Endoscopic Ultrasound-Guided Biliary Drainage of First Intent With a Lumen-Apposing Metal Stent vs Endoscopic Retrograde Cholangiopancreatography in Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Study (ELEMENT Trial).

BACKGROUND & AIMS: Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent (EUS-CDS) is a promising modality for management of malignant distal biliary obstruction (MDBO) with potential for better stent patency. We compared its outcomes with endoscopic retrograde cholangiopancreatography with metal stenting (ERCP-M). METHODS: In this multicenter randomized controlled trial, we recruited patients with MDBO secondary to borderline resectable, locally advanced, or unresectable peri-ampullary cancers across 10 Canadian institutions and 1 French institution. This was a superiority trial with a noninferiority assessment of technical success. Patients were randomized to EUS-CDS or ERCP-M. The primary end point was the rate of stent dysfunction at 1 year, considering competing risks of death, clinical failure, and surgical resection. Analyses were performed according to intention-to-treat principles. RESULTS: From February 2019 to February 2022, 144 patients were recruited; 73 were randomized to EUS-CDS and 71 were randomized to ERCP-M. The mean (SD) procedure time was 14.0 (11.4) minutes for EUS-CDS and 23.1 (15.6) minutes for ERCP-M (P < .01); 40% of the former was performed without fluoroscopy. Technical success was achieved in 90.4% (95% CI, 81.5% to 95.3%) of EUS-CDS and 83.1% (95% CI, 72.7% to 90.1%) of ERCP-M with a risk difference of 7.3% (95% CI, -4.0% to 18.8%) indicating noninferiority. Stent dysfunction occurred in 9.6% vs 9.9% of EUS-CDS and ERCP-M cases, respectively (P = .96). No differences in adverse events, pancreaticoduodenectomy and oncologic outcomes, or quality of life were noted. CONCLUSIONS: Although not superior in stent function, EUS-CDS is an efficient and safe alternative to ERCP-M in patients with MDBO. These findings provide evidence for greater adoption of EUS-CDS in clinical practice as a complementary and exchangeable first-line modality to ERCP in patients with MDBO. CLINICALTRIALS: gov, Number: NCT03870386.

Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event.

BACKGROUND: Gallstone disease will affect 15% of the adult population with concomitant common bile duct stone (CBDS) occurring in up to 30%. Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for removal of CBDS, as cholecystectomy for the prevention of recurrent biliary event (RBE). RBE occurs in up to 47% if cholecystectomy is not done. The goal of this study was to evaluate the timing of occurrence of RBE after common bile duct clearance with ERCP and associated outcomes. METHODS: The records of all patients who underwent ERCP for gallstone disease followed by cholecystectomy, in a single center from 2010 to 2022, were reviewed. All RBE were identified. Actuarial incidence of RBE was built. Patients with and without RBE were compared. RESULTS: The study population is composed of 529 patients. Mean age was 58.0 (18-95). There were 221 RBE in 151 patients (28.5%), 39/151 (25.8%) having more than one episode. The most frequent RBE was acute cholecystitis (n = 104) followed by recurrent CBDS (n = 95). Median time for first RBE was 34 days. Actuarial incidence of RBE started from 2.5% at 7 days to reach 53.3% at 1 year. Incidence-rate of RBE was 2.9 per 100 person-months. Patients with RBE had significant longer hospitalisation time (11.7 vs 6.4 days; P < 0.0001), longer operative time (66 vs 48 min; P < 0.0001), longer postoperative stay (2.9 vs 0.9 days; P < 0.0001), higher open surgery rate (7.9% vs 1.3%; P < 0.0001), and more complicated pathology (23.8% vs 5.8%; P < 0.0001) and cholecystitis (64.2% vs 25.9%; P < 0.0001) as final diagnoses. CONCLUSIONS: RBE occurred in 28.5% of the subjects at a median time of 34 days, with an incidence of 2.5% as early as 1 week. Cholecystectomy should be done preferably within 7 days after common bile duct clearance in order to prevent RBE and adverse outcomes.

Cholecystectomy following endoscopic clearance of common bile duct during the same admission.

BACKGROUND: The recurrence of common bile duct stones and other biliary events after endoscopic retrograde cholangiopancreatography (ERCP) is frequent. Despite recommendations for early cholecystectomy, intervention during the same admission is carried out inconsistently. METHODS: We reviewed the records of patients who underwent ERCP for gallstone disease and common bile duct clearance followed by cholecystectomy between July 2012 and June 2022. Patients were divided into 2 groups: the index group underwent cholecystectomy during the same admission and the delayed group was discharged and had their cholecystectomy postponed. Data on demographics and prognosis factors were collected and analyzed. RESULTS: The study population was composed of 268 patients, with 71 (26.6%) having undergone cholecystectomy during the same admission after common bile duct clearance with ERCP. A greater proportion of patients aged 80 years and older were in the index group than in the delayed group. The American Society of Anesthesiologists score was significantly higher in the index group. There was no significant difference between groups regarding surgical complications, open cholecystectomy and death. The operative time was significantly longer in the delayed group. Among patients with delayed cholecystectomy, 18.3% had at least 1 recurrence of common bile duct stones (CBDS) and 38.6% had recurrence of any gallstone-related events before cholecystectomy. None of these events occurred in the the index group. There was no difference in the recurrence of CBDS and other biliary events after initial diagnosis associated with stone disease. CONCLUSION: Cholecystectomy during the same admission after common bile duct clearance is safe, even in older adults with comorbidities. Compared with delayed cholecystectomy, it was not associated with adverse outcomes and may have prevented recurrence of biliary events.

