Low delayed bleeding and high complete closure rate of mucosal defects with the novel through-the-scope dual-action tissue clip after endoscopic resection of large nonpedunculated colorectal lesions (with video).

BACKGROUND AND AIMS: Complete closure after endoscopic resection of large nonpedunculated colorectal lesions (LNPCLs) can reduce delayed bleeding but is challenging with conventional through-the-scope (TTS) clips alone. The novel dual-action tissue (DAT) clip has clip arms that open and close independently of each other, facilitating tissue approximation. We aimed to evaluate the rate of complete closure and delayed bleeding with the DAT clip after endoscopic resection of LNPCLs. METHODS: This was a multicenter prospective cohort study of all patients who underwent defect closure with the DAT clip after EMR or endoscopic submucosal dissection (ESD) of LNPCLs ≥20 mm from July 2022 to May 2023. Delayed bleeding was defined as a bleeding event requiring hospitalization, blood transfusion, or any intervention within 30 days after the procedure. Complete closure was defined as apposition of mucosal defect margins without visible submucosal areas <3 mm along the closure line. RESULTS: One hundred seven patients (median age, 64 years; 42.5% women) underwent EMR (n = 63) or ESD (n = 44) of LNPCLs (median size, 40 mm; 74.8% right-sided colon) followed by defect closure. Complete closure was achieved in 96.3% (n = 103) with a mean of 1.4 ± .6 DAT clips and 2.9 ± 1.8 TTS clips. Delayed bleeding occurred in 1 patient (.9%) without requiring additional interventions. CONCLUSIONS: The use of the DAT clip in conjunction with TTS clips achieved high complete defect closure after endoscopic resection of large LNPCLs and was associated with a .9% delayed bleeding rate. Future comparative trials and formal cost-analyses are needed to validate these findings. (Clinical trial registration number: NCT05852457.).

EUS-Guided Vascular Interventions: Recent Advances.

Endoscopic ultrasound (EUS)-guided vascular interventions were first reported in 2000 in a study that evaluated the utility of EUS in sclerotherapy of esophageal varices. Currently, gastric variceal therapy and portosystemic pressure gradient (PPG) measurements are the most widely utilized applications. Ectopic variceal obliteration, splenic artery embolization, aneurysm/pseudoaneurysm treatment, portal venous sampling, and portosystemic shunt creation using EUS are some of the other emerging interventions. Since the release of the American Gastroenterological Association (AGA)'s commentary in 2023, which primarily endorses EUS-guided gastric variceal therapy and EUS-PPG measurement, several new studies have been published supporting the use of EUS for various vascular conditions. In this review, we present the recent advances in this field, critically appraising new studies and trials.

Double-balloon enteroscopy with EUS-guided rendezvous for failed cannulation in patients with history of Roux-en-Y gastric bypass.

Video 1Double-balloon enteroscopy with EUS-guided rendezvous for biliary access in patients with a history of Roux-n-Y gastric bypass.

Helix tack for lumen-apposing metal stent fixation in single-session EUS-directed transgastric ERCP.

Video 1Helix tack for lumen-apposing metal stent fixation in single-session EUS-directed transgastric ERCP.

Trends and outcomes of percutaneous endoscopic gastrostomy in hospitalized patients with malignant and nonmalignant ascites: a nationwide population study.

BACKGROUND: Patients with ascites resulting from chronic debilitating diseases often require non-oral enteral nutrition and undergo placement of a percutaneous endoscopic gastrostomy (PEG) tube. The aim of our study was to assess the nationwide trends and outcomes of PEG tube placement among patients with ascites. METHODS: Using the Nationwide Inpatient Sample (NIS), we conducted a retrospective analysis of adult patients (≥18 years) who underwent PEG tube placement (n=789,167) from 2010-2014. We divided these patients into 2 groups: with or without ascites. We compared demographics, complications, and in-hospital outcomes between the groups. STATA-13 was used for statistical analysis. Statistical significance was assigned at P<0.05. RESULTS: Patients with ascites who underwent PEG tube placement were found to have a significantly higher rate of complications, including peritonitis (7.52 vs. 0.72%; P<0.001), aspiration pneumonia (20.41 vs. 2.69%; P<0.001), hemoperitoneum (0.72 vs. 0.19%; P<0.001), procedure-related hemorrhage (1.69 vs. 0.9%; P<0.001) and esophageal perforation (0.51 vs. 0.47%; P<0.001). In addition, these patients also had higher in-hospital mortality (16.33% vs. 7.02%; P<0.001) despite having a relatively lower prevalence of comorbidities. Length of stay was longer in the ascites group (28.08 vs. 19.45 days; 0.001). Over the study period, however, we observed an increasing trend for PEG tube placement in hospitalized patients with ascites. CONCLUSION: PEG tube placement in hospitalized patients with ascites is associated with significantly higher mortality, a longer stay, and more procedure-related complications.

