Liquid nitrogen spray cryotherapy for eradication of dysplastic Barrett's esophagus: results from a multicenter prospective registry.

BACKGROUND AND AIMS: Liquid nitrogen spray cryotherapy (SCT) is an alternative to radiofrequency ablation (RFA) for eradication of dysplastic Barrett's esophagus (BE). We aimed to assess the safety, efficacy, and durability of SCT in a multicenter U.S. registry. METHODS: This is a multicenter prospective registry of adults with BE treated with truFreeze Spray Cryotherapy (Steris, Mentor, Ohio, USA) (4 community and 11 academic sites, 2013-2022). Complete eradication of intestinal metaplasia (CEIM) and dysplasia (CED) were assessed in BE with dysplasia or intramucosal adenocarcinoma. Kaplan-Meier analysis of CEIM and CED was performed. Hazard ratios for CEIM stratified by baseline risk factors were calculated. RESULTS: Among 138 subjects with low-grade dysplasia (24%), high-grade dysplasia (49%), and intramucosal adenocarcinoma (27%), 34% received prior RFA therapy. Subjects received a median of 2 SCT sessions. Adverse events were uncommon, with 5.5% reporting strictures and 0.7% a perforation. Rates of CEIM and CED, respectively, were 66% and 84% after 2 years and 67% and 92% after 3 years. In RFA-naïve patients, CEIM was 77% and CED was 96% at 3 years. Increasing BE length (per centimeter: adjusted hazard ratio, 0.90; 95% confidence interval, 0.83-0.96) and prior treatment with RFA (adjusted hazard ratio, 0.39; 95% confidence interval, 0.22-0.69) were associated with a lower rate of CEIM. Recurrence occurred in 8.8% (n = 6) at a mean follow-up of 2.5 years after CEIM. CONCLUSION: In this largest reported prospective cohort, liquid nitrogen SCT was safe and effective for the treatment of dysplastic and neoplastic BE. Response was lower in those with prior failed RFA; in that cohort, approximately 50% attained CEIM at 3 years.

A Successful 12-Month Trial of a Lumen-Apposing Self-Expandable Metallic Stent on a Benign Recalcitrant After Surgical Stricture.

Gastrojejunal anastomotic strictures are common postsurgical complications that may be treated endoscopically. In some cases, conventional endoscopic dilations may prove ineffective, prompting consideration of covered self-expandable metal stents as the next step. However, the efficacy of these stents may be limited by their risk of migration. Lumen-apposing self-expandable metallic stents pose a lower migration risk because of their unique design and offer a possible off-label solution for recalcitrant strictures. We describe a patient with a postsurgical, gastrojejunal anastomotic stricture refractory to several interventions, who achieved long-lasting remission of symptoms after a 12-month trial of lumen-apposing self-expandable metallic stent placement.

Increased Prevalence of Alcohol-Related Gastrointestinal and Liver Diseases During the COVID-19 Pandemic.

BACKGROUND: Higher prevalence of alcohol-related gastrointestinal (GI) and liver diseases (ARGLDs) were anecdotally reported during the COVID-19 pandemic, but little published evidence exists. METHODS: A healthcare system audit of inpatient GI consults was performed during the pandemic's lockdown phase (3/23/2020-5/10/2020, n=558) and reopening phase (6/1/2020-7/19/2020, n=711) with comparison to those timeframes in 2019. RESULTS: Consult volume decreased by 27.7% during the lockdown, but the proportion of ARGLDs increased by 59.6% (p=0.03). This trend continued during reopening, with potentially more severe disease as more patients required endoscopic intervention. Patients with alcoholic hepatitis during reopening were younger compared to the lockdown. CONCLUSIONS: Our study demonstrates increased prevalence and severity of ARGLDs amongst younger individuals during the COVID-19 pandemic. This increase started during the lockdown but worsened despite relaxation of restrictions. Systems to increase screening for and treatment of alcohol use disorder as society recovers from the pandemic remain imperative.

Effect of Proton Pump Inhibitor Therapy on NOX5, mPGES1 and iNOS expression in Barrett's Esophagus.

Acid reflux may contribute to the progression from Barrett's esophagus (BE) to esophageal adenocarcinoma (EA). However, it is not clear whether the molecular changes present in BE patients are reversible after proton pump inhibitor (PPI) treatment. In this study we examined whether PPI treatment affects NOX5, microsomal prostaglandin E synthase (mPGES)-1 and inducible nitric oxide synthase (iNOS) expression. We found that NADPH oxidase 5 (NOX5), mPGES-1 and iNOS were significantly increased in BE mucosa. One-month PPI treatment significantly decreased NOX5, mPGES1 and iNOS. In BAR-T cells, NOX5 mRNA and p16 promoter methylation increased after pulsed acid treatment in a time-dependent manner. Four or eight-week-acid induced increase in NOX5 mRNA, NOX5 protein and p16 methylation may be reversible. Twelve-week acid treatment also significantly increased NOX5, mPGES1 and iNOS mRNA expression. However, twelve-week-acid-induced changes only partially restored or did not recover at all after the cells were cultured at pH 7.2 for 8 weeks. We conclude that NOX5, mPGES1 and iNOS may be reversible after PPI treatment. Short-term acid-induced increase in NOX5 expression and p16 methylation might be reversible, whereas long-term acid-induced changes only partially recovered 8 weeks after removal of acid treatment.

