Impact of COVID-19 Infection on Pancreato-Biliary Diseases Requiring Endoscopic Retrograde Cholangiopancreatography.

BACKGROUND: Viral infections are known to impact the pancreato-biliary system; however, there are limited data showing that the same is true of COVID-19. Endoscopic retrograde cholangiopancreatography (ERCP) can safely be performed in patients with COVID-19 infection, but outcomes of patients with COVID-19 infections and concomitant pancreatic and biliary disease requiring endoscopic intervention are unknown. AIMS: This study aims to evaluate the severity of pancreaticobiliary diseases and post-ERCP outcomes in COVID-19 patients. METHODS: Patients with pancreato-biliary disease that required inpatient ERCP from five centers in the United States and South America between January 1, 2020, and October 31, 2020 were included. A representative cohort of patients from each month were randomly selected from each site. Disease severity and post-ERCP outcomes were compared between COVID-19 positive and COVID-19 negative patients. RESULTS: A total of 175 patients were included: 95 COVID positive and 80 COVID negative. Mean CTSI score for the patients who had pancreatitis was higher in COVID-positive cohort by 3.2 points (p < .00001). The COVID-positive group had more cases with severe disease (n = 41) versus the COVID-negative group (n = 2) (p < .00001). Mortality was higher in the COVID-19 positive group (19%) compared to COVID-negative group (7.5%) even though the COVID-19-negative group had higher incidence of malignancy (n = 17, 21% vs n = 7, 7.3%) (p = 0.0455). CONCLUSIONS: This study shows that patients with COVID infection have more severe pancreato-biliary disease and worse post-ERCP outcomes, including longer length of stay and higher mortality rate. These are important considerations when planning for endoscopic intervention. CLINICALTRIALS: gov: (NCT05051358).

Three Simple Parameters on Admission to the Emergency Department are Predictors for Endoscopic Intervention in Patients with Suspected Nonvariceal Upper Gastrointestinal Bleeding.

BACKGROUND: A considerable number of patients with nonvariceal upper gastrointestinal bleeding (UGIB) need endoscopic intervention. OBJECTIVE: The aim of this study was to determine factors that predict the need for endoscopic intervention at the time of admission to the emergency department. METHODS: Consecutive patients with International Classification of Diseases, Tenth Revision diagnosis code K92.2 (gastrointestinal hemorrhage) who underwent upper endoscopy between February 2019 and February 2022, including patients diagnosed with nonvariceal UGIB in the emergency department in the study were reviewed retrospectively. The patients were divided into two groups: those treated endoscopically and those not treated endoscopically. These two groups were compared according to clinical and laboratory findings at admission and independent predictors for endoscopic intervention were determined using multivariate regression analysis. RESULTS: Although 123 patients (30.3%) were treated endoscopically, endoscopic treatment was not required in 283 (69.7%) patients. Syncope, mean arterial pressure (MAP), and blood urea nitrogen (BUN) at admission were independent predictors for endoscopic intervention in the multivariate analysis, after adjusting for endoscopy time. The area under the curve of the syncope+MAP+BUN combination for endoscopic intervention was 0.648 (95% CI 0.588-0.708). Although the syncope+MAP+BUN combination predicted the need for intervention significantly better than pre-endoscopy Rockall and AIMS65 scores (p = 0.010 and p < 0.001, respectively), there was no significant difference in its comparison with the Glasgow-Blatchford score (p = 0.103). CONCLUSIONS: Syncope, MAP, and BUN at admission were independent predictors for endoscopic therapy in patients with nonvariceal UGIB. Rather than using complicated scores, it would be more practical and easier to predict the need for endoscopic intervention with these three simple parameters, which are included in the Glasgow-Blatchford score.

Acute hemorrhagic cholecystitis as a rare cause of hemobilia.