Zollinger Ellison Syndrome in a Patient with Multiple Endocrine Neoplasia Type 1: A Classic Presentation.

Zollinger Ellison Syndrome (ZES) is characterized by a wide spectrum of conditions including severe gastroesophageal reflux disease, peptic ulcer disease, watery diarrhea, and weight loss. We present a case of a 60-year-old woman being evaluated for severe dyspepsia, vomiting, and chronic diarrhea, who was diagnosed to have ZES associated with a pancreatic neuroendocrine tumor, in the setting of multiple endocrine neoplasia (MEN) type 1. Although cases of ZES have been reported previously, we believe that our case is a classic presentation of ZES diagnosed on the basis of typical radiologic, endoscopic, and endosonographic features.

Mirror-image pain after nerve reconstruction in rats is related to enhanced density of epidermal peptidergic nerve fibers.

Mirror-image pain is a phenomenon in which unprovoked pain is detected on the uninjured contralateral side after unilateral nerve injury. Although it has been implicated that enhanced production of nerve growth factor (NGF) in the contralateral dorsal root ganglion is important in the development of mirror-image pain, it is not known if this is related to enhanced expression of nociceptive fibers in the contralateral skin. Mechanical and thermal sensitivity in the contralateral hind paw was measured at four different time points (5, 10, 20 and 30weeks) after transection and immediate end-to-end reconstruction of the sciatic nerve in rats. These findings were compared to the density of epidermal (peptidergic and non-peptidergic) nerve fibers on the contralateral hind paw. Mechanical hypersensitivity of the contralateral hind paw was observed at 10weeks PO, a time point in which both subgroups of epidermal nerve fibers reached control values. Thermal hypersensitivity was observed with simultaneous increase in the density of epidermal peptidergic nerve fibers of the contralateral hind paw at 20weeks PO. Both thermal sensitivity and the density of epidermal nerve fibers returned to control values 30weeks PO. We conclude that changes in skin innervation and sensitivity are present on the uninjured corresponding side in a transient pain model. Therefore, the contralateral side cannot serve as control. Moreover, the current study confirms the involvement of the peripheral nervous system in the development of mirror-image pain.

Innervation mapping of the hind paw of the rat using Evans Blue extravasation, Optical Surface Mapping and CASAM.

BACKGROUND: Although numerous studies investigate sensory regeneration and reinnervation of the hind paw of the rat after nerve damage, no comprehensive overview of its normal innervation is present in literature. The Evans Blue extravasation technique is a well-known technique to study patterns of skin innervation. This technique has been performed differently by various groups but was never used to study the entire skin innervation in rats' hind paw including all three branches of the sciatic nerve and the saphenous nerve in detail. NEW METHOD: In this paper, we have used the Evans Blue extravasation technique to chart the skin areas innervated by the sural, peroneal, tibial and/or saphenous nerves, which together innervate the entire hind paw of the rat, and use a new technique to analyze the distribution, overlap and variability of the results. The technique is based on analysis of whole hind paws using Optical Surface Mapping (OSM) in combination with the Computer Assisted Surgical Anatomy Mapping (CASAM) technology. RESULTS: While the plantar hind paw is mainly innervated by the tibial nerve, the dorsal hind paw is supplied by the sural, peroneal and the saphenous nerve. COMPARISON WITH EXISTING METHODS: Although our results basically concur with the general nerve-specific innervation of the rat hind paw, they show considerable detail in their areas of overlap as well as in the amount of variability between animals. CONCLUSION: These results will be invaluable to study and evaluate patterns of innervation and reinnervation of intact and damaged nerve fibers.

Thermo-sensitive TRP channels in peripheral nerve injury: a review of their role in cold intolerance.

One of the sensory complications of traumatic peripheral nerve injury is thermal intolerance, which manifests in humans mainly as cold intolerance. It has a major effect on the quality of life, and adequate therapy is not yet available. In order to better understand the pathophysiological background of thermal intolerance, we focus first on the various transient receptor potential (TRP) channels that are involved in temperature sensation, including their presence in peripheral nerves and in keratinocytes. Second, the role of thermo-sensitive TRP channels in cold and heat intolerance is described showing three different mechanisms that contribute to thermal intolerance in the skin: (a) an increased expression of TRP channels on nerve fibres and on keratinocytes, (b) a lower activation threshold of TRP channels and (c) the sprouting of non-injured nerve fibres. Finally, the data that are available on the effects of TRP channel agonists and antagonists and their clinical use are discussed. In conclusion, TRP channels play a major role in temperature sensation and in cold and heat intolerance. Unfortunately, the available pharmaceutical agents that successfully target TRP channels and counteract thermal intolerance are still very limited. Yet, our focus should remain on TRP channels since it is difficult to imagine a reliable treatment for thermal intolerance that will not involve TRP channels.