Endoscopic repair of duodenal perforations, a scoping review.

BACKGROUND: There is a discrepancy in the surgical and endoscopic literature for managing duodenal perforations. Although often managed conservatively, surgical repair is the standard treatment for duodenal perforations. This contrasts with the gastroenterology literature, which now recommends endoscopic repair of duodenal perforations, which are more frequently iatrogenic from the growing field of advanced endoscopic procedures. This study aims to provide a scoping review to summarize the current literature content and quality on endoscopic repair of duodenal perforations. METHODS: The protocol for performing this scoping review was outlined by the Joanna Briggs Institute. All studies that reported primary outcomes of patients who had undergone endoscopic repair of duodenal perforations before February 2022, regardless of perforation etiology or repair type were reviewed, with studies after 1999 meeting inclusion criteria. The study excluded articles that did not report clinical outcomes of endoscopic repair, articles that did not describe where in the gastrointestinal tract the endoscopic repair occurred, pediatric patients, and animal studies. RESULTS: 7606 abstracts were screened, with 474 full articles reviewed and 152 studies met inclusion criteria. 560 patients had duodenal perforations repaired endoscopically, with a technical success rate of 90.4% and a survival rate of 86.7%. Most of these perforations (74.5%) were iatrogenic from endoscopic procedures or surgery. Only one randomized control trial (RCT) was found, and 53% of studies were case reports. CONCLUSION: These results suggest that endoscopic repair could emerge as a viable first-line treatment for duodenal perforation and highlight the need for more high-quality research in this topic.

Ampullary tumors: French Intergroup Clinical Practice Guidelines for diagnosis, treatments and follow-up (TNCD, SNFGE, FFCD, UNICANCER, GERCOR, SFCD, SFED, ACHBT, AFC, SFRO, RENAPE, SNFCP, AFEF, SFP, SFR).

BACKGROUND: Management of ampullary tumors (AT) is challenging because of a low level of scientific evidence. This document is a summary of the French intergroup guidelines regarding the management of AT, either adenoma (AA) or carcinoma (AC), published in July 2023, available on the website of the French Society of Gastroenterology (SNFGE) (www.tncd.org). METHODS: A collaborative work was conducted under the auspices of French medical, endoscopic, oncological and surgical societies involved in the management of AT. Recommendations are based on recent literature review and expert opinions and graded in three categories (A, B, C), according to quality of evidence. RESULTS: Accurate diagnosis of AT requires at least duodenoscopy and EUS. All patients should be discussed in multidisciplinary tumor board before treatment. Surveillance may only be proposed for small AA in familial adenomatous polyposis. For AA, endoscopic papillectomy is the preferred option only if R0 resection can be achieved. When not possible, surgical papillectomy should be considered. For AC beyond pT1a N0, pancreaticoduodenectomy is the procedure of choice. Adjuvant monochemotherapy (gemcitabine, 5FU) may be proposed. For aggressive tumors (pT3/T4, pN+, R1, poorly differentiated AC, pancreatobiliary differentiation) with high risk of recurrence, 6 months polychemotherapy (CAPOX/FOLFOX for the intestinal subtype and mFOLFIRINOX for the pancreatobiliary or the mixed subtype) may be a valid alternative. Clinical and radiological follow up is recommended for 5 years. CONCLUSIONS: These guidelines help to homogenize and highlight unmet needs in the management of AA and AC. Each individual case should be discussed by a multidisciplinary team.

Brain Abscess Secondary to Streptococcus Intermedius Following an EGD with Biopsy in a Patient with Eosinophilic Esophagitis.

Brain abscess is a rare complication of esophagogastro- duodenoscopy (EGD) with few reported cases in the literature. In this report, we discuss a patient presenting with altered mental status, headache, and dysarthria due to brain abscess caused by S. intermedius shortly after an EGD with an esophageal biopsy showing a new diagnosis of eosinophilic esophagitis. We highlight the rare association of EGD and brain abscess, and discuss the importance of prompt diagnosis and treatment.

Long-term outcomes of endoscopic resection for well-differentiated nonampullary duodenal neuroendocrine tumors.