Hemobilia is an unusual type of gastrointestinal bleeding most frequently due to iatrogenic injury, trauma, or neoplasia. Acute cholecystitis as a cause of hemobilia is rare. We present the case study of a patient with bleeding from eroded gallbladder mucosa in the setting of severe calculous cholecystitis. The hemorrhagic episode was preceded by acute ERCP due to obstructive icterus with extraction of the calculi, followed by the development of severe acute pancreatitis. These factors initially misled the diagnosis. The bleeding was not hemodynamically important and routine diagnostic methods did not reveal its exact source. Direct choledochoscopy (SpyGlassTM) proved to be helpful in determining the right diagnosis, as it ruled out any injury or tumor in the main bile ducts and considerably supported the assumption of intrabladder bleeding. Surgical revision confirmed the cause, and subsequent cholecystectomy solved the whole problem.

Modified N score is helpful for identifying patients who need endoscopic intervention among those with black stools without hematemesis.

OBJECTIVES: Although black stools are one of the signs of upper gastrointestinal bleeding, not all patients without hematemesis need endoscopic intervention. There is no apparent indicator to select who needs treatment thus far. The aim of this study was to establish a novel score that predicts the need for endoscopic intervention in patients with black stools without hematemesis. METHODS: We retrospectively enrolled 721 consecutive patients with black stools without hematemesis who underwent emergency endoscopy from two facilities. In the development stage (from January 2016 to December 2018), risk factors that predict the need for endoscopic intervention were determined from the data of 422 patients by multivariate logistic regression analysis, and a novel scoring system, named the modified Nagoya University score (modified N score), was developed. In the validation stage (from January 2019 to September 2020), we evaluated the diagnostic value of the modified N score for 299 patients. RESULTS: Multivariate logistic regression analysis revealed four predictive factors for endoscopic intervention: syncope, the blood urea nitrogen (BUN) level, and the BUN/creatinine ratio as positive indicators and anticoagulant drug use as a negative indicator. In the validation stage, the area under the curve of the modified N score was 0.731, and the modified N score showed a sensitivity of 82.0% and a specificity of 58.8%. CONCLUSIONS: Our modified N score, which consists of only four factors, can identify patients who need endoscopic intervention among those with black stools without hematemesis.

Long-term outcomes of over-the-scope clip for refractory gastrointestinal diseases.

BACKGROUND: The Over-The-Scope Clip (OTSC) can effectively treat refractory gastrointestinal diseases. However, most reports have focused on short-term effectiveness. We examined clinical outcomes of the deployed clips and long-term characteristics. MATERIAL AND METHODS: Of 47 patients with OTSC treatment, 35 with follow-up periods of ≥3 months were retrospectively examined. The indications were 11 bleedings, 17 perforations, and seven fistulas. The observation period was defined as medium-term (3 to <12 months) or long-term (≥12 months). The primary outcome was the clinical success rate without disease recurrence. The secondary outcomes were the complication rate, survival duration, and clip retention rate. RESULTS: The medium- and long-term clinical success rates were 100% during the observation period (median, 44 months; range, 3-78 months). The complication rate was 2.9% (n = 1). The median survival time was 1,634 days for bleeding, 1,757 days for perforation, and 444 days for fistulas. The overall clip retention rates were 56.4%, 38.1%, 30.9%, and 25.9% after one, six, and 12 months and at the final follow-up, respectively. The average clip retention duration was 244 days in bleeding, 656 days in perforations, and 188 days in fistulas. CONCLUSIONS: Regardless of clip detachment, the OTSC can be effective in long-term.

The Effect of Peroral Endoscopic Myotomy in Achalasia Patients with Prior Endoscopic Intervention: A Systematic Review and Meta-Analysis.

