Triangle Tip-Jet Knife used as "probe mode" can reduce the risk of mucosal damage during incision and tunneling phase of peroral endoscopic myotomy (POEM) procedures.

Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic technique for the treatment of achalasia and its use has been widely spread in recent years. The Triangle Tip-Jet (TTJ) (Olympus Triangle TipKnife-J, KD645L) has become very popular in this field and currently one of the most used knives for POEM procedures. It has the capability of knife dissection along with submucosal injection and its triangle tip shape is especially useful for pulling tissue during the myotomy phase. However, its length may be too long in situations such as tight esophagogastric junction (EGJ), narrow submucosa due to fibrosis, trimming after mucosal incision and/or less experienced endoscopists3 in which preserving the integrity of the mucosa is vitally important. Distal attachment conical caps like ST Hood (DH28GR,29CR; Fujifilm, Tokyo, Japan) are commonly used for POEM, resting the distal end of the TTJ on the cap, with only the triangular tip protruding. By using straight caps, you can get a wider view and greater maneuverability, however is more difficult to calculate the distance between the triangle tip and the distal attachment end due to its straight shape. The T-shape of the distal TTJ tip was designed for its use in an open position. In this way, while using straight caps and/or less experiences endoscopists during challenging procedures (tight EGJ, submucosal fibrosis) can make them feel unsafe during incision and/or tunneling phase. Herein, we suggest the use of the TTJ knife in "probe mode"4 to reduce the distal knife length from 4.5 mm to 0.3 mm, thus allowing a greater control of the knife tip. In addition, the TTJ probe mode can be safely used with both contact and non-contact currents, which are becoming increasingly popular in recent years.

Over-The-Scope clip closure of an acquired bronchoesophageal fistula secondary to an esophageal diverticulum.

Esophagorespiratory fistula is a rare entity that occurs as a result of malignant and non-malignant causes. This condition is associated with high morbidity and mortality. Surgical repair has traditionally been the most common treatment and self-expandable metal stent are the first choice among non-surgical techniques. Here, we report a non-malignant bronchoesophageal fistula secondary to an esophageal diverticulum that was successfully closed using an over-the-scope clip.

Predictive models for hepatocellular carcinoma development after sustained virological response in advanced hepatitis C.

BACKGROUND & AIMS: Life-long hepatocellular carcinoma (HCC) surveillance is recommended after sustained virological response (SVR) in patients with advanced hepatitis C. Since the identification of patients who could be safely discontinued for surveillance is essential, we aimed to identify subsets of patients with low-risk HCC. METHODS: 491 patients with advanced and compensated fibrosis (≥F3) were prospectively followed after achieving SVR with interferon-free therapies. Clinical-biological parameters and liver stiffness measurement (LSM) were performed before starting treatment (ST) and at SVR, and HCC surveillance was carried out. RESULTS: During a median follow-up of 49.8 months, 29 (5.9%) patients developed HCC [incidence rate: 1.6/100 patient-years (PYs)]. Two predictive models based on LSM (Model-A) or FIB-4 score (Model-B) were proposed. Only SVR parameters were included in the models, because they showed a higher accuracy for predicting HCC than ST measurements. Variables independently associated with HCC were LSM (HR, 1.03; 95% CI, 1.01-1.05), age (HR, 1.04; 95% CI, 1.01-1.08) and albumin levels (HR, 0.90; 95% CI, 0.84-0.97) in Model-A, and FIB-4 (HR, 1.22; 95% CI, 1.08-1.37) and albumin (HR, 0.90; 95% CI, 0.84-0.97) in model-B. Both models allow HCC risk stratification, identifying low-risk groups with an HCC incidence rate of 0.16/100 and 0.25/100 PYs, respectively. An overall increased hazard of HCC was observed over time. CONCLUSION: Simple models based on non-invasive markers of liver fibrosis, LSM or FIB-4, together with age and albumin levels at SVR permit to identify subsets of patients with HCC risk clearly <1%/year, for whom HCC surveillance might not be cost-effective.

Endoscopy-Related Bleeding and Thromboembolic Events in Patients on Direct Oral Anticoagulants or Vitamin K Antagonists.