BACKGROUND AND AIMS: Nonampullary duodenal neuroendocrine tumors (NAD-NETs) are rare, with limited evidence regarding endoscopic treatment. This study investigated the efficacy and safety of endoscopic resection of well-differentiated NAD-NETs and evaluated long-term outcomes, including local recurrence and metastasis. METHODS: Seventy-eight patients with NAD-NETs who underwent endoscopic resection between January 2011 and August 2022 were included. Clinicopathologic characteristics and treatment outcomes were collected and analyzed. RESULTS: En-bloc resection was achieved for 74 tumors (94.9%) and R0 resection for 68 tumors (87.2%). Univariate analysis identified tumors in the second part of the duodenum, tumor size ≥10 mm, and muscularis propria invasion as risk factors for noncurative resection. Two patients with R1 resection (vertical margin involvement) and 2 patients with lymphovascular invasion underwent additional surgery. Four patients experienced adverse events (5.1%), including 2 cases of delayed bleeding and 2 cases of perforation, all successfully managed conservatively. During a median follow-up period of 62.6 months, recurrence and lymph node metastasis were only detected in 1 patient with R1 resection 3 months after the original procedure. CONCLUSIONS: Endoscopic resection is safe and effective and provides a favorable long-term outcome for patients with well-differentiated NAD-NETs without regional lymph node or distant metastasis.

Resectability of Small Duodenal Tumors: A Randomized Controlled Trial Comparing Underwater Endoscopic Mucosal Resection and Cold Snare Polypectomy.

INTRODUCTION: Underwater endoscopic mucosal resection (UEMR) and cold snare polypectomy (CSP) are novel endoscopic procedures for superficial nonampullary duodenal epithelial tumors (SNADET). However, consensus on how to use both procedures appropriately has not been established. In this study, we evaluated treatment outcomes of both procedures, including resectability. METHODS: In this single-center randomized controlled study conducted between January 2020 and June 2022, patients with SNADET ≤12 mm were randomly allocated to UEMR and CSP groups. The primary end point was sufficient vertical R0 resection (SVR0), which was defined as R0 resection including a sufficient submucosal layer. We compared treatment outcomes including SVR0 rate between groups. RESULTS: The SVR0 rate was significantly higher in the UEMR group than in the CSP group (65.6% vs 41.5%, P = 0.01). By contrast, the R0 resection rate was not significantly different between study groups (70.3% vs 61.5%, P = 0.29). The submucosal layer thickness was significantly greater in the UEMR group than in the CSP group (median 546 [range, 309-833] µm vs 69 [0-295] µm, P < 0.01). CSP had a shorter total procedure time (median 12 [range, 8-16] min vs 1 [1-3] min, P < 0.01) and fewer total bleeding events (9.4% vs 1.5%, P = 0.06). DISCUSSION: UEMR has superior vertical resectability compared with CSP, but CSP has a shorter procedure time and fewer bleeding events. Although CSP is preferable for most small SNADET, UEMR should be selected for lesions that cannot be definitively diagnosed as mucosal low-grade neoplasias.

A systematic review, pairwise meta-analysis and network meta-analysis of randomized controlled trials exploring the role of fecal microbiota transplantation in irritable bowel syndrome.

BACKGROUND: Treatment is a challenge in Irritable Bowel Syndrome (IBS) and fecal microbiota transplantation (FMT) has attracted significant interest. Network meta-analysis (NWM) has been established as an evidence-synthesis tool that incorporates direct and indirect evidence in a collection of randomized controlled trials (RCTs) comparing therapeutic intervention competing for similar therapeutic results. No NWM exists concerning the comparative effectiveness and safety of various FMT modalities for IBS. AIM: We updated pairwise meta-analyses published in the past and assessed the comparative effectiveness and safety of various FMT delivery modalities for IBS. METHODS: Pairwise meta-analyses and Bayesian NWM were performed. Heterogeneity, consistency of results and publication bias were explored. RESULTS: Of 510 titles raised by initial search, seven RCTs were entered into meta-analyses and NWM. They included 470 patients and controls, in whom four FMT delivery modalities were used, that is via colonoscopy, nasojejunal tube, duodenoscope and capsules per os. In the pairwise meta-analysis, the pooled results showed that overall FMT was not superior to placebo, whereas the subgroup analyses showed that FMT via duodenoscope and nasojejunal tube was superior. The NWM showed that 60-g FMT via duodenoscope had the highest efficacy (OR, 26.38; 95% CI, 9.22-75.51) and was by far the highest in the efficacy ranking (SUCRA, 98.8%). CONCLUSION: The pooled results showed no overall advantage of FMT over placebo in IBS. However, upper GI delivery (via duodenoscopy or nasojejunal tube) proved to be effective. Consequently, well-designed RCTs are needed to ensure the efficacy and safety profile before FMT can be applied in everyday clinical practice for IBS patients.

