Over-the-scope-clip (OTSC®) as a rescue treatment for gastrointestinal bleeding secondary to peptic ulcer disease.

BACKGROUND AND AIMS: over-the-scope-clips (OTSC®) have been proposed as a rescue treatment for bleeding peptic ulcers. However, their effectiveness has not been evaluated in Spain. METHODS: this retrospective and single-center study (January 2018-December 2021) assessed the technical success, clinical success and safety of the device within 30 days. All patients with upper gastrointestinal bleeding due to a peptic ulcer and treated with the OTSC® clip (OVESCO) as a rescue therapy were included in the study. RESULTS: a total of eleven patients were included in the study, nine due to rebleeding and two due to persistent bleeding. Technical success was 81.9 % (9/11, confidence interval [CI] 95 %: 52-95 %). The per-protocol and intention-to-treat clinical success were 88.9 % (8/9, CI 95 %: 57-98 %) and 72.7 % (8/11, CI 95 %: 43-90 %), respectively. No device-related adverse effects were recorded. CONCLUSION: the OTSC® clip was an effective and safe rescue therapy for bleeding peptic ulcers.

Disposable duodenoscopes. Is healthcare system affordability the main hindrance?

The performance of an endoscopic procedure involves introducing an endoscope through the mouth or the anus, which may potentially lead to lethal infection. The risk increases when complex and difficult-to-clean scopes are used, as in the case of duodenoscopes. Side-viewing duodenoscopes are complex in design, with the camera and working channel exit located on one side of the endoscope's distal end, and with an elevator nail also located at this point for catheter redirection. This complex design may facilitate the presence of blind areas not easy to access for cleaning, resulting in suboptimal disinfection of the duodenoscope and therefore a higher risk of bacterial infection. This is of particular importance in particularly vulnerable patients like those who are immunosuppressed (e.g., transplanted patients) or have a malignant disease and are receiving chemotherapy. Moreover, in the era of ¨superbugs¨, like carbapenem-resistant Enterobacteriaceae, infection outbreaks related to endoscopic retrograde cholangiopancreatography (ERCP) have been reported with a significant mortality rate.

Anti-Hu-mediated paraneoplastic chronic intestinal pseudo-obstruction associated with extraskeletal myxoid chondrosarcoma.

Chronic intestinal pseudo-obstruction (CIPO) is characterized by symptoms and signs of bowel obstruction in the absence of an anatomical cause. Almost 50 % of cases are secondary to systemic diseases of neurological, paraneoplastic, autoimmune, metabolic, or infectious origin.

The endoscopic ultrasound-assisted Rendez-Vous technique for treatment of recurrent pancreatitis due to pancreas divisum and ansa pancreatica.

Endoscopic treatment of pancreatic ductal malformations causing recurrent acute pancreatitis, such as pancreas divisum or ansa pancreatica, is mainly based on the sphincterotomy of the minor papilla. However, the technical complexity of conventional endoscopic retrograde cholangiopancreatography (ERCP) is increased in patients presenting anatomical variants like these and it may be unsuccessful. We report the case of a pancreas divisum combined with ansa pancreatica and describe the cannulation and sphincterotomy of the minor papilla using an ultrasound-assisted Rendez-Vous technique.

Evaluation of the short- and long-term effectiveness and safety of fully covered self-expandable metal stents for drainage of pancreatic fluid collections: results of a Spanish nationwide registry.

BACKGROUND AND AIMS: Initial reports suggest that fully covered self-expandable metal stents (FCSEMSs) may be better suited for drainage of dense pancreatic fluid collections (PFCs), such as walled-off pancreatic necrosis. The primary aim was to analyze the effectiveness and safety of FCSEMSs for drainage of different types of PFCs in a large cohort. The secondary aim was to investigate which type of FCSEMS is superior. METHODS: This was a retrospective, noncomparative review of a nationwide database involving all hospitals in Spain performing EUS-guided PFC drainage. From April 2008 to August 2013, all patients undergoing PFC drainage with an FCSEMS were included in a database. The main outcome measurements were technical success, short-term (2 weeks) and long-term (6 months) effectiveness, adverse events, and need for surgery. RESULTS: The study included 211 patients (pseudocyst/walled-off pancreatic necrosis, 53%/47%). The FCSEMSs used were straight biliary (66%) or lumen-apposing (34%). Technical success was achieved in 97% of patients (95% confidence interval [CI], 93%-99%). Short-term- and long-term clinical success was obtained in 94% (95% CI, 89%-97%) and 85% (95% CI, 79%-89%) of patients, respectively. Adverse events occurred in 21% of patients (95% CI, 16%-27%): infection (11%), bleeding (7%), and stent migration and/or perforation (3%). By multivariate analysis, patient age (>58 years) and previous failed drainage were the most important factors associated with negative outcome. CONCLUSIONS: An FCSEMS is effective and safe for PFC drainage. Older patients with a history of unsuccessful drainage are more likely to fail EUS-guided drainage. The type of FCSEMS does not seem to influence patient outcome.