Rare etiology of colonic intussusception involving an adult with emphysematous cystic enteropathy: A case report and review of literature.

BACKGROUND: Pneumatosis cystoides intestinalis (PCI), characterized by a collection of gas-filled cysts in the intestinal wall, is an uncommon but well-known condition in gastroenterology. Abdominal pain is the most frequent symptom associated with PCI. Intussusception represents a potential cause of recurrent abdominal pain or emergency presentation. However, the occurrence of colonic intussusception secondary to PCI is very unusual in adulthood. CASE SUMMARY: A 52-year-old male, known with idiopathic PCI, presented seventeen months after initial diagnosis with a new right upper quadrant pain. A computed tomography-scan demonstrated a colonic intussusception at the hepatic flexure. PCI did not progress compared with initial investigation. The patient underwent an emergency right hemicolectomy. CONCLUSION: Resection was recommended in this case because PCI proved to be persisting with no identified curable cause. Surgery allowed to address the underlying pathology, the potential relapse of intussusception, and the likely cause of recurrent abdominal pain, either invagination or PCI itself.

First splenic rupture following an endoscopic esophageal myotomy: A case report.

BACKGROUND: The occurrence of splenic rupture is extremely rare during an upper gastro-intestinal endoscopy. Although infrequent, splenic rupture is a known complication secondary to colonoscopy. However, occurrence of splenic rupture after peroral endoscopic myotomy (POEM) has never been reported to date. CASE SUMMARY: We describe a case of a splenic rupture following a POEM for recurrent achalasia in a patient who previously had a Heller myotomy. Splenic rupture remains very uncommon after an upper gastro-intestinal endoscopic procedure. The most plausible cause for this rare splenic injury appears to be the stretching of the gastro-splenic ligament during the endoscopy. A previous surgery may be a risk factor contributing to this complication. CONCLUSION: The possibility for the occurrence of specific complications, such as splenic rupture, does exist even with the development of advanced endoscopic procedures, as presented in the present case after POEM.

Three colonic cancers, two sites of complete occlusion, one patient: A case report.

BACKGROUND: Synchronous colonic cancer incidence is uncommon, and awareness about this rare condition is improved recently. However, in the presence of acute colonic obstruction, investigation and management of synchronous colonic cancer can be difficult and challenging. CASE SUMMARY: A patient presented with acute colonic obstruction with impending rupture and complete examination of this patient revealed the presence of three colonic cancers, of which two were completely occluding. CONCLUSION: The presence of multiple colonic cancers must be ruled out in order to plan the best management. We present the case with a review of literature and discuss the management of the case.

Same-day endoscopic ultrasound, retrograde cholangiopancreatography and stone extraction, followed by cholecystectomy: A case report and literature review.

INTRODUCTION: Common bile duct stone-related events and their recurrence are frequent even after endoscopic retrograde cholangiopancreatography and stone extraction. Cholecystectomy should be carried out as soon as possible after the initial episode to prevent complications. CASE PRESENTATION: We present a case of a patient who underwent endoscopic ultrasound, cholangiopancreatography with stone extraction and cholecystectomy on the same day. DISCUSSION: After a common bile duct stone-related event, investigation, and stone extraction, cholecystectomy should be carried out as soon as possible to avoid high rates of recurrence and complications. Rise in health care costs nowadays mandate such an approach as a pre-emptive measure to prevent health complications while lowering health costs. CONCLUSION: Diagnosis of common bile duct stone followed by extraction with endoscopic cholangiopancreatography and cholecystectomy on the same day is feasible, safe, and has many potential advantages.

Primary cultures of human hepatocytes isolated from hepatitis C virus-infected cirrhotic livers as a model to study hepatitis C infection.

BACKGROUND/AIM: Since the discovery of hepatitis C virus (HCV), researchers have encountered difficulties with in vitro models. The aim of this study was to determine whether HCV-infected human primary hepatocytes, isolated from cirrhotic livers at liver transplantation, can be used as a model to study HCV infection. METHODS: Hepatocytes were isolated with collagenase and cultured over a 20-day period on different matrices. Viral kinetics was monitored with/without treatment by real-time polymerase chain reaction. RESULTS: Cell yield and viability were higher with uninfected/non-cirrhotic livers (77.2+/-1.8%) in comparison with HCV-infected cirrhotic livers (68.8+/-12%). HCV-infected hepatocytes behaved similar to non-infected cells and expressed albumin and cytochrome P4502E1. HCV-positive strand was identified in supernatants and cell lysates. HCV-negative strand was only found inside cells and correlated with viral RNA recovery in the medium. Improvement in the degree of hepatocyte differentiation was associated with better HCV recovery. Antiviral treatment with interferon-alpha, EX4 and cyclosporine A induced significant reductions in HCV RNA. CONCLUSION: Primary cultures of HCV-infected human hepatocytes from end-stage cirrhotic livers is feasible, represents an excellent model to study specific virus-host interactions and can be used to assess viral replication.