KRAS G12D mutation in Brunner gland adenoma.

Brunner gland lesions (BGLs) encompass benign proliferations of the homonymous glands and have been designated as hyperplasia, adenoma (BGA), hamartoma or nodule. In general terms, lesions larger than 0.5 cm are considered true neoplasia with unknown malignant potential and unclear pathogenesis. Genetic alterations have seldom been reported in BGL, and include SMAD4/DPC4 and LRIG1, but not KRAS (Kirsten rat sarcoma viral oncogene homologue) to the best of our knowledge.We present the case of a man in his 60s, evaluated for iron deficiency anaemia harbouring a 1.5 cm BGA found by duodenoscopy. Immunohistochemistry failed to reveal microsatellite instability, and next-generation sequencing revealed a KRAS G12D point mutation.

Current status and perspectives for endoscopic diagnosis of superficial nonampullary duodenal epithelial tumors.

In recent years, there have been significant advances in the endoscopic resection (ER) procedures of superficial nonampullary duodenal epithelial tumors (SNADETs). A preoperative endoscopic diagnosis is thus deemed necessary in determining the indication for subsequent ER. For the histologic and endoscopic diagnosis of SNADETs, understanding the mucin phenotype is inevitable. Recently, two diagnostic algorithms for the differential diagnosis of SNADETs from nonneoplastic lesions under magnifying endoscopy with narrow-band imaging have been proposed. In addition, various endoscopic approaches have been proposed to differentiate low- and high-grade adenomas/carcinomas, including white light endoscopy, magnifying image-enhanced endoscopy, and endocytoscopy. These methods, however, have not been standardized with respect to the classification of their findings and the validation of their diagnostic accuracy. Moreover, there are still concerns with respect to the histologic criteria required to establish a SNADETs diagnosis. Standardization in the histologic and endoscopic diagnosis of SNADETs is needed.

Sedative effect and safety of different doses of S-ketamine in combination with propofol during gastro-duodenoscopy in school-aged children: a prospective, randomized study.

BACKGROUND: Propofol combined with opioids can reduce the dosage of propofol and improve the safety of endoscopy. However, there are few studies on propofol combined with S-ketamine in children undergoing gastro-duodenoscopy. We aim to determine the sedative effect and safety of different doses of S-ketamine in combination with propofol in school-aged children undergoing gastro-duodenoscopy. METHODS: This is a prospective, randomized trial. Totally, 120 school-aged children who underwent gastro-duodenoscopy were randomly allocated into Group P, Group S0.3, Group S0.5 and Group S0.7. During induction, children in Group P, Group S0.3, Group S0.5 and Group S0.7 received 0, 0.3 mg.kg-1, 0.5 mg.kg-1 and 0.7 mg.kg-1 S-ketamine, respectively, following 3 mg.kg-1 propofol injection. During gastro-duodenoscopy, 1 mg.kg-1 of propofol was added according to the condition of the children and the BIS (bispectral index) value. The primary outcome was smooth placement rate of the first endoscope insertion. The secondary outcome was the times of additional propofol, the total amount of propofol, adverse events, recovery time, length of PACU (post anesthesia care unit) stay and endoscopist satisfaction. RESULTS: The smooth placement rate of the first endoscope insertion in Group P, Group S0.3 and Group S0.5 was significantly lower than that in Group S0.7 (16.70%, 34.50%, 50.00% vs. 83.30%, respectively, P < 0.001). The times of additional propofol in Group S0.3 (P = 0.018), Group S0.5 (P = 0.014) and Group S0.7 (P = 0.001) were significantly less than Group P. The total amount of propofol in Group S0.7 was significantly less than Group P (P < 0.001). The incidence of intraoperative hypotension in Group S0.5 and Group S0.7 was low. Group S0.7 had significantly higher incidence of postoperative dizziness (P = 0.003), longer PACU stay (P = 0.018) and higher endoscopist satisfaction (P = 0.001) than Group P. There was no difference in the recovery time among groups. CONCLUSION: S-ketamine (0.7 mg.kg-1) in combination with propofol can provide satisfactory sedative effect and reduce the dosage of propofol in school-aged children undergoing gastro-duodenoscopy, but there are higher incidence of postoperative dizziness and longer PACU stay.