ERCP during pregnancy.

BACKGROUND AND AIMS: ERCP during pregnancy is always challenging for the entire team performing the endoscopic intervention. In this study techniques and different interventional aspects used at several centres about the clinical experience on ERCP in pregnant women are analyzed. PATIENTS AND METHODS: the practice on ERCP in pregnant women in six centres during a period of ten years is reported. RESULTS: eleven patients were included in the study. Mean age was 30.6 years. Indication for ERCP was always symptomatic common bile duct stone (CBDS) disease. Before the procedure abdominal ultrasound was performed at all times and magnetic resonance cholangiopancreatography in four occasions. Conscious sedation by means of midazolam and fentanyl or meperidine was applied. Sphincterotomes and guidewires were used for bilary cannulation. Sometimes, rapid exchange platforms with short-length guidewires controlled by the same endoscopist were employed. Biliary cannulation was confirmed in 9 occasions by bile aspiration. In five procedures, a mean of 30 seconds of fluoroscopy was used, both to verify cannulation and to corroborate complete CBDS clearance. These patients had the pelvic zone protected with a lead shield and radiation dose was measured. Ten biliary sphincterotomies were performed followed by CBDS extraction. Two plastic stents were inserted. Relief of biliary obstruction was attained in all circumstances. Only one patient had hyperamylasemia after ERCP. All pregnant women had healthy foetuses with normal deliveries. CONCLUSIONS: with experience, ERCP appears to be a safe technique during pregnancy. With simple measures fluoroscopic time can be diminished or even abolished. It seems that ERCP during pregnancy is underused in our working areas, although it has shown to be a useful technique for relieving biliary obstruction.

Gastric polyps: analysis of endoscopic and histological features in our center.

BACKGROUND AND OBJECTIVE: the prevalence of gastric polyps in esophagogastroduodenoscopies (EGDs) ranges between 0.33 and 6.35%. The relative frequency of histological subspecies varies widely among published series. The objective is to describe the endoscopic and histological characteristics of the polypoid lesions, and to study possible associations. MATERIAL AND METHODS: we retrospectively revised the EGDs done in our center in 2009. Demographic, endoscopic and histological data were gathered. We proceeded to a descriptive analysis and studied possible associations. RESULTS: gastric polypoid lesions were found in 269 of the 6,307 (4.2%) reviewed EGDs, 61% were found in women. Mean age was 64.93 years (SD: ±15.23). A single polyp was found in 186 patients (69.1%), over 10 lesions appeared in 31 (11.5%). An estimated size of ≤ 3 mm was found in 108 lesions (37.2%) and greater than 10 mm in 52 cases (17.9%). Most lesions were sessile (90.8%). The location of 34.8% was the gastric antrum, 39.3% were found in the gastric body and 25.9% were in the fundus. Chronic gastritis was confirmed in 53.5% of the patients and 46.5% had received protom pump inhibitors (PPIs). Histopathological diagnosis was: hyperplastic polyps 50.9%, fundic gland polyps 7.4%, adenomas 3%, adenocarcinomas 1.9% and normal mucosa 29.7%. We found no significant association between the histopathological type of lesions and the use of proton pump inhibitor. CONCLUSIONS: we found polypoid lesions in 4.2% of the EGDs. The most frequent histopathological findings were hyperplastic polyps (50.9%), followed by fundic gland polyps (7.4%), adenomas (3%), and adenocarcinomas (1.9%).

[Applications of clips in current endoscopic therapeutics]. / Aplicaciones de los clips en la terapéutica endoscópica actual.