Successful Treatment of Bleeding Rectal Varices with Balloon-Occluded Antegrade Transvenous Obliteration.

We report the first described case in the United States of balloon-occluded antegrade transvenous obliteration (BATO) performed in a cirrhotic patient with recurrent bleeding from large rectal varices. This is a novel interventional radiology approach to treat bleeding rectal varices. Our patient was a poor candidate for transjugular intrahepatic portosystemic shunt and endoscopic band ligation. Successful BATO produced complete resolution of rectal varices and no further rectal bleeding. There are no established guidelines for the management of rectal varices. We demonstrate that the BATO technique is a viable option to treat recurrent bleeding due to rectal varices.

Continued evidence for safety of endoscopic retrograde cholangiopancreatography during pregnancy.

AIM: To report the safety of continued use of endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy at various maternal ages. METHODS: A retrospective chart review of pregnant patients who underwent ERCP at a tertiary academic center was undertaken between 2002 and 2012. Pertinent past medical history and initial presenting laboratory data were collected. Review of the procedure note for each ERCP performed provided documentation of lead shielding, type of sedation, fluoroscopy time, and post-procedure complications. Patients' clinical courses were reviewed until the time of delivery and pregnancy complications with fetal outcomes were examined. Data was stratified based upon the mother's age at the time of ERCP: 18-21, 22-29, and ≥ 30 years of age. RESULTS: Twenty pregnant patients who underwent ERCP between 2002 and 2012 were identified. The mean age at the time of ERCP was 26.4 years (18-38 years) and the average trimester was the second. The indications for ERCP were choledocholithiasis in 17 patients, gallstone pancreatitis in 2 patients, and cholangitis in 1 patient. The mean fluoroscopy time of ERCP was 3.8 min (0.3-23.6 min). Sphincterotomy was performed in 18 patients with therapeutic intent and not as a prophylactic measure to prevent recurrences. Clinical documentation of use of protective shielding was found in only 8 notes (40%). Post procedure complications were limited to two cases of post-ERCP pancreatitis (10%). Elective cholecystectomy was performed shortly after ERCP in 11 of the pregnant patients. Birth records were available for 16 patients, of which 15 had full-term pregnancies. Cesarean sections were performed in 5 (31%) patients. Term birth weight was greater than 2500 g in all cases except one in which the mother had a known hypercoagulable state. CONCLUSION: ERCP during pregnancy is both safe and efficacious regardless of maternal age or trimester.

Predictors of gastroesophageal reflux symptoms in pregnant women screened for sleep disordered breathing: a secondary analysis.

BACKGROUND: Gastroesophageal reflux disease (GERD) is common in pregnancy. The cause is multifactorial, including a decreased or transient lower esophageal sphincter relaxation, increased intra-abdominal pressure, and gastrointestinal motility disturbances. AIMS: Evaluate the incidence of GERD in pregnancy and assess predictors and predisposing factors. METHOD: This is a secondary analysis of a survey of postpartum women regarding symptoms of sleep disordered breathing (SDB) and GERD performed at a large tertiary care center. Patients rated heartburn frequency during pregnancy as either never, occasionally/sometimes, or frequently/always. Pregnancy outcomes and newborn information was collected. Categorical variables were compared by Fisher's exact test and continuous variables were compared by Anova or Kruskal-Wallis test. Multinominal logistic regression was also performed. RESULTS: Information regarding 1000 mothers and 1025 newborns was reviewed. The majority of mothers were Caucasian (68.8%) with mean age 29 ± 6.1 years. A total of 56.7% had GERD frequently/always; and 25.5% had none. GERD symptoms correlated with pre-pregnancy body mass index (BMI), BMI at delivery, maternal age, smoking and symptoms of SDB. There was no significant correlation between fetal weight and maternal weight gain with GERD symptoms. Symptoms were more frequent in white non-Hispanic women than in other racial groups. CONCLUSIONS: This study suggests that GERD symptoms correlate with pre-pregnancy BMI and BMI at delivery, but not with the amount of weight gain during pregnancy. Maternal age, smoking, race, and SDB are also associated with GERD. Interestingly, fetal weight/uterine size did not seem predictive of developing GERD in pregnancy.

Current state of endoscopic therapies in Barrett's esophagus and esophageal cancer.

Barrett's esophagus (BE) is a premalignant condition that predisposes patients to esophageal adenocarcinoma. This risk increases with increasing dysplasia, especially in patients with BE and high-grade dysplasia. Radical esophagectomy had long been the only option for these patients; however, it has been associated with significant morbidity and mortality. Endoscopic therapies have been increasingly used as an alternative to radical esophagectomy given the minimally invasive nature and tolerability of the procedure relative to surgery. Currently, the most widely used endoscopic therapies include endoscopic mucosal resection, photodynamic therapy, CryoSpray ablation, and radiofrequency ablation. Retrospective and prospective studies on the use of each of these modalities in patients with nondysplastic BE, dysplastic BE, and early esophageal cancer have demonstrated their effectiveness in eradication of dysplasia with or without reversion of Barrett's epithelium to normal squamous epithelium of the esophagus. These modalities are well tolerated, safe, and have few side effects. Ultimately, more research is needed regarding their ability to fully displace surgical intervention as the gold standard, although at this point their role in poor operative candidates or patients seeking conservative approaches remains promising.