Routine Use of Esophago-gastro-duodenoscopy (EGD) in Bariatric Surgery-an International Survey of Our Current Practice.

INTRODUCTION: The role of esophago-gastro-duodenoscopy (EGD) in bariatric surgery has been widely discussed. In 2020, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued recommendations on the routine use of EGD before and after bariatric surgery. However, little is known of our current practice and the guidance uptake. METHODS: We conducted an international survey assessing bariatric surgeons' practice on the use of EGD. The survey aimed to identify whether surgeons offer EGD in the following settings: pre-operative, post-operative at 1 year, every 2-3 years following longitudinal sleeve gastrectomy (LSG) or one-anastomosis gastric bypass (OAGB). Data was analyzed using descriptive statistics. RESULTS: Among 121 respondents, 72% are aware of the IFSO recommendations. The commonly performed bariatric procedures were LSG, Roux-en-Y gastric bypass (RYGB), and OAGB. 53.7% surgeons routinely offer pre-operative EGD and 14.3% routinely offer post-operative EGD for bariatric patients at 1 year after surgery. Majority do not routinely offer EGD after LSG (74.8%) or OAGB (79.7%) every 2-3 years as proposed by IFSO. CONCLUSION: The uptake of IFSO recommendation is variable according to each recommendation with better compliance among surgeons with regard to pre-operative EGD. Further research is necessary to develop robust evidence-base for the role of endoscopy after bariatric surgery with the inclusion of patient and public involvement.

Tolerance of biofilm of a carbapenem-resistant Klebsiella pneumoniae involved in a duodenoscopy-associated outbreak to the disinfectant used in reprocessing.

BACKGROUND: One possible transmission route for nosocomial pathogens is contaminated medical devices. Formation of biofilms can exacerbate the problem. We report on a carbapenemase-producing Klebsiella pneumoniae that had caused an outbreak linked to contaminated duodenoscopes. To determine whether increased tolerance to disinfectants may have contributed to the outbreak, we investigated the susceptibility of the outbreak strain to disinfectants commonly used for duodenoscope reprocessing. Disinfection efficacy was tested on planktonic bacteria and on biofilm. METHODS: Disinfectant efficacy testing was performed for planktonic bacteria according to EN standards 13727 and 14561 and for biofilm using the Bead Assay for Biofilms. Disinfection was defined as ≥ 5log10 reduction in recoverable colony forming units (CFU). RESULTS: The outbreak strain was an OXA-48 carbapenemase-producing K. pneumoniae of sequence type 101. We found a slightly increased tolerance of the outbreak strain in planktonic form to peracetic acid (PAA), but not to other disinfectants tested. Since PAA was the disinfectant used for duodenoscope reprocessing, we investigated the effect of PAA on biofilm of the outbreak strain. Remarkably, disinfection of biofilm of the outbreak strain could not be achieved by the standard PAA concentration used for duodenoscope reprocessing at the time of outbreak. An increased tolerance to PAA was not observed in a K. pneumoniae type strain tested in parallel. CONCLUSIONS: Biofilm of the K. pneumoniae outbreak strain was tolerant to standard disinfection during duodenoscope reprocessing. This study establishes for the first time a direct link between biofilm formation, increased tolerance to disinfectants, reprocessing failure of duodenoscopes and nosocomial transmission of carbapenem-resistant K. pneumoniae.