The applications of clips in current therapeutics are increasingly numerous. Endoscopic hemoclipping for acute nonvariceal bleeding is a highly effective and safe modality for hemostasis with initial hemostatic rates of between 85 and 98% and a rebleeding rate of approximately 5-10% both in patients with peptic ulcer bleeding and signs of endoscopic risk (Forrest Ia-IIb) and in bleeding secondary to submucosal lesions, diverticular bleeding, Mallory-Weiss tear, bleeding Dieulafoy's lesions, and postpolypectomy bleeding. In addition to the effectiveness of this technique as a hemostatic mechanism, many publications have demonstrated the utility of these clips to close perforations and fistulas, to serve as a radiopaque marker and as a tool to fix accessories (feeding tubes or prostheses). However, endoscopic clipping has certain limitations depending on the nature of the injury and the type of patient, as well as high economic cost and some technical limitations.

Lumen-apposing metal stents versus biliary fully-covered metal stents for EUS-guided drainage of pancreatic fluid collections: a case control study: Meeting presentations: European Society of Gastrointestinal Endoscopy ESGE Days 2018.

Background and study aims Endoscopic ultrasound (EUS)-guided drainage has become first-line treatment for pancreatic fluid collections (PFC). The aim of this study was to compare the effectiveness and safety of biliary fully-covered self-expandable metal stents (BFCSEMS) and lumen-apposing metal stents with electrocautery (EC-LAMS). Patients and methods From April 2008 to March 2017, consecutive patients with symptomatic PFC drained under EUS-guidance with metal stents were included. Patients drained with EC-LAMS were considered the study group and those drained with BFCSEMS the control group. Two primary endpoints were evaluated: effectiveness (defined as reduction of ≥ 50 % of PFC size in cross-sectional imaging and improvement of symptoms 6 months after the transmural drainage) and safety. Results Thirty patients were drained with EC-LAMS and 60 patients with BFCSEMS. Patients and PFC baseline characteristics in both groups were similar. Use of a coaxial double pigtail plastic stent and a nasocystic lavage catheter was significantly less frequent in patients drained with EC-LAMS (33 % vs. 100 %, and 13 % vs. 58 %, respectively; P  < 0.0001). Technical success was 100 % in both groups. Procedure time was < 30 minutes in all patients drained with EC-LAMS and over 30 minutes in all patients drained with BFCSEMS ( P  = 0.0001). Clinical success was higher with a tendency to significance in patients drained with EC-LAMS (96 % vs. 82 %, P  = 0.055) and the adverse event rate was lower (4 % vs. 18 %, P  = 0.04). No case of procedure-related mortality was recorded. Conclusions EC-LAMS and BFCSEMS are both effective for EUS-guided drainage of PFC. However, EC-LAMS requires less time to be performed and appears to be safer.

[Multiple lymphomatous polyposis, favorable outcome after chemotherapy]. / Poliposis linfomatosa múltiple, evolución favorable tras tratamiento quimioterapéutico.

Multiple lymphomatous polyposis is a rare type of non Hodgkin lymphoma that has aggressive biological behavior, early systemic dissemination and poor prognosis. In most cases it is considered to be a gastrointestinal manifestation of mantle cell nodal lymphoma. We describe a case of a 55 year old man, with favorable outcome after chemotherapy.

Biliary sphincterotomy reduces the risk of acute gallstone pancreatitis recurrence in non-candidates for cholecystectomy.

BACKGROUND: Population aging and comorbidity are leading to an increase in patients unfit for cholecystectomy. AIMS: To evaluate whether endoscopic biliary sphincterotomy after a first episode of acute gallstone pancreatitis reduces the risk of pancreatitis recurrence and gallstone-related events in non-surgical candidates. METHODS: Retrospective study of patients admitted for a first episode of acute gallstone pancreatitis rejected for cholecystectomy between 2013-2018. The role of endoscopic sphincterotomy was evaluated by adjusting for age, severity of pancreatitis, and presence of choledocholithiasis. RESULTS: We included 247 patients (mean age 80 ±â€¯12 years; Charlson index: 5; severity of pancreatitis: 72% mild). Sphincterotomy was performed in 23.9%. Recurrence of pancreatitis occurred in 17.4% patients (median follow-up: 426 days). The one-year cumulative incidence of a new episode of pancreatitis was 1.8% (95% confidence interval [CI]: 0.2-12%) and 23% (95% CI: 17-31%) in patients with and without sphincterotomy, respectively (p = 0.006). In multivariate analysis, sphincterotomy showed a protective role for recurrence of pancreatitis (adjusted hazard ratio [HR]: 0.29, 95% CI: 0.08-0.92, p = 0.037) and for any gallstone-related event (HR 0.46, 95% CI: 0.21-0.98, p = 0.043). CONCLUSIONS: Endoscopic biliary sphincterotomy reduced the risk of gallstone pancreatitis recurrence and other biliary-related disorders in patients with a first episode of pancreatitis non-candidates for cholecystectomy.