BACKGROUND: Peroral endoscopic myotomy (POEM) has been reported to be effective in achalasia patients with prior failed endoscopic intervention (PFI). We performed this meta-analysis to compare and summarize the clinical outcome of POEM in patients with or without prior endoscopic intervention. METHOD: We searched relevant studies published up to March 2020. Meta-analysis for technical success, clinical success, Eckardt score, lower esophageal sphincter (LES) pressure, clinical reflux, and adverse event were conducted based on a random-effects model. RESULTS: Eight studies enrolling 1,797 patients who underwent POEM were enrolled, including 1,128 naïve achalasia patients and 669 patients with PFI. In the PFI group, the pooled estimated rate of technical success was 97.7% (95% confidence interval [CI], 95.8-98.8%), the pooled clinical success rate was 91.0% (95% CI, 88.0-93.4%), and the pooled adverse events rate was 23.5% (95% CI, 10.6-44.1%). The Eckardt score significantly decreased by 5.95 points (95% CI, 5.50-6.40, p < 0.00001) and the LES pressure significantly reduced by 19.74 mm Hg (95% CI, 14.10-25.39, p < 0.00001) in the PFI group. There were no difference in the technical success, clinical success, and adverse events rate between the treatment-naïve group and PFI group, with a risk ratio of 1.0 (95% CI, 0.99-1.01, p = 0.89), 1.02 (95% CI, 0.98-1.06, p = 0.36), and 0.88 (95% CI, 0.67-1.16, p = 0.38), respectively. CONCLUSIONS: POEM is an effective and safe treatment for achalasia patients with prior endoscopic intervention. Randomized clinical trials are needed to further verify the efficiency and safety of the POEM in those patients.

Steroid eluting biocompatible stent for subglottic stenosis.

OBJECTIVE: Develop a prototype steroid eluting stent suitable for endoscopic treatment of subglottic stenosis. METHODS: Rectangular-shaped spoke design stents thermally molded into horseshoe-shaped stents were developed using AutoCAD program, and printed on a Lulzbot 3D printer with polycaprolactone (PCL). Kenalog saturated AEROSIL 200 was embedded in the PCL filament. Horizontal radial force measurements were measured at baseline, 1 day, and 1 month when deformation switched from bending to compression. Amount of Kenalog eluted after 1 day, 1 week and 1 month were measured using HPLC. RESULTS: Horizontal pressure applied to the PCL stent corresponding to a 5-0 ET were 1.27 ± 0.38 lb. at baseline, 1.79 ± 0.045 lb. at 1 day, 1.94 ± - 0.22 lb. at 1 week and 2.07 ± 0.11 lb. at 1 month. The horizontal pressure applied to PCL stent corresponding to an 8-0 ET tube were 0.82 ± 0.018 lb. at baseline, 1.008 ± 0.045 lb. at 1 day, 0.95 ± - 0.064 lb. at 1 week and 1.078 ± 0.021 lb. at 1 month. The amount of Kenalog eluted increased from 5.78 µg/mL at 1 day to 15.01 µg/mL at 1 week to 19.35 µg/mL at 1 month. CONCLUSION: This proof-of-concept project is an initial step to demonstrate and create a novel stent in the treatment of subglottic stenosis that applies expansile force on the trachea, elutes steroids and dissolves. Over time the expansile force along the trachea increases allowing the PCL to mucosalize, while it dissolves and continues to elute steroids. The limitations of this in vitro study necessitate experiments on animal models, such as rabbit tracheas to observe for complications and histologic changes. LEVEL OF EVIDENCE: This proof-of-concept project is a Level 5 mechanism-based reasoning study.

Feasibility and outcomes of anti-reflux mucosectomy for proton pump inhibitor dependent gastroesophageal reflux disease: First Indian study (with video).

