ENDOLUMINAL RADIOFREQUENCY ABLATION WITH STENTING VS STENTING ONLY IN PATIENTS WITH MALIGNANT BILIARY OBSTRUCTION: A META-ANALYSIS OF RANDOMISED TRIALS.

INTRODUCTION: Endoluminal radiofrequency ablation (RFA) is a palliative treatment for patients suffering from malignant biliary obstruction. We aimed to conduct a meta-analysis to evaluate the impact of RFA on stent patency, patient survival, and adverse events. METHODS: Major databases were searched through November 2023 for patients who underwent stenting with or without RFA for extra-hepatic malignant biliary obstruction. A random effects model was employed for analysis and results conveyed using relative risk ratio with 95% confidence interval. RESULTS: Nine RCTs involving 750 subjects (n=374 RFA plus stent vs. n=376 stent only) with malignant biliary obstruction were included. Meta-analysis revealed similar risks of stent patency at 3 months (RR = 1.01; 95% CI [0.92 - 1.11], I2=4% for RFA plus stenting vs. stent only). Meta-analysis showed improved survival at 6 months (RR = 0.84; 95% CI [0.73 - 0.96], I2=21%, P=0.01 for RFA plus stenting vs. stent only). Subgroup analysis comparing plastic vs uncovered metal stents showed that stent patency was unaffected at 3 months (RR = 1.06; 95% CI [0.91 - 1.23]; I2=17%). Subgroup analysis showed that patients with cholangiocarcinoma experienced an overall survival benefit with RFA plus stenting vs. stent only (P<0.001), however, stent patency remained unaffected (P=0.08). An increased incidence of cholecystitis was noted with RFA plus stent vs. stent only (5.1%; 95% CI [3.1% - 7.8%] vs 0.3%; 95% CI [0.01% - 1.5%], respectively). CONCLUSION: Combining endoluminal RFA and stenting may improve overall survival in patients with malignant biliary obstruction. RFA did not impact stent patency significantly.

Patient adverse events and technical failures with the bravo capsule pH system: insights from the MAUDE database.

BACKGROUND: The BRAVO pH monitor system can benefit patients with ongoing GERD symptoms despite treatment and/or atypical symptoms. We aim to investigate the number and type of complications associated with the BRAVO pH capsule. METHODS: From April 2016 through February 2021, we analyzed post-marketing surveillance data from the FDA Manufacturer and User Facility Device Experience (MAUDE) database. RESULTS: During the study period, approximately 1,651 reports were identified with 2391 cases associated with a device failure, and 254 reporting a patient-related adverse event. Most device complications were due to aspiration n = 153), followed by reported pain (n = 79), injury (unspecified) (n = 63), and additional radiologic imaging (n = 44). Laceration and bleeding accounted for 29 and 19 cases. Furthermore, three patients suffered perforation. Most device failures were due to loss or failure of the Bravo capsule to bond or adhere to the esophageal mucosa as planned (n = 1269), followed by an activation or positioning failure (n = 972), premature detachment of device (n = 284), and failure of the device to record or transmit data (n = 158). CONCLUSIONS: Findings from the MAUDE database highlight the risk of aspiration, hemorrhage/bleeding, perforation, injury, and retention as potential complications of BRAVO capsule placement.

Real-World Experience of Intragastric Balloons for Obesity: Insights from the FDA Manufacturer and User Facility Device Experience (MAUDE) Database.

Intragastric balloons have been used to bridge the obesity treatment gap. We aim to investigate the number and type of complications associated with intragastric balloons using public-access governmental databanks. We analyzed post-marketing surveillance data from the FDA Manufacturer and User Facility Device Experience (MAUDE) database from Jan 2017 through Nov 2020. During the study period, approximately 773 cases with 830 device issues and 1134 patient complications were identified. Most balloon complications were due to leaks (33.4%). The most reported adverse events were vomiting (26.6%), abdominal pain (25.3%), and nausea (15.8%). Findings from the MAUDE database highlight patient and device adverse outcomes that should be addressed to improve clinical success.

A rare cause of the abdominal pain in a 48-year-old woman with a history of prior colon surgery.

Fecal retention in the blind loop of end to side colonic anastomosis can lead to fecaloma without significant colonic distension. Imaging study and colonoscopy examination can assist in making a definite diagnosis. Revision surgery is the last choice when colonoscopic extraction fails.

Miller Fisher Variant of Guillain-Barré Syndrome: A Great Masquerader.

Guillain-Barré Syndrome (GBS) is an acquired degenerative, demyelinating neurological disorder classically characterized by progressive, symmetrical ascending paralysis. Often associated to occur after a viral illness, most commonly an upper respiratory infection (URI), followed by gastrointestinal illnesses. Here we present a case of Miller Fisher syndrome (MFS) which is a rare variant of GBS. MFS presents with a triad of ataxia, areflexia, and opthalmoplegia. MFS is a clinical diagnosis but can be confirmed serologically with positive anti-ganglioside antibodies.

Isolated Gastric Varices due to Essential Thrombocytosis Related to Splenic Vein Thrombosis: A Challenge to Uncover the Concealed Diagnosis.

Essential thrombocytosis is associated with gastrointestinal (GI) vascular thrombosis. Sinistral portal hypertension (left-sided portal hypertension) due to splenic vein thrombosis can lead to isolated gastric varices and should be suspected in a patient with obscure GI bleeding with normal liver function. This case reviews the challenges presented in diagnosing isolated gastric varices due to splenic vein thrombosis through radiologic or endoscopic studies. Unrevealing radiologic or endoscopic studies does not rule out splenic vein thrombosis, which should be suspected in a patient with essential thrombocytosis and obscure GI bleeding.

A Rare Case of Disseminated Mycobacterium avium-intracellulare Presenting as Proctitis.

Mycobacterium avium intracellulare (MAI) infections are common in Human Immuno-deficiency Virus (HIV) positive patients. MAI infection can have localized or disseminated presentation, patients with low CD4 count presenting with disseminated infection. Fever, abdominal pain, diarrhea, and weight loss are generally the presenting symptoms of disseminated MAI. We present a rare case of a patient with HIV and low CD4 count presenting with proctitis as manifestation of disseminated MAI infection. A 25 year-old-man with HIV came to the emergency room (ER) with complaints of intermittent rectal bleeding for two months. His CD4 count was less than 20 cells/µL. He was MSM (men having sex with men) and has receptive anal intercourse with men. His stool work-up was unrevealing for infectious etiology. Swabs for gonorrhea and chlamydia were negative. Colonoscopy revealed erythematous, congested, friable rectal mucosa with two superficial ulcers. Biopsies of the ulcer were positive for acid fast staining bacteria and the culture grew MAI. His blood culture was negative for growth of acid-fast bacteria (AFB). However, liver biopsy performed for elevated alkaline phosphatase of 958 units/L revealed noncaseating granuloma. Gastro-duodenoscopy with duodenal biopsy did not reveal any mucosal abnormality. He was managed as with disseminated MAI infection using clarithromycin, ethambutol, and rifabutin in addition to HAART therapy. Interval Colonoscopy in 20 months showed resolution of rectal ulcer. The gut is often involved in patients with disseminated MAI infection, with the duodenum being the most common site. MAI infection should be suspected as possible etiology for proctitis in HIV positive patient with low CD4 count, as proctitis, though infrequent can be the sole presentation for disseminated MAI infection in patients with HIV and low CD4 count.