BACKGROUND & AIMS: Few prospective studies have assessed the safety of direct oral anticoagulants (DOACs) in elective endoscopy. Our primary aim was to compare the risks of endoscopy-related gastrointestinal bleeding and thromboembolic events in patients on DOACs or vitamin K antagonists (VKAs) in this setting. Secondarily, we examined the impact of the timing of anticoagulant resumption on the risk of delayed bleeding in high-risk therapeutic procedures. METHODS: We conducted a multicenter, prospective, observational study from January 2018 to March 2020 of 1602 patients on oral anticoagulants (1004 on VKAs and 598 on DOACs) undergoing 1874 elective endoscopic procedures. Our primary outcomes were 90-day thromboembolic events and 30-day endoscopy-related gastrointestinal bleeding. The inverse probability of treatment weighting propensity score method was used for baseline covariate adjustment. RESULTS: The 2 groups had similar risks of endoscopy-related gastrointestinal bleeding (VKAs vs DOACs, 6.2% vs 6.7%; adjusted odds ratio [OR], 1.05; 95% CI, 0.67-1.65) and thromboembolic events (VKAs vs DOACs, 1.3% vs 1.5%; adjusted OR, 0.90; 95% CI, 0.34-2.38). In high bleeding risk procedures (n = 747), delayed anticoagulant resumption (> 48 hours or 24-48 hours vs < 24 hours) did not reduce the risk of postprocedural bleeding (10.3%, 9%, and 5.8%, respectively; adjusted P = .43). Hot and cold snare polypectomy were the most frequent high-risk interventions (41.8% and 39.8%, respectively). CONCLUSION: In a prospective study of patients on DOACs or VKAs undergoing elective endoscopy, endoscopy-related bleeding and thromboembolic events showed similar risk. Our study suggests that early anticoagulant resumption is safe in most patients, but more data are needed for advanced high-risk therapeutic procedures.

Acute upper gastrointestinal bleeding secondary to aortoesophageal fistula. Endoscopic treatment using the over-the-scope clip (OTSC®) system.

Aortoesophageal fistula is an extremely rare cause of upper gastrointestinal bleeding associated with high morbidity and mortality. Early clinical suspicion, as well as correct management since diagnosis, can increase the probability of survival of this gastrointestinal emergency. We present the first case reported of an aortoesophageal fistula successfully treated with the OTSC system, representing another therapeutic option for this high-risk entity.

Endoscopic diagnosis of primary aortoesophageal fistula: An extremely rare cause of acute upper gastrointestinal bleeding.

Primary aortoesophageal fistula, an abnormal communication between native aorta and oesophagus, is an extremely rare cause of upper gastrointestinal bleeding. The typical symptoms, known as the Chiari´s triad, are only present in 45% of cases. It has a high mortality, so early diagnosis is essential to increase the probability of survival. We present a case report of a patient with massive upper gastrointestinal bleeding due to primary aortoesophageal fistula.

Regorafenib Efficacy After Sorafenib in Patients With Recurrent Hepatocellular Carcinoma After Liver Transplantation: A Retrospective Study.

Safety of regorafenib in hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) has been recently demonstrated. We aimed to assess the survival benefit of regorafenib compared with best supportive care (BSC) in LT patients after sorafenib discontinuation. This observational multicenter retrospective study included LT patients with HCC recurrence who discontinued first-line sorafenib. Group 1 comprised regorafenib-treated patients, whereas the control group was selected among patients treated with BSC due to unavailability of second-line options at the time of sorafenib discontinuation and who were sorafenib-tolerant progressors (group 2). Primary endpoint was overall survival (OS) of group 1 compared with group 2. Secondary endpoints were safety and OS of sequential treatment with sorafenib + regorafenib/BSC. Among 132 LT patients who discontinued sorafenib included in the study, 81 were sorafenib tolerant: 36 received regorafenib (group 1) and 45 (group 2) received BSC. Overall, 24 (67%) patients died in group 1 and 40 (89%) in group 2: the median OS was significantly longer in group 1 than in group 2 (13.1 versus 5.5 months; P < 0.01). Regorafenib treatment was an independent predictor of reduced mortality (hazard ratio, 0.37; 95% confidence interval [CI], 0.16-0.89; P = 0.02). Median treatment duration with regorafenib was 7.0 (95% CI, 5.5-8.5) months; regorafenib dose was reduced in 22 (61%) patients for adverse events and discontinued for tumor progression in 93% (n = 28). The median OS calculated from sorafenib start was 28.8 months (95% CI, 17.6-40.1) in group 1 versus 15.3 months (95% CI, 8.8-21.7) in group 2 (P < 0.01). Regorafenib is an effective second-line treatment after sorafenib in patients with HCC recurrence after LT.