BACKGROUND: Anti-reflux mucosectomy (ARMS) is a newfangled minimally invasive technique, with successful outcomes for the management of gastroesophageal reflux (GER). We present our initial experience (success rate) and safety profile for this procedure. METHODS: Consecutive patients with daily dependence on proton pump inhibitor (PPI) for GER were prospectively enrolled from September 2016 to August 2019 and underwent ARMS using a cap assisted endoscopic mucosal resection. Severity was assessed by gastroesophageal reflux disease questionnaire. Gastroscopy and 24-h pH-metry was done pre and post procedure. Patient characteristics, PPI requirement, adverse events and follow-up were documented. RESULTS: Sixty-two patients [44 (71%) male] underwent successful ARMS with a mean age (SD) of 36 (9.9) years. Technical success was achieved in 100 % of patients. Intraoperative bleeding was noted in 62 (100%) patients, endoscopic hemostasis was successfully achieved. At follow-up dysphagia was seen in 5 (8%) patients which needed a single session of endoscopic dilation. At 2 months, mean (SD) DeMeester score normalized in 45 (72.5%) patients from 76.8 (18.3) to 14.3 (6.1) (P < 0.001). PPI could be stopped in 43 (69.4%) patients. The mean (SD) GERD-Q score reduced from 10.6 (1.9) to 3.4 (1.5) (P < 0.001). However, in 12 (19.3%) patients low dose of PPIs was continued, while 7 (11.3%) patients continued full dose. Thirty-eight (61.3%) patients telephonically reported symptomatic improvement and were off PPIs at 12 months. CONCLUSIONS: Anti-reflux mucosectomy is safe and effective for treatment of GER. The long term outcomes are favorable, response is durable and promising at our center. Appropriate patient selection still remains primal to the overall success of ARMS.

Emergency endoscopic variceal band ligation in a COVID-19 patient presented with hematemesis while on mechanical ventilation.

COVID-19, caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2), is now a global pandemic with serious health consequences. Currently, many strict control measures are applied in health care settings, including endoscopy units, in order to limit virus spread. Several recommendations called to limit endoscopic procedures to emergent endoscopies; however, several uncertainties still exist concerning patient safety, protective measures, and infection control methods in emergency endoscopic settings. In this case report, we present a case of successful endoscopic band ligation for bleeding esophageal varices in man with COVID-19 disease who presented with an acute attack of hematemesis while on mechanical ventilation (MV). Esophago-gastroduodenoscopy was performed in the ICU room after preparing the setting, and revealed large, risky esophageal varices. Endoscopic band ligation was done with successful control of bleeding. Third-level measures of medical protection were applied for the participating medical personnel, and patient monitoring was maintained all through the procedure. After the procedure, the bleeding stopped, and the patient was vitally stable and conscious. We conclude that emergency endoscopic interventions could be performed safely with appropriate arrangements in patients with confirmed COVID-19 on MV.

Therapeutic Outcomes of 15 Postoperative Bronchopleural Fistulas Including Seven Endoscopic Interventions.

Therapeutic approaches to bronchopleural fistula (BPF) closure after lung resection are surgical or endoscopic interventions. We evaluated therapeutic outcomes to determine the optimal approach. We reviewed 15 patients who had developed BPF after lung resection for thoracic malignant diseases at our institution in the 10 years since 2008. The patients were 11 men and 4 women (mean age 68 years). We performed one pneumonectomy, 6 lobectomies, 7 segmentectomies, and one partial resection for malignant diseases. The median interval from lung resection to the BPF diagnosis was 46 days. The BPF-associated mortality rate was 26.7% (4/15). The rate of successful BPF closure was 66.6% (10/15). The endoscopic and surgical intervention success rates were 14.2% (1/7) and 69.2% (9/13), respectively (p<0.01). Of 5 patients who had failed BPF treatments, 4 died, and one transferred out without BPF closure. The therapeutic outcomes were related to preoperative comorbidities, performance status at the BPF diagnosis, time intervals from lung resection to BPF diagnosis, and presence of active pneumonia. The difference between endoscopic and surgical outcomes was nonsignificant, although the surgical intervention success rate was somewhat higher. The selection of endoscopic or surgical intervention for BPF does not significantly affect therapeutic outcomes.

The Role of History of Gastro-Duodenal Ulcer in Patients with Upper Gastrointestinal Bleeding.