[A rare cause of gastric outlet obstruction: Bouveret's syndrome]. / Una causa infrecuente de obstrucción gástrica: síndrome de Bouveret.

Bouveret's syndrome is a rare type of gallstone ileus in which a gallstone enters the intestinal tract via a cholecystoenteric fistula and is lodged in the duodenum or the stomach. Since the first description by León Bouveret in 1896, fewer than 200 cases have been described in the worldwide literature. Mortality is high, at 25%, but may be related to the advanced age of the typical patient and comorbidities, as well as diagnostic delay. Diagnosis may be made with radiological (abdominal X-ray, ultrasound, computed tomography or magnetic resonance imaging) and endoscopic techniques. Endoscopy is preferred as the first therapeutic option but is frequently unsuccessful and surgery is often required. We present the case of a patient admitted to hospital with a history of vomiting after eating and epigastric pain. The management of this rare cause of gastric outlet obstruction is discussed.

What Is the Value of the Learning Curve in Endoscopic Balloon Dilatation of the Major Papilla?

INTRODUCTION: Endoscopic papillary large balloon dilatation (EPLBD) is an alternative for the treatment of common bile duct (CBD) stones. Existing evidence of factors associated with its outcomes is contradictory. OBJECTIVE: To identify predictors (including the experience of an endoscopist) of success and adverse events in EPLBD. METHODS: We reviewed the first 200 EPLBD with endoscopic sphincterotomy (EST) performed at our center. Demographic, clinical, and anatomic variables were studied, as well as the performance characteristics, correlating them with individual and group experience. RESULTS: Global success was obtained in 87% of cases, and adverse events occurred in 16% of cases. Success was associated with stone size, CBD diameter, and the need to perform mechanical lithotripsy (ML). Despite that adverse events were not univariately associated with any factor, severe adverse events were more likely to occur in stones > 13.5 mm. Multivariate analysis which disclosed success was higher when ML was not required and stones were < 13.5 mm. It also showed that no factor was associated with adverse events or their severity. No differences were found on success or adverse events that could be directly related to experience. CONCLUSIONS: Success of EPLBD-EST is higher in stones < 13.5 mm and when ML is not required. Experience does not appear to play a major role.

Efectividad del sistema over-the-scope-clip (OTSC®) como tratamiento de rescate en la hemorragia digestiva alta secundaria a úlcera péptica / Over-the-scope-clip (OTSC®) as a rescue treatment for gastrointestinal bleeding secondary to peptic ulcer disease

Introducción: el clip OTSC® (over-the-scope-clip) se ha postulado como tratamiento de rescate de la hemorragia digestiva alta por úlcera péptica, aunque su efectividad no ha sido evaluada en nuestro medio. Métodos: en este estudio retrospectivo y unicéntrico (enero 2018-diciembre 2021) se evaluaron el éxito técnico, el éxito clínico y la seguridad del dispositivo a 30 días. Se incluyeron todos los pacientes con hemorragia digestiva alta por úlcera péptica en los que se utilizó el clip OTSC® como tratamiento de rescate. Resultados: se incluyeron once pacientes (nueve por resangrado y dos por sangrado persistente). El éxito técnico fue del 81,9 % (9/11, intervalo de confianza [IC] 95 %: 52-95 %). El éxito clínico por protocolo y por intención de tratar fue del 88,9 % (8/9, IC 95 %: 57-98 %) y del 72,7 % (8/11, IC 95 %: 43-90 %) (8/11), respectivamente. No se registraron efectos adversos relacionados con el dispositivo. Conclusiones: el clip OTSC® fue un tratamiento de rescate efectivo y seguro de la hemorragia digestiva por úlcera péptica (AU)