastric pH was recorded for 72 h. The CYP2C19 variant alleles (*2, *3, *17) were analyzed and the serum concentrations of OME and 5-hydroxyomeprazole (5-OH OME) were determined. RESULTS: Altogether 41 Caucasians (18 in the OME infusion [OI] group and 23 in the OME bolus [OB] group) were analyzed. The median percentage of time with an intragastric pH > 4.0 was higher in the infusion group than in the OB group over 48 h (100% vs 96.6%, P = 0.009) and 72 h (100% vs 87.6%, P = 0.006), and that at an intragastric pH >6.0 was higher in the OI group than the OB group over 72 h (97.9% vs 63.5%, P = 0.04). Helicobacter pylori infection was correlated with the fastest increase in intragastric pH, especially in the OI group. In both groups, CYP2C19 genotypes (*1/*1, *1/*17, *17/*17) had no essential effect on intragastric pH. CONCLUSIONS: In patients with NVUGIB, OME i.v. bolus followed by continuous infusion is more effective than OME i.v. bolus every 12 h in maintaining higher intragastric pH, regardless of CYP2C19 genetic polymorphisms. H. pylori infection accelerates the initial elevation of intragastric pH.

Buried bumper syndrome: a rare complication of percutaneous endoscopic gastrostomy.

Feeding via percutaneous endoscopic gastrostomy (PEG) is the preferred form of alimentation when oral feeding is impossible. Although it is a relatively safe method, some complications may occur. One uncommon PEG complication is buried bumper syndrome. In this paper we report a case of buried bumper syndrome, successfully managed with PEG tube repositioning.

Endoscopic management of gastrointestinal perforations, leaks and fistulas.

Gastrointestinal perforations, leaks and fistulas may be serious and life-threatening. The increasing number of endoscopic procedures with a high risk of perforation and the increasing incidence of leakage associated with bariatric operations call for a minimally invasive treatment for these complications. The therapeutic approach can vary greatly depending on the size, location, and timing of gastrointestinal wall defect recognition. Some asymptomatic patients can be treated conservatively, while patients with septic symptoms or cardio-pulmonary insufficiency may require intensive care and urgent surgical treatment. However, most gastrointestinal wall defects can be satisfactorily treated by endoscopy. Although the initial endoscopic closure rates of chronic fistulas is very high, the long-term results of these treatments remain a clinical problem. The efficacy of endoscopic therapy depends on several factors and the best mode of treatment will depend on a precise localization of the site, the extent of the leak and the endoscopic appearance of the lesion. Many endoscopic tools for effective closure of gastrointestinal wall defects are currently available. In this review, we summarized the basic principles of the management of acute iatrogenic perforations, as well as of postoperative leaks and chronic fistulas of the gastrointestinal tract. We also described the effectiveness of various endoscopic methods based on current research and our experience.

Application of cyanoacrylate in difficult-to-arrest acute non-variceal gastrointestinal bleeding.

Gastrointestinal bleeding is a common medical emergency. Although endoscopic treatment is effective in controlling non-variceal upper gastrointestinal bleeding, in cases of persistent bleeding radiological or surgical interventions are required. Application of cyanoacrylate for treatment of difficult-to-arrest non-variceal upper gastrointestinal bleeding is poorly investigated. We describe patients in whom cyanoacrylate for acute non-variceal gastrointestinal bleeding was used to stop the bleeding after failure of conventional endoscopic treatment. Five patients were treated with cyanoacrylate application (injection and/or spraying) for persistent bleeding (duodenal ulcer in 3, gastric ulcer in 1 and gastric Dieulafoy's lesion in 1) despite conventional endoscopic therapies. Hemostasis was achieved in all patients (100%). One patient (20%) developed recurrent bleeding 4 days after initial treatment. No complications or adverse events attributed to the cyanoacrylate application during the follow-up period of 57 days were observed. Application of cyanoacrylate is a safe and effective method to achieve immediate hemostasis when conventional endoscopic treatment is unsuccessful. This technique is easy to perform and should be considered in cases of patients with difficult-to-arrest acute non-variceal upper gastrointestinal bleeding.

Own experiences of endoscopic self-expandable stent placement for malignant colorectal ileus.