BACKGROUND: Some scoring systems have been introduced to predict the need for performing urgent endoscopy in patients with upper gastrointestinal bleeding (UGIB). However, in an emergency situation, this intervention is insufficient and cannot easily provide the required treatment. AIM: To identify new risk factors that can predict the need for endoscopic intervention (EI) in UGIB patients. METHODS: This is a retrospective cross-sectional study. Patients with UGIB admitted from April 2011 to August 2014 were included. The proportion of cases requiring EI and clinical factors (age, gender, antiplatelet/anticoagulant therapy, history of gastro-duodenal ulcer (GDU), systolic blood pressure, heart rate, hemoglobin, mean corpuscular volume, blood urea nitrogen-creatinine ratio (BUN/Cr ratio), prothrombin time-international normalized ratio, and Glasgow-Blatchford Score (GBS) were analyzed using logistic regression models. RESULT: Of 378 patients who were included in this study, 180 were found to be with GDU. The proportion of cases requiring EI was significantly higher in those with GDU than in other causes except variceal bleeding (53.5 vs. 37.0%, p < 0.01). Multivariate analysis revealed that a history of GDU was an independent risk factor (OR 1.78, 95% CI 1.06-3.00) in addition to BUN/Cr ratio (OR 1.02, 95% CI 1.00-1.03) and GBS (OR 1.19, 95% CI 1.08-1.33). CONCLUSION: A history of GDU was an independent risk factor for predicting the need for EI in UGIB in addition to BUN/Cr ratio and GBS.

Long-term results after endoscopic drainage of pancreatic pseudocysts: A single-center experience.

BACKGROUND: Pancreatic pseudocysts (PPC) are collections of fluid encapsulated within a well-defined inflammatory wall that develop during pancreatic inflammation. Internal drainage represents the standard of care in lesions that persist and lead to symptoms and complications. Only limited data are available on long-term results and recurrence of PPC after drainage procedures. Thus, the aim of the present study was to analyse the long-term outcome after endoscopic drainage of PPC. MATERIAL AND METHODS: Patient data were retrospectively collected by review of clinical records of the University Medical Center Mannheim. We assessed the clinical short-term outcome (results in the first 30 days after initial drainage procedure), medium-term outcome (results 6 months after initial drainage procedure) and long-term outcome (results after stent removal). We performed statistical analysis to identify possible risk factors for recurrence of PPC. RESULTS: We identified 51 patients with initially successful endoscopic drainage of the PPC (n = 51/53, 96%). Among this cohort, 43 patients were available for assessment of medium-term results. In 82.9% of these 43 patients the drainage could be removed after successful treatment of the PPC. Thirty patients were available for long term follow-up with a mean observation period of 42.2 months (SD 32.8 months). Among these patients, seven (n = 7/30, 23.3%) had recurrent PPC. Approximately half of the recurrent cysts arose in different anatomical regions and most patients with recurrence had chronic pancreatitis. CONCLUSION: Endoscopic drainage represents an effective treatment for PPC. Approximately one quarter of the patients developed recurrent PPC. Half of recurrent PPC developed in different pancreatic regions than the initial PPC.

Risk factors for rebleeding in gastroduodenal ulcers.