Congenital Extrahepatic Portosystemic Shunts (Abernethy Malformation): An International Observational Study.

Congenital extrahepatic portosystemic shunt (CEPS) or Abernethy malformation is a rare condition in which splanchnic venous blood bypasses the liver draining directly into systemic circulation through a congenital shunt. Patients may develop hepatic encephalopathy (HE), pulmonary hypertension (PaHT), or liver tumors, among other complications. However, the actual incidence of such complications is unknown, mainly because of the lack of a protocolized approach to these patients. This study characterizes the clinical manifestations and outcome of a large cohort of CEPS patients with the aim of proposing a guide for their management. This is an observational, multicenter, international study. Sixty-six patients were included; median age at the end of follow-up was 30 years. Nineteen patients (28%) presented HE. Ten-, 20-, and 30-year HE incidence rates were 13%, 24%, and 28%, respectively. No clinical factors predicted HE. Twenty-five patients had benign nodular lesions. Ten patients developed adenomas (median age, 18 years), and another 8 developed HCC (median age, 39 years). Of 10 patients with dyspnea, PaHT was diagnosed in 8 and hepatopulmonary syndrome in 2. Pulmonary complications were only screened for in 19 asymptomatic patients, and PaHT was identified in 2. Six patients underwent liver transplantation for hepatocellular carcinoma or adenoma. Shunt closure was performed in 15 patients with improvement/stability/cure of CEPS manifestations. Conclusion: CEPS patients may develop severe complications. Screening for asymptomatic complications and close surveillance is needed. Shunt closure should be considered both as a therapeutic and prophylactic approach.

Changes in the characteristics of hospital admissions due to decompensated cirrhosis in the era of direct-acting antivirals against hepatitis C virus.

BACKGROUND: the development of interferon-free regimens, based on direct acting antivirals (DAAs) has revolutionized the treatment of hepatitis C virus (HCV) infection. AIMS: to determine if there have been changes in the characteristics of hospital admissions due to decompensated cirrhosis in a general hospital since the introduction of DAAs. PATIENTS AND METHODS: this was a prospective study of all hospital admissions due to decompensated cirrhosis during two periods: October 2012-October 2014 (P-I) and July 2016-July 2018 (P-II). Clinical and demographic variables were collected and standard statistical methods were used for the analysis. RESULTS: there were 746 hospital admissions; 347 in P-I and 399 in P-II. P-I patients were younger (59 vs 63 years; p = 0.034), while the proportion of admissions due to HCV-cirrhosis was lower in P-II (15.8 % vs 21.6 %; p = 0.041). There were no significant differences in the proportion of admissions due to other etiologies of cirrhosis between both periods. Patients in the P-II group presented an active viral infection (57.1 vs 97.3 %; p = 0.001) less frequently and had a higher rate of excessive alcohol consumption (55.5 vs 30.7 %; p = 0.003) when admitted, while HIV co-infection was less frequent (1.6 % vs 10.7 %; p = 0.039). CONCLUSION: the proportion of admissions due to decompensated HCV-related cirrhosis has decreased by almost 30 % since the introduction of the DAA. In addition, the characteristics of patients admitted have changed since the application of interferon-free regimens.

Endoscopic full-thickness resection (EFTR) after neoadjuvant chemotherapy: is it feasible?