Safety and efficacy of endoscopic submucosal dissection for rectal neoplasia: a multicenter North American experience.

Background and aims Rectal lesions traditionally represent the first lesions approached during endoscopic submucosal dissection (ESD) training in the West. We evaluated the safety and efficacy of rectal ESD in North America. Methods This is a multicenter retrospective analysis of rectal ESD between January 2010 and September 2018 in 15 centers. End points included: rates of en bloc resection, R0 resection, adverse events, comparison of pre- and post-ESD histology, and factors associated with failed resection. Results In total, 171 patients (median age 63 years; 56 % men) underwent rectal ESD (median size 43 mm). En bloc resection was achieved in 141 cases (82.5 %; 95 %CI 76.8-88.2), including 24 of 27 (88.9 %) with prior failed endoscopic mucosal resection (EMR). R0 resection rate was 74.9 % (95 %CI 68.4-81.4). Post-ESD bleeding and perforation occurred in 4 (2.3 %) and 7 (4.1 %), respectively. Covert submucosal invasive cancer (SMIC) was identified in 8.6 % of post-ESD specimens. There was one case (1/120; 0.8 %) of recurrence at a median follow-up of 31 weeks; IQR: 19-76 weeks). Older age and higher body mass index (BMI) were predictors of failed R0 resection, whereas submucosal fibrosis was associated with a higher likelihood of both failed en bloc and R0 resection. Conclusion Rectal ESD in North America is safe and is associated with high en bloc and R0 resection rates. The presence of submucosal fibrosis was the main predictor of failed en bloc and R0 resection. ESD can be considered for select rectal lesions, and serves not only to establish a definitive tissue diagnosis but also to provide curative resection for lesions with covert advanced disease.

Needle Fracture during Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Suspicious Thoracic Lymph Nodes.

Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is used to make a cytopathologic diagnosis of suspicious lesions located around the gastrointestinal tract. It is a safe technique with few complications. The most common complications of EUS-FNA are related to pancreatic lesions (pancreatitis, bleeding, and abdominal pain). Rare complications have been noted such as stent malfunction, air embolism, infection, neural and vascular injuries, and tumor cell seeding. There are very few studies examining equipment malfunctions. We report a case of needle fracture during the EUS-FNA of suspicious thoracic lymph nodes in a 79-year-old man investigated for unexplained weight loss.

Adding Water to the Mill: Olmesartan-Induced Collagenous Sprue-A Case Report and Brief Literature Review.

Collagenous sprue (CS) is a distinct clinicopathological disorder histologically defined by a thickened subepithelial band (Freeman, 2011). It is a rare condition which has been recently observed in a significant proportion of sprue-like enteropathy associated with olmesartan, a novel entity described by Rubio-Tapia et al. in 2012. CS is historically associated with a poor prognosis (Marthey et al., 2014). However, histological and clinical improvements have been described in most studies with concomitant usage of corticosteroids and/or gluten-free diet (Marthey et al., 2014). We report a unique case of olmesartan-induced collagenous sprue in a 79-year-old man that showed complete histological and clinical remission with the sole withdrawal of the incriminating drug. The literature on this topic is briefly reviewed.

Role of intraoperative enteroscopy in the management of obscure gastointestinal bleeding at the time of video-capsule endoscopy.

BACKGROUND: This study aimed at evaluating the role of intraoperative enteroscopy (IOE) for the management of obscure gastrointestinal (GI) bleeding in patients who had been preoperatively explored by video-capsule endoscopy (VCE). METHODS: Eighteen patients who underwent IOE for obscure GI bleeding were prospectively recorded between November 2000 and January 2007. The bleeding site was preoperatively localized by VCE in the small bowel in 15 patients, but the origin of bleeding remained unknown in 3 patients. RESULTS: In the 3 patients with negative VCE, IOE was normal, but intraoperative conventional endoscopy identified gastric (n = 1) and colonic (n = 2) lesions. Among the 15 patients with VCE positive for small-bowel lesions, laparotomy and IOE yielded localization and treatment (surgical n = 11 and endoscopic n = 2) guidance for 13 of 15 (87%) lesions. At median 19-month follow-up, 3 bleeding recurrences (3 of 15 [20%]) were recorded, resulting in a 73% therapeutic efficacy of IOE. CONCLUSIONS: IOE remains useful for the management of obscure GI bleeding when preoperative VCE is positive for small-bowel lesions that are not reachable by nonoperative enteroscopy. When VCE is negative, new conventional endoscopy should be proposed instead of IOE.