BACKGROUND: Rebleeding after hemostasis of the gastroduodenal ulcer (GDU) is one of the indicators associated with death among GDU patients. However, there are few studies on risk score that contribute to rebleeding after endoscopic hemostasis of bleeding peptic ulcers. AIMS: The aim of this study was to identify factors associated with rebleeding, including patient factors, after endoscopic hemostasis of bleeding gastroduodenal ulcers and to stratify the risk of rebleeding. METHODS: We retrospectively enrolled 587 consecutive patients who were treated for Forrest Ia to IIa bleeding gastroduodenal ulcers with endoscopic hemostasis at three institutions. Risk factors associated with rebleeding were assessed using univariate and multivariate logistic regression analyses. The Rebleeding Nagoya University (Rebleeding-N) scoring system was developed based on the extracted factors. The Rebleeding-N score was internally validated using bootstrap resampling methods. RESULTS: Sixty-four patients (11%) had rebleeding after hemostasis of gastroduodenal ulcers. Multivariate logistic regression analysis revealed four independent rebleeding risk factors: blood transfusion, albumin <2.5, duodenal ulcer, and diameter of the exposed vessel ≧2 mm. Patients with 4 risk factors in the Rebleeding-N score had a 54% rebleeding rate, and patients with 3 risk factors had 44% and 25% rebleeding rates. In the internal validation, the mean area under the curve of the Rebleeding-N score was 0.830 (95% CI = 0.786-0.870). CONCLUSIONS: Rebleeding after clip hemostasis of bleeding gastroduodenal ulcers was associated with blood transfusion, albumin <2.5, diameter of the exposed vessel ≧2 mm, and duodenal ulcer. The Rebleeding-N score was able to stratify the risk of rebleeding.

Unmasking the Invisible: A Case Study of Aspiration Pneumonia Unveiling a Bronchoesophageal Fistula.

Bronchoesophageal fistula (BEF) is a rare, yet clinically significant, condition characterized by an abnormal connection between the bronchial tree and the esophagus. We present the case of a 25-year-old female who initially presented with symptoms of aspiration pneumonitis and was subsequently diagnosed with BEF, attributed to poorly differentiated squamous cell carcinoma. Despite initial attempts at palliative intervention through esophageal stent placement, persistent symptoms prompted further investigation, revealing the underlying malignancy. This case underscores the diagnostic challenges associated with BEF, particularly when malignancy is involved, and emphasizes the importance of a multidisciplinary approach in optimizing patient outcomes. Early recognition, thorough evaluation, and comprehensive oncological management are essential in addressing the clinical complexities posed by BEF. Further research is warranted to better understand the pathophysiology and optimal management strategies for this rare but clinically significant condition.

Early and late effects of endoscopic interventions in patients with malignant afferent loop syndrome: A single-center experience and literature review.

BACKGROUND/PURPOSE: Afferent loop syndrome (ALS) is a rare adverse event after gastrointestinal surgery requiring appropriate early decompression treatment. Several endoscopic interventions have been attempted for treatment, including endoscopic enteral metal stent placement (EMSP), endoscopic ultrasound (EUS)-guided entero-enterostomy (EUS-EE), and EUS-guided hepaticogastrostomy (EUS-HGS). However, there are limited data on outcomes, including duration of stent patency. In this study, we evaluated the usefulness of each endoscopic intervention for malignant ALS. METHODS: We retrospectively investigated nine patients with malignant ALS who underwent EMSP, EUS-EE, or EUS-HGS. Information on technical success, clinical efficacy, adverse events, stent dysfunction, and overall survival was collected and analyzed. RESULTS: The most common symptoms were abdominal pain and cholangitis. ALS was treated by EMSP in three patients, EUS-EE in three patients, and EUS-HGS in three patients. Stent placement was successful and clinically effective in all patients with no adverse events. During follow-up, stent dysfunction occurred in two patients treated by EUS-HGS. Eight patients died of primary disease during a median follow-up of 157 days. CONCLUSIONS: Each of the available endoscopic interventions for malignant ALS can be expected to produce similar outcomes, including duration of stent patency. The choice of endoscopic intervention should be made based on the characteristics of each treatment.

Bouveret Syndrome: Etiology, Clinical Presentation, Differential Diagnosis, Complications, and Treatment Options.