Endoscopic full-thickness resection (EFTR) is a new technique for the resection of colonic lesions with limitations for other techniques such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) due to fibrosis, the location of the lesion or invasion depth. In addition, techniques such as ESD require a long learning curve and unfortunately they are not fully implemented in Western countries. EFTR has numerous indications, which are expanding daily. The Full-Thickness Resection Device® (FTRD) is a promising tool, although it has many limitations and is associated with some risks. One of the main limitations of this resection device is the size of the lesion and it is not recommended for the resection of lesions > 30 mm. Furthermore, tumor size is directly related to the "en bloc" resection rate. On the one hand, this case report suggests that neoadjuvant chemotherapy can modify the lesion size and larger lesions become candidates for EFTR in a second attempt. On the other hand, the concomitant use of systemic anticancer therapy could be a contraindication for the use of FTRD® as it may be associated with late perforations. It is necessary to establish the time between the use of chemotherapy and the use of FTRD® in order to avoid complications. These considerations must be analyzed in future prospective studies.

Primary squamous cell carcinoma of the stomach: a rare entity.

We present the case of a primary squamous cell carcinoma (PSCC) and inform about the evidence to date and also highlight the diagnostic criteria. We present the case report of a 78-year-old female was admitted due to a 2-week history of abdominal pain, weight loss and vomiting.

Is it time for Cold-Endoscopic Submucosal Dissection? A feasibility study in an esophageal and colorectal live porcine model.

Background and study aims Use of cold endoscopic resection has increased due to excellent results with it and the ability to avoid electrosurgery related complications. The aim of this study was to evaluate the feasibility and safety of cold-endoscopic submucosal dissection (C-ESD) in an in vivo porcine model. Patients and methods C-ESD with circumferential incision and submucosal dissection with a predominantly cold technique was tested in the esophagus and colorectum. Incision and dissection were attempted with a cold technique with a biopsy forceps and an endoscopic Maryland dissector. Large vessels were pre-coagulated with the latter device. Different traction methods were applied. Results Twelve dissections were performed: four esophageal, four colonic, and four rectal. Tunnel and pocket methods were applied successfully. Full C-ESD was possible in the colorectum. In the esophagus, an initial incision had to be done with electrocautery. No major bleeding occurred. Two perforations occurred in the colon, one was endoscopically treated. Conclusions Full C-ESD is feasible in the colorectum, whereas a small hot incision is needed in the esophagus. However, in 50 % of the colonic cases, there were perforations caused by the biopsy forceps making the circumferential incision. Therefore, potential benefits of endoscopic resection without cautery would warrant futures studies in humans initially in esophagus and rectal locations.

Triangle Tip-Jet Knife used as “probe mode” can reduce the risk of mucosal damage during incision and tunneling phase of peroral endoscopic myotomy (POEM) procedures

Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic technique for the treatment of achalasia and its use has been widely spread in recent years. The Triangle Tip-Jet (TTJ) (Olympus Triangle TipKnife-J, KD645L) has become very popular in this field and currently one of the most used knives for POEM procedures. It has the capability of knife dissection along with submucosal injection and its triangle tip shape is especially useful for pulling tissue during the myotomy phase. However, its length may be too long in situations such as tight esophagogastric junction (EGJ), narrow submucosa due to fibrosis, trimming after mucosal incision and/or less experienced endoscopists3 in which preserving the integrity of the mucosa is vitally important. Distal attachment conical caps like ST Hood (DH28GR,29CR; Fujifilm, Tokyo, Japan) are commonly used for POEM, resting the distal end of the TTJ on the cap, with only the triangular tip protruding. By using straight caps, you can get a wider view and greater maneuverability, however is more difficult to calculate the distance between the triangle tip and the distal attachment end due to its straight shape. The T-shape of the distal TTJ tip was designed for its use in an open position. In this way, while using straight caps and/or less experiences endoscopists during challenging procedures (tight EGJ, submucosal fibrosis) can make them feel unsafe during incision and/or tunneling phase. Herein, we suggest the use of the TTJ knife in “probe mode”4 to reduce the distal knife length from 4.5 mm to 0.3 mm, thus allowing a greater control of the knife tip. In addition, the TTJ probe mode can be safely used with both contact and non-contact currents, which are becoming increasingly popular in recent years. (AU)

Hemorragia gastrointestinal en paciente con púrpura de Schönlein-Henoch / Gastrointestinal bleeding in a Schönlein-Henoch purpura patient

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