INTRODUCTION: Acute low neoplasm ileus requires emergency surgery. Nowadays there are increased numbers of patients with comorbidities, which causes higher risk of intra- and postoperative complications. AIM: To evaluate the clinical usefulness of endoscopic self-expandable stent placement for malignant colorectal ileus. MATERIAL AND METHODS: Twenty-one patients (8 women and 13 men), mean age 66.7 years, with low neoplasm obstruction, underwent endoscopic stenting of the stricture. This procedure was performed as a bridge to the surgery especially for high-risk patients. Eight of them had coagulation system impairment, 5 severe metabolic disorders, 4 circulatory insufficiency, 3 severe malnutrition and 1 patient undiagnosed synchronic rectal tumor. In 10 patients cancer was located in the sigmoid colon, in 7 in the rectum, in 2 in the ascending colon, and the transverse and ascending colon was involved in another 2 patients. RESULTS: All 21 patients (100%) underwent endoscopic stenting successfully. There were no complications after stent placement. The authors underline that placement of expandable metallic stents for patients with malignant colon obstruction with acute ileus is a safe and effective method. It gives an opportunity for quick balance of fluid, electrolyte, and the coagulation system and improvement of efficiency of the circulatory and respiratory system. CONCLUSIONS: Endoscopic treatment of ileus helps precisely estimate tumor advancement and gives the possibility of a single stage radical surgical procedure.

Comparison of the efficacy of two combined therapies for peptic ulcer bleeding: adrenaline injection plus haemoclipping versus adrenaline injection followed by bipolar electrocoagulation.

INTRODUCTION: Peptic ulcer remains the most frequent cause of upper gastrointestinal bleeding. Treatment of bleeding with simultaneous combination of two endoscopic techniques has proved to be more efficient than monotherapy. None of the published comparative studies of various contact coagulation modalities have confirmed the superiority of one of these techniques over the others. AIM: To compare the therapeutic outcomes of the use of a device enabling both injection of adrenaline solution and bipolar electrocoagulation (A + BE) to those of combined adrenaline injection with mechanical therapy (haemostatic clips) (A + HC) in the treatment of peptic ulcer bleeding. MATERIAL AND METHODS: Fifty-two subjects with bleeding ulcers were assigned to the A + BE group, and 55 patients were treated with A + HC. RESULTS: Overall, treatment failed in 20 patients (20/107, 18.7%): in 10 individuals from the A + BE group (10/52; 18.2%) and in 10 individuals from the A + HC group (10/55; 19.2%) (p > 0.05). Primary haemostasis was not obtained in 7 patients (6.5%): in 4 patients in the A + BE group and in 3 patients in the A + HC group (p > 0.05). Ten individuals (9.3%) experienced recurrent bleeding during hospitalisation: 4 patients from the A + BE group and 6 patients from the A + HC group (p > 0.05). Finally, in 96.3% of the patients (n = 103) the endoscopic treatment proved efficient with regards to obtaining haemostasis during hospitalisation. Surgical intervention was required in 4 individuals (3.7%): 2 patients in the A + BE group and 2 patients treated with A + HC (p > 0.05). Three patients (2.8%) - all from the A + HC group - died during hospitalisation. No significant intergroup differences were documented with regards to the mean number of transfused blood units and the mean length of hospital stay. CONCLUSIONS: The efficacy of combined endoscopic treatment of ulcer bleeding with a probe enabling simultaneous bipolar electrocoagulation and adrenaline injection seems comparable to the widely used dual technique of adrenaline injection and haemostatic clipping.

Gastric band migration following laparoscopic adjustable gastric banding (LAGB): two cases of endoscopic management using a gastric band cutter.

Laparoscopic adjustable gastric banding (LAGB) is one of the most frequently used minimally invasive and reversible procedures for the treatment of morbid obesity. Migration of the gastric band into the gastric lumen is a rare late complication of LAGB. Previous attempts at endoscopic removal of migrated bands have included the use of endoscopic scissors, laser ablation and argon plasma coagulation (APC). We report two cases of successful endoscopic management of gastric band migration using a gastric band cutter.

Magnification endoscopy and chromoendoscopy in evaluation of specialized intestinal metaplasia in Barrett's Esophagus.

BACKGROUND: Specialized intestinal metaplasia (SIM) in Barrett's esophagus is a risk factor of esophageal adenocarcinoma. It often occurs focally and cannot be distinguished from surrounding columnar epithelium with conventional endoscopy. AIMS: The purpose of this study was evaluation of methylene blue (MB) staining and magnification endoscopy with comparison of pit-pattern classifications according to Endo and Guelrud, in detection of SIM in Barrett's esophagus. METHODS: Twenty-five patients, aged 33-77 years (average 57 years), with displacement of Z line were prospectively enrolled and underwent gastroscopy with the use of magnification up to 115 times (Olympus GIF Q160Z). Biopsy for histopathologic examination was taken from sites stained with MB and/or places with particular pit patterns. A control group consisted of ten patients with normal gastro-esophageal junction. RESULTS: SIM was proved in nine patients, and significantly more frequently in patients with hiatal hernia and Barrett's segment longer than 3 cm. Round or thin linear pit patterns according to Guelrud's and small round and straight pit patterns according to Endo's classification were coupled with columnar epithelium. SIM was associated with deep linear and foveolar pit patterns in Guelrud's classification. Other pit patterns were less characteristic. Both classifications had high sensitivity (Endo's 85.7%, Guelrud's 92.8%) but poor specificity (respectively, 21.15 and 28.4%) in detection of SIM. Sensitivity and specificity of MB staining were, respectively, 71.4 and 40.6%. CONCLUSIONS: Despite existing association between mucosal surface structure and histology, we find no convincing data indicating that pit-pattern evaluation may replace multiple biopsies taken according to recommendations from Seattle for detection of SIM in Barrett's esophagus.

Serum interleukin 6 (IL-6) and C-reactive protein (CRP) levels in colorectal adenoma and cancer patients.

BACKGROUND: Colorectal cancer is one of the most common cancers of the gastrointestinal tract and the fourth cause of cancer death in the world. It has been shown that local chronic inflammation may lead to colorectal carcinogenesis via adenomatous polyps. Interleukin-6 and C-reactive protein are biomarkers of inflammation and indicators of the immune response to tumors. METHODS: Serum levels of interleukin-6, carcinoembryonic antigen and carbohydrate antigen 19-9 were determined using immunoenzymatic assays, and C-reactive protein concentrations by immunoturbidimetric kits in 76 colorectal cancer patients before surgery, in 38 colorectal adenoma patients and in 35 healthy controls. RESULTS: Serum levels of interleukin-6, C-reactive protein and carcinoembryonic antigen were significantly higher in cancer patients when compared to adenoma patients and healthy subjects, and increased in more advanced stages of disease and in patients with non-resectable tumors. Based on Cox's analysis, the elevated preoperative serum level of C-reactive protein was an independent significant prognostic factor for patients' survival. CONCLUSIONS: Our findings suggest the usefulness of interleukin-6 in the diagnosis of colorectal cancer patients and C-reactive protein in the survival prognosis.

[Focal villous atrophy of the duodenum in children who have outgrown cow's milk allergy. Chromoendoscopy and magnification endoscopy evaluation]. / Ogniskowy zanik kosmków blony sluzowej dwunastnicy u starszych dzieci z alergia na bialka mleka krowiego rozpoznana w wieku niemowlecym. Badania z zastosowaniem endoskopii z powiekszeniem i chromoendoskopii.

UNLABELLED: Patchy villous atrophy of duodenal mucosa has been described in young children with cow's milk allergy (CMA). Cow's milk protein-sensitive enteropathy may persist in older children and shows characteristic histological features. The advent of magnification endoscopy may allow the macroscopic detection of unrecognised villous atrophy in these patients. AIM: the aim of the study was to evaluate the duodenum mucosa in older children with CM A in infancy using chromoendoscopy and magnification endoscopy. METHODS: the study involved 15 children (mean age 15 years; range 12-18) with CM A diagnosed and treated in infancy, currently on normal diet, referred to our department due to abdominal pain. The control group consisted of 8 children with abdominal pain without any evidence of allergy (mean age 15 years, range 13-18). In all patients magnification endoscopy and chromoendoscopy was performed under general anaesthesia (GIFQ 160Z, Olympus). The bulb and the descending portion of the duodenum were examined. 1% methylene blue was used for staining. Each endoscopy was recorded on DVD. Patients with celiac disease, after surgery or treated for other disorders were excluded from this part of the investigation. RESULTS: seven of 15 patients with CM A in infancy had focal villous atrophy of the descending part of the duodenum. In the control group, the villous atrophy was seen in one case. CONCLUSIONS: 1. Magnification endoscopy and chromoendoscopy are a valuable method of detecting focal villous atrophy in patients with suspected food allergy. 2. Focal villous atrophy may indicate the presence of food hypersensitivity of persisting from infancy process.

Does gastro-esophageal reflux provoke the myocardial ischemia in patients with CAD?

BACKGROUND: Gastro-esophageal reflux disease (GERD) may cause chest pain. The aim was to determine the correlation between ischemia and gastro-esophageal reflux in patients with CAD and to assess the influence of short-term "anti-reflux" therapy on the ischemia in patients with GERD and CAD. METHODS: Fifty patients with angiographically proven CAD underwent simultaneous 24-h continuous ECG and esophageal pH monitoring. We assessed the number of ST-segment depression episodes (ST dep.) and total duration of ischemic episodes, expressed as total ischemic burden (TIB). In pH-metry, we assessed: time percentage of pH lower than 4, total time of pH lower than 4 and the number of pathological refluxes (PR). Patients fulfilling the GERD criteria received a 7-day therapy with omeprazole 20 mg bid. On the 7th day of therapy, simultaneous Holter and esophageal pH monitoring was repeated. RESULTS: Total number of 224 PRs in 42 patients (84%) was recorded during esophageal pH-metry. GERD criteria were fulfilled in 23 patients (46%). Out of 218 episodes of ST dep., 45 (20.6%) correlated with PR. GERD patients had larger TIB and higher number of ST dep. (p<0.015 and p<0.035, respectively). The anti-reflux therapy reduced all analyzed parameters of esophageal pH monitoring (p<0.0022) as well as the number of ST dep. (p<0.012) and TIB (p<0.05). CONCLUSIONS: Gastro-esophageal reflux disease is common in patients with CAD and may provoke myocardial ischemia. Short-term proton pump inhibitors therapy that restores normal esophageal pH significantly reduces myocardial ischemia, possibly due to elimination of acid-derived esophago-cardiac reflex compromising coronary perfusion-the phenomenon known as "linked angina".

[Endoscopic treatment of gastroesophageal reflux disease--new possibilities]. / Leczenie endoskopowe choroby refluksowej przelyku--nowe mozliwosci.

Gastro-esophageal reflux disease (GERD) is one of the most important problems of gastroenterology at present. The symptoms of GERD have negative influence of patients' life on a daily basis. The principal aim of reflux disease treatment is to eliminate or alleviate the symptoms, to heal tissue damages and to reduce the frequency and duration of recurrences. Lifestyle and dietary modification are of only limited value in GERD treatment. Proton pump inhibitors (PPI) are the mainstay of GERD pharmacotherapy for both initial episode and long-term management. Surgical treatment is indicated in: complicated GERD, in patients who need high effective dose of medication, young patients who need lifelong PPI, patients with big hiatus hernia. Laparoscopic Nissen fundoplication has become the operation of choice. Nevertheless patients who have undergone fundoplication may experience adverse post operative complication. The useful alternatives in the management of GERD may indeed eventually prove the new endoscopic methods of minimally invasive treatment which are currently under thorough evaluation. The most promising methods of endoscopic treatment of GERD have been discussed: radiofrequency ablation (the Streett's procedure), endoscopic gastroplasty, endoscopic implantation of biopolymer hydrogel prosthesis.

[Therapeutic management of peptic ulcer bleeding]. / Postepowanie farmakologiczne w krwawieniach w chorobie wrzodowej zoladka i dwunastnicy.

Despite development of new diagnostic and therapeutic methods bleeding from peptic ulcer is still associated with high rate of complications and mortality. Apart from endoscopic therapy, pharmacological treatment is of great importance. Affecting platelet aggregation and fibrin formation low pH level of gastric juice impairs processes of coagulation. The fastest and most stable control of acid secretion is achieved by proton pump inhibitors. In the cases of active bleeding from peptic ulcer or signs of recent bleeding such as visible vessel or adhering clot, administration of high doses of proton pump inhibitors by continuous intravenous infusion significantly reduces bleeding recurrence rate. Among patients with Helicobacter pylori (H. pylori) infection, eradication of the bacteria after bleeding episode is mandatory.

[Ischemic heart disease and gastro-oesophageal reflux disease--simultaneous 24 monitoring of ECG and oesophageal pH]. / Choroba niedokrwienna serca a choroba refluksowa przelyku-ocena za pomoca jednoczasowego 24-godzinnego monitorowania EKG i pH w przelyku.

AIM: To determine the correlation between episodes of ischaemia in ECG recordings with pathologic gastro-esophageal reflux during simultaneous 24 hour monitoring of ECG and oesophageal pH. METHODS: Simultaneous 24 hour monitoring of ECG and oesophageal pH was performed in 30 patients (p) (26 M/4F, aged 39-74) with coronary artery disease of CCS class II-III, CAD was confirmed in coronary angiography. Analysis of the oesophageal pH was performed by using the Polygram programme (PW-version 2.04 Esophogram-version 2.01). ST depression > 1 mm and lasting at least 1 min was regarded as significant in ECG monitoring. Pathologic gastro-esophageal reflux was defined as a drop in pH < 4 lasting more than 5 min. Gastrooesophageal reflux disease (GERD) was diagnosed when a drop in pH < 4 lasted for more than 5% of the monitoring period. Gastro-oesophageal reflux dependent ST depression was defined as an ST depression that occurred during reflux episode and lasted up until 10 min from the end of the reflux. RESULTS: 26 patients (87%) had a total of 116 episodes of ST depression and 21 out of the 116 episodes (18%) were Gastro-oesophageal reflux time dependent. Fifteen patients (50%), had at least one episode of ST depression, depending on the time of reflux. Pathologic gastro-esophageal reflux was present in 25 patients (85%). In 14 patients (46.6%), the GERD pH criteria were fulfilled. In this group of patients, there was a significantly longer time of total ST depression (total ischaemic burden). CONCLUSIONS: 1. GERD is a frequent disease in patients with angiographically proven coronary artery disease. 2. Pathological gastroesophageal reflux can induce myocardial ischaemia, which can be determined by analysis of ST depression during 24 hour monitoring of ECG.