Bouveret syndrome is one of the complications of gallstone disease possibly fatal, which proposes the presence of a large stone obliterating the lumen of the duodenum or stomach because of the formation of a bilioenteric fistula. This review article, therefore, plans to review the causes, patient characteristics, diagnostic workup, associated conditions, and treatment of Bouveret syndrome. A literature search was also performed through scientific databases such as Scopus, Google Scholar, and PubMed concerning articles related to Bouveret syndrome written by different authors. The terms employed for the search were bilioduodenal fistula, Bouveret syndrome, gastric outlet obstruction, and gallstone ileus. Both case reports and systematic reviews that were written in the English language and published between the years 2000 and 2024 were considered. Finally, the review establishes the relevant concerns surrounding the diagnosis of Bouveret syndrome, focusing on the diagnosing issues. It emphasises the need for some specialities' involvement and focuses on the importance of endoscopic intervention. For patients, endoscopy remains the first line of treatment, while surgery is necessary in cases where conservative methods cannot be used. The article also focuses on new approaches to treating the conditions, such as percutaneous gallbladder stone dissolution. Latterly, further developments in minimally invasive surgery pertain to refining methods, including endoscopic removal and lithotripsy, to improve the survival rate of patients. Further investigation is required, especially regarding the administration schedule in relation to this disorder and goals that can reduce mortality and morbidity, especially in elderly patients with comorbid diseases.

A case of early-onset idiopathic chronic pancreatitis associated with a loss-of-function TRPV6 p.R483Q variant successfully treated by pancreatic duct stenting.

Several pancreatitis-related genetic variants have been identified. Recently, the association of loss-of-function variants in the transient receptor potential cation channel subfamily V member 6 (TRPV6) gene and early-onset non-alcoholic chronic pancreatitis (CP) has been reported. However, detailed clinical presentation of the cases carrying TRPV6 variants remains largely unknown. We report a case of early CP carrying a TRPV6 variant in which recurrent attacks of pancreatitis were successfully managed by pancreatic duct stenting. A 12-year-old boy with CP was referred to our hospital for further investigation. He had experienced recurrent pancreatitis attacks since he was 11 years old. Pancreatic ductal anomalies were not identified on magnetic resonance cholangiopancreatography. Genetic analysis revealed that the patient had a loss-of-function TRPV6 c.1448G > A (p.R483Q) variant in a heterozygous form. Conservative treatments were not effective; thus, we placed pancreatic duct stent by endoscopic intervention, and the frequency of relapses have dramatically decreased. We present the first pediatric report of early CP associated with the TRPV6 variant that was successfully treated with pancreatic duct stenting. This case suggests that pancreatic duct stenting is effective in preventing the relapse of pancreatitis related to the TRPV6 variant.

Therapeutic and prophylactic effects of radiation therapy in the management of recurrent granulation tissue induced tracheal stenosis: a review on the role of Endobronchial brachytherapy and external beam radiation therapy.

PURPOSE: Granulation tissue-induced tracheal stenosis (mainly secondary to intubation or lung transplantation) is one of the most common etiologies of benign airway obstructions. Recurrence rates after standard treatment options (surgical resection and/or endobronchial interventions) can inadvertently worsen the stricture through the stimulation of more granulation tissue generation (via increased fibroblast activity and roliferation). Low-dose radiotherapy could be a promising tool to prevent granulation tissue formation after surgery and/or endobronchial interventions regarding its established role in the treatment of keloids or hypertrophic scars, two benign diseases with similar a pathophysiology to tracheal stenosis. This study reviews case reports and small series that used endobronchial brachytherapy (EBBT) or external beam radiotherapy (EBRT) for the management of refractory granulation tissue-induced tracheal stenosis after surgery and/or endobronchial interventions. METHODS AND MATERIALS: Case reports and series (published up to October 2022) that reported outcomes of patients with recurrent granulation tissue-induced tracheal stenosis (after surgery and/or endobronchial interventions) treated by EBBT or EBRT (in definitive or prophylactic settings) were eligible. RESULTS: Sixteen studies (EBBT: nine studies including 69 patients, EBRT: seven studies including 32 patients) were reviewed. The pooled success rate across all studies was 74% and 97% for EBBT and EBRT, respectively. CONCLUSIONS: Radiation therapy appears to be effective in the management of selected patients with recurrent/refractory tracheal stenosis. Response to this treatment is usually good, but further studies with a larger number of patients and long-term followup are necessary to determine the optimal technique, dose, and timing of radiation therapy, late complications, the durability of response, and criteria for patient selection.

Role of endoscopic ultrasound for pre-intervention evaluation in early esophageal cancer.

BACKGROUND: Endoscopic ultrasound (EUS) stands as an accurate imaging modality for esophageal cancer staging, however utilization of EUS in early-stage cancer management remains controversial. Identification of non-applicability of endoscopic interventions with deep muscular invasion with EUS in pre-intervention evaluation of early-stage esophageal cancer is compared to endoscopic and histologic indicators. AIM: To display the role of EUS in pre-intervention early esophageal cancer staging and how the index endoscopic features of invasive esophageal malignancy compare for prediction of depth of invasion and cancer management. METHODS: This was a retrospective study of patients who underwent pre-resection EUS after a diagnosis of esophageal cancer at a tertiary medical center from 2012 to 2022. Patient clinical data, initial esophagogastroduodenoscopy/biopsy, EUS, and final resection pathology reports were abstracted, and statistical analysis was conducted to assess the role of EUS in management decisions. RESULTS: Forty nine patients were identified for this study. EUS T stage was concordant with histological T stage in 75.5% of patients. In determining submucosal involvement (T1a vs T1b), EUS had a specificity of 85.0%, sensitivity of 53.9%, and accuracy of 72.7%. Endoscopic features of tumor size > 2 cm and the presence of esophageal ulceration were significantly associated with deep invasion of cancer on histology. EUS affected management from endoscopic mucosal resection/submucosal dissection to esophagectomy in 23.5% of patients without esophageal ulceration and 6.9% of patients with tumor size < 2 cm. In patients without both endoscopic findings, EUS identified deeper cancer and changed management in 4.8% (1/20) of cases. CONCLUSION: EUS was reasonably specific in ruling out submucosal invasion but had relatively poor sensitivity. Data validated endoscopic indicators suggested superficial cancers in the group with a tumor size < 2 cm and the lack of esophageal ulceration. In patients with these findings, EUS rarely identified a deep cancer that warranted a change in management.

Effect of turbinoplasty in concha bullosa induced rhinogenic headache, a randomized clinical trial.

BACKGROUND: Rhinogenic origin is an important source for headache, which may be treated by medical or endoscopic intervention. An aim of this study was to clarify whether the surgical or medical intervention is superior. MATERIALS AND METHODS: In this randomized double blind clinical trial study, 44 patients (19 male and 25 female) with periorbital or frontal pain were enrolled. Patients were divided into 2 groups of surgical or medical intervention randomly. Medical group received 3 courses of 1.5 months 125 µg per puff, fluticason nasal spray (2 puffs Q 24 hours in each side), and oral Pseudoephedrin 30 mg Q 8 hours with 2 weeks intervals. Surgical group underwent turbinoplasty with functional endoscopic sinus surgery approach. Duration (per hour), frequency (per week) and severities of the headaches were measured by Visual Analog Scale (VAS) before treatment, and at 1.5, 3 and 6 months after institution of treatment by an examiner, who was unaware of the patients' treatment plan. RESULTS: Before treatment, chronicity (P = 0.980), severity (P = 0.742), frequency (P = 0.730), and duration (P = 0.603) of the headaches were not significantly different. The severities of the headaches in surgical group were significantly lower at 1.5, 3 and 6 months (P < 0.001), also the frequencies and the durations of the headaches were significantly lower at 6 months after an institution of treatment compared to medical group (P = 0.027, P = 0.008, respectively). CONCLUSION: Turbinoplasty in chonca bullusa patients is an acceptable and a simple procedure for relieving pain in rhinogenic headaches, compared with